BRS Abdomen

Question 1

1. A 63-year-old man comes to the emergency department with back pain, weakness, and shortness of breath. On examination, he has an aneurysm of the abdominal aorta at the aortic hiatus of the diaphragm. Which of the following pairs of structures would most likely be compressed?
   A) Vagus nerve and azygos vein
   (B) Esophagus and vagus nerve
   (C) Azygos vein and thoracic duct
   (D) Thoracic duct and vagus nerve
   (E)Inferior vena cava (IVC) and phrenic nerve

Answer 1

1. The answer is C. Azygos vein and thoracic duct
   The aortic hiatus of the diaphragm transmits the azygos vein and thoracic duct. The vagus nerve passes through the esophageal hiatus, and the right phrenic nerve may run through the vena caval hiatus.

Question 2

2. A 36-year-old woman with yellow pigmentation of the skin and sclerae presents at the outpatient clinic. Which of the following conditions most likely is the cause of her obstructive jaundice?
   (A) Aneurysm of the splenic artery
   (B) Perforated ulcer of the stomach
   (C) Obstruction of the main pancreatic duct
   (D) Cancer in the head of the pancreas
   (E)Cancer in the body of the pancreas

Answer 2

2. The answer is D. -Cancer in the head of the pancreas

Because the bile duct traverses the head of the pancreas, cancer in the head of the pancreas obstructs the bile duct, resulting in jaundice. Aneurysm of the splenic artery, ob- struction of the main pancreatic duct, a stomach ulcer, and cancer in the body of the pancreas are not closely associated with the bile duct. The tail of the pancreas is located at the hilus of the spleen, which lies far from the bile duct.

Question 3

3. A 2-year-old boy presents with pain in his groin that has been increasing in nature over the past few weeks. He is found to have a degenerative malformation of the transversalis fascia during development. Which of the following structures on the anterior abdominal wall is likely defective?
(A) Superficial inguinal ring
(B) Deep inguinal ring
(C) Inguinal ligament
(D) Sac of a direct inguinal hernia
(E)Anterior wall of the inguinal canal

Answer 3

3. The answer is B. Deep inguinal ring

The deep inguinal ring lies in the transversalis fascia, just lateral to the inferior epigastric vessels. The superficial inguinal ring is in the aponeurosis of the external oblique muscle. The inguinal ligament and the anterior wall of the inguinal canal are formed by the aponeurosis of the external oblique muscle. The sac of a direct inguinal hernia is formed by the peritoneum

Question 4

4. A 29-year-old man comes to a local hospital with duodenal peptic ulcer and complains of cramping epigastric pain. Which of the following structures harbors the cell bodies of abdominal pain fibers?
(A) Lateral horn of the spinal cord
(B) Anterior horn of the spinal cord
(C) Dorsal root ganglion
(D) Sympathetic chain ganglion
 (E) Celiac ganglion

Answer 4

4. The answer is C. Dorsal root ganglion
   Cell bodies of the abdominal pain fibers are located in the dorsal root ganglion. The lateral horn of the spinal cord contains cell bodies of sympathetic preganglionic nerve fibers; the anterior horn contains cell bodies of general somatic efferent (GSE) fibers. The sympathetic chain ganglion contains cell bodies of sympathetic postganglionic fibers, which supply blood vessels, sweat glands, and hair follicles. The celiac ganglion contains cell bodies of sympathetic postganglionic fibers, which supply the visceral organs such as stomach and intestine.

Question 5

5. A 42-year-old obese woman with seven children is brought to a local hospital by her daughter. Physical examination and her radiograph reveal that large gallstones have ulcerated through the posterior wall of the fundus of the gallbladder into the intestine. Which of the following parts of the intestine is most likely to initially contain gallstones?
A-Cecum 
B- Ascending colon 
C- Transverse colon 
D- Descending colon 
E- Sigmoid colon

Answer 5

5. The answer is C. Transverse colon
   The fundus of the gallbladder is in contact with the transverse colon, and thus, gallstones erode through the posterior wall of the gallbladder and enter the transverse co- lon. They are passed naturally to the rectum through the descending colon and sigmoid colon. Gallstones lodged in the body of the gallbladder may ulcerate through the posterior wall of the body of the gallbladder into the duodenum (because the gallbladder body is in contact with the duodenum) and may be held up at the ileocecal junction, producing an intestinal obstruction

Question 6

6. A 35-year-old woman comes to a local hospital with abdominal tenderness and acute pain. On examination, her physician observes that an abdominal infection has spread retroperitoneally. Which of the following structures is most likely affected?
A- Stomach 
B- Transverse colon 
C- Jejunum 
D-Descending colon
E- Spleen

Answer 6

6. The answer is D. Descending colon

The descending colon is a retroperitoneal organ. The rest of the organs are surrounded by peritoneum

Question 7

7. During an annual health examination of a 46-year-old woman, a physician finds hypersecretion of norepinephrine from her suprarenal medulla. Which of the following types of nerve fibers are most likely overstimulated?
   (A) Preganglionic sympathetic fibers
   (B) Postganglionic sympathetic fibers
   (C) Somatic motor fibers
   (D) Postganglionic parasympathetic fibers
   (E) Preganglionic parasympathetic fibers

Answer 7

7. The answer is A. Preganglionic sympathetic fibers

The suprarenal medulla is the only organ that receives preganglionic sympathetic fibers. No other nerve fibers are involved in secretion of norepinephrine from the suprarenal medulla

Question 8

8. A 6-year-old girl comes to her pediatrician with constipation, abdominal distention, and vomiting. After thorough examination, she is diagnosed as having Hirschsprung disease (aganglionic megacolon), which is a congenital disease and leads to dilation of the colon. This condition is caused by an absence of which of the following kinds of neural cell bodies?
   (A) Sympathetic preganglionic neuron cell bodies
   (B) Sympathetic postganglionic neuron cell bodies
   (C) Parasympathetic preganglionic neuron cell bodies
   (D) Parasympathetic postganglionic neuron
   E Sensory neuron cell bodies

Answer 8

8. The answer is D. Parasympathetic postganglionic neuron
Aganglionic megacolon (Hirschsprung disease) is caused by the absence of enteric ganglia (parasympathetic postganglionic neuron cell bodies) in the lower part of the colon, which leads to dilatation of the colon proximal to the inactive segment, resulting in an inability to evacuate the bowels. The other neuron cell bodies listed are not involved in this condition.

Question 9

9. A pediatric surgeon is resecting a possible malignant mass from the liver of a neonate with cerebral palsy. The surgeon divides the round ligament of the liver during surgery. A fibrous remnant of which of the following fetal vessels is severed?
(A) Ductus venosus
(B) Ductus arteriosus
(C) Left umbilical vein
(D) Right umbilical vein
(E) Umbilical artery

Answer 9

9. The answer is C. Left umbilical vein
   The left umbilical vein becomes the round ligament of the liver after birth. The right umbilical vein did not leave a fibrous remnant because it was degenerated during the early embryonic period. The ductus venosus forms the ligamentum venosum; the ductus arteriosus forms the ligamentum arteriosum; the umbilical artery forms the medial umbilical ligament

Question 10

10. A 27-year-old woman has suffered a gunshot wound to her midabdomen. After examining the patient’s angiogram, a trauma surgeon locates the source of bleeding from pairs of veins that typically terminate in the same vein. Which of the following veins are damaged?
(A) Left and right ovarian veins
(B) Left and right gastroepiploic veins
(C) Left and right colic veins
(D) Left and right suprarenal veins
(E) Left and right hepatic veins

Answer 10

10. The answer is E. Left and right hepatic veins

The right and left hepatic veins drain into the inferior vena cava (IVC). The right gastroepiploic vein drains into the superior mesenteric vein, but the left one drains into the splenic vein. The right gonadal and suprarenal veins drain into the IVC, whereas the left ones drain into the left renal vein. The right colic vein ends in the superior mesenteric vein, but
the left one terminates in the inferior mesenteric vein

Question 11

11. A 43-year-old man complains of abdominal pain just above his umbilicus. On examination, a tumor is found anterior to the IVC. Which of the following structures would most likely be compressed by this tumor?
(A) Right sympathetic trunk
(B) Left third lumbar artery
(C) Third part of the duodenum
(D) Left renal artery
(E) Cisterna chyli

Answer 11

11. The answer is C. Third part of the duodenum
    The third part of the duodenum (transverse portion) crosses anterior to the IVC. The other structures do not cross the IVC anteriorly

Question 12

12. A 33-year-old man with a perforated gastric ulcer complains of excruciating pain in his stomach. It is observed that the pain comes from peritoneal irritation by gastric contents in the lesser sac. Which of the following nerves contain sensory nerve fibers that convey this sharp, stabbing pain?
(A) Vagus nerves
(B) Greater splanchnic nerves
 (C) Lower intercostal nerves
 (D) White rami communicantes
 (E) Gray rami communicantes

Answer 12

12. The answer is C. Lower intercostal nerves
    Pain sensation originating from peritoneal irritation by gastric contents in the lesser sac is carried by lower intercostals nerves. The vagus nerves carry sensory fibers as- sociated with reflexes in the gastrointestinal (GI) tract. The greater splanchnic nerves and white rami communicantes carry pain (general visceral afferent [GVA]) fibers from the wall of the stomach and other areas of the GI tract. The gray rami communicantes contains no sensory fibers but contain sympathetic postganglionic fibers

Question 13

13. A young boy is brought to the hospital after a bicycle accident and possible pelvic fracture. While awaiting a computed tomography (CT) scan of his pelvis, a physician proceeds with a focal neurologic examination. In testing the child’s reflexes, which of the following nerves would carry afferent impulses of the cremasteric reflex?
(A) Subcostal nerve
(B) Lateral femoral cutaneous nerve 
(C) Genitofemoral nerve
(D) Iliohypogastric nerve
(E) Femoral nerve

Answer 13

13. The answer is C. Genitofemoral nerve
    Stimulation of the cremaster muscle draws the testis up from the scrotum toward the superficial inguinal ring. The efferent limb of the reflex arc is the genital branch of the genitofemoral nerve, whereas the afferent limb is the femoral branch of the genitofemoral nerve. The other nerves are not involved in the cremasteric reflex.

Question 14

14. A 21-year-old man receives a penetrating knife wound in the abdomen and is injured in both the superior mesenteric artery and the vagus nerve. Which portion of the colon would most likely be impaired by this injury?
(A) Ascending and descending colons 
(B) Transverse and sigmoid colons
(C) Descending and sigmoid colons 
(D) Ascending and transverse colons 
(E) Transverse and descending colons

Answer 14

14. The answer is D. Ascending and transverse colons

The ascending and transverse colons receive blood from the superior mesen- teric artery and parasympathetic nerve fibers from the vagus nerve. However, the descending and sigmoid colons receive blood from the inferior mesenteric artery and the parasympathetic nerve fibers from the pelvic splanchnic nerve arising from sacral spinal nerves (S2–S4).

Question 15

15. A 42-year-old man with portal hypertension secondary to cirrhosis of the liver and subsequent massive ascites presents to the emergency department. He refuses to have a transjugular intrahepatic portosystemic shunt (TIPS) procedure and prefers surgery. Which of the following surgical connections is involved in the most practical method of shunting portal blood around the liver?
    (A) Superior mesenteric vein to the inferior mesenteric vein
    (B) Portal vein to the superior vena cava
    (C) Portal vein to the left renal vein
    (D) Splenic vein to the left renal vein
    (E) Superior rectal vein to the left colic vein

Answer 15

15. The answer is D. Splenic vein to the left renal vein

Portal hypertension can be reduced by diverting blood from the portal to the caval system. This is accomplished by connecting the splenic vein to the left renal vein or by creating a communication between the portal vein and the IVC. A connection between a hepatic vein and a branch of the portal vein can be accomplished by the transjugular intrahepatic portosystemic shunt (TIPS) procedure in the treatment of bleeding esophageal varices.

Question 16

16. A 78-year-old man is suffering from ischemia of the suprarenal glands. This condition results from rapid occlusion of direct branches of which of the following arteries?
    (A) Aorta, splenic, and inferior phrenic arteries
    (B) Renal, splenic, and inferior mesenteric
    arteries
    (C) Aorta, inferior phrenic, and renal arteries
    (D) Superior mesenteric, inferior mesenteric,
    and renal arteries
    (E) Aorta and hepatic and renal arteries

Answer 16

16. The answer is C. Aorta, inferior phrenic, and renal arteries

The suprarenal gland receives arteries from three sources. The superior suprarenal artery arises from the inferior phrenic artery, the middle suprarenal artery arises from the abdominal aorta, and the inferior suprarenal artery arises from the renal artery. The hepatic, superior mesenteric, inferior mesenteric, and splenic arteries do not supply the suprarenal gland.

Question 17

17. A radiograph of a 32-year-old woman reveals a perforation in the posterior wall of
    the stomach in which the gastric contents have spilled into the lesser sac. The general surgeon has opened the lienogastric (gastrosplenic) ligament to reach the lesser sac and notes erosion of the ulcer into an artery. Which of the follow- ing vessels is most likely involved?
    (A) Splenic artery
    (B) Gastroduodenal artery
    (C) Left gastric artery
    (D) Right gastric artery
    (E) Left gastroepiploic artery

Answer 17

17. The answer is E. Left gastroepiploic artery
    The left gastroepiploic artery runs through the lienogastric ligament, and hence, it is the artery most likely injured. The splenic artery is found in the lienorenal ligament. The right and left gastric arteries run within the lesser omentum. The gastroduodenal artery de- scends between the duodenum and the head of the pancreas.

Question 18

18. A 35-year-old woman with a history of cholecystectomy arrives in the emergency department with intractable hiccups most likely caused by an abdominal abscess secondary
    to surgical infection. Which of the following nerves carries pain sensation caused by irritation of the peritoneum on the central portion of the inferior surface of the diaphragm?
    (A) Vagus nerve
    (B) Lower intercostal nerve
    (C) Phrenic nerve
    (D) Greater splanchnic nerve
    (E) Subcostal nerve

Answer 18

18. The answer is C. Phrenic nerve
    The diaphragm receives somatic motor fibers solely from the phrenic nerves. However, the peritoneum on the central part of the diaphragm receives sensory fibers from the phrenic nerve, and the peripheral part of the diaphragm receives such fibers from the lower intercostal nerves. The subcostal nerve supplies the peritoneum inferior to the diaphragm. The vagus and greater splanchnic nerves do not carry pain fibers from the peritoneum.

Question 19

19. A 16-year-old boy with a ruptured spleen comes to the emergency department for splenectomy. Soon after ligation of the splenic artery just distal to its origin, a surgical resident observes that the patient is healing normally. Normal blood flow would occur in which of the following arteries?
(A) Short gastric arteries
(B) Dorsal pancreatic artery
(C) Inferior pancreaticoduodenal artery
(D) Left gastroepiploic artery
(E) Artery in the lienorenal ligament

Answer 19

19. The answer is C. Inferior pancreaticoduodenal artery

The inferior pancreaticoduodenal artery is a branch of the superior mesenteric artery. All of other arteries are branches of the splenic artery.

Question 20

20. A 9-year-old boy was admitted to the emergency department complaining of nausea, vomiting, fever, and loss of appetite. On examination, he was found to have tenderness and pain on the right lower quadrant. Based on signs and symptoms, the diagnosis of acute appendicitis was made. During an appendectomy performed at McBurney point, which of the fol- lowing structures is most likely to be injured?
(A) Deep circumflex femoral artery 
(B) Inferior epigastric artery
(C) Iliohypogastric nerve
(D) Genitofemoral nerve
(E) Spermatic cord

Answer 20

20. The answer is C. Iliohypogastric nerve
    The iliohypogastric nerve runs medially and inferiorly between the internal oblique and transverse abdominal muscles near the McBurney point, the point at the junction of the lateral one-third of the line between the anterior superior iliac spine and the umbilicus. Other structures are not found near the McBurney point.

Question 21

21. A 54-year-old man with a long history
    of alcohol abuse presents to the emergency department with rapidly increasing abdominal distention most likely resulting from an alteration in portal systemic blood flow. Which of the following characteristics is associated with the portal vein or the portal venous system?
    (A) Lower blood pressure than in the IVC
    (B) Least risk of venous varices because of portal hypertension
    (C) Distention of the portal vein resulting from
    its numerous valves
    (D) Caput medusae and hemorrhoids caused
    by portal hypertension
    (E) Less blood flow than in the hepatic artery

Answer 21

21. The answer is D. - Caput medusae and hemorrhoids caused by portal hypertension

Portal hypertension can cause esophageal varices, caput medusa, and hemorrhoids. The portal vein has higher pressure than systemic veins; the vein and its tributaries have no valves, or, if present, they are insignificant. In addition, the portal vein carries two to three times as much blood as the hepatic artery.

Question 22

22. While examining radiographs and angiograms of a 52-year-old patient, a physician is trying to distinguish the jejunum from the ileum. He has observed that the jejunum has:
    (A) Fewer plicae circulares
    (B) Fewer mesenteric arterial arcades
    (C) Less digestion and absorption of nutrients (D) Shorter vasa recta
    (E) More fat in its mesentery

Answer 22

22. The answer is B. The jejunum has fewer mesenteric arterial arcades but longer vasa recta than the ileum. The plicae circulares (circular folds) are tall and closely packed in the jejunum and are low and sparse in the ileum, and the lower part of the ileum has no plicae circulares. More digestion and absorption of nutrients occurs in the jejunum than in the ileum, and less fat is found in the mesentery of the jejunum.

Question 23

23. A 67-year-old woman with a long history of liver cirrhosis was seen in the emergency department. In this patient with portal hypertension, which of the following veins is most likely to be dilated?
(A) Right colic vein
(B) Inferior epigastric vein 
(C) Inferior phrenic vein
(D) Suprarenal vein
(E) Ovarian vein

Answer 23

23. The answer is A. Right colic vein

The right colic vein belongs to the portal venous system and empties into the superior mesenteric vein, which joins the splenic vein to form the portal vein. The inferior epi- gastric, inferior phrenic, suprarenal, and ovarian veins belong to the systemic (or caval) venous system and drain directly or indirectly into the IVC.

Question 24

24. A 26-year-old patient is admitted to a local hospital with a retroperitoneal infection. Which of the following arteries is most likely to be infected?
(A) Left gastric artery
(B) Proper hepatic artery
(C) Middle colic artery
(D) Sigmoid arteries
(E) Dorsal pancreatic artery

Answer 24

24. The answer is E. Dorsal pancreatic artery

The pancreas is a retroperitoneal organ, except for a small portion of its tail. The dorsal pancreatic artery would be the infected artery because it arises from the splenic artery and runs retroperitoneally along the superior border of the pancreas behind the peritoneum. The other arteries run within layers of the peritoneum. The left gastric arteries run within the lesser omentum; the proper hepatic artery runs within the free margin of the lesser omentum; the middle colic artery runs within the transverse mesocolon; the sigmoid arteries run within the sigmoid mesocolon.

Question 25

25. A pediatric surgeon has resected a structure that is a fibrous remnant of an embryonic or fetal artery in a 5-year-old child. Which of the following structures is most likely to be divided?
(A) Lateral umbilical fold
(B) Medial umbilical fold
(C) Median umbilical fold
(D) Ligamentum teres hepatis
(E) Ligamentum venosum

Answer 25

25. The answer is B. Medial umbilical fold
    The medial umbilical fold or ligament contains a fibrous remnant of the umbilical artery. The median umbilical fold contains a fibrous remnant of the urachus. The lateral umbilical fold (ligament) contains the inferior epigastric artery and vein, which are adult blood vessels. The ligamentum venosum contains a fibrous remnant of the ductus venosus, and the ligamentum teres hepatic contains a fibrous remnant of the left umbilical vein.

Question 26

26. A 57-year-old patient has a tumor in the body of the pancreas that obstructs the inferior mesenteric vein just before joining the splenic vein. Which of the following veins is most likely to be enlarged?
(A) Middle colic vein
(B) Left gastroepiploic vein
(C) Inferior pancreaticoduodenal vein
(D) Ileocolic vein
(E) Left colic vein

Answer 26

26. The answer is E. Left colic vein

The left colic vein is a tributary of the inferior mesenteric vein. The middle colic, inferior pancreaticoduodenal, and ileocolic veins drain into the superior mesenteric vein. The left gastroepiploic vein empties into the splenic vein.

Question 27

27. An elderly man with prostatic hypertrophy returns to his urologist with another case of epididymitis. An acute infection involving the dartos muscle layer of the scrotum most likely leads to an enlargement of which of the following lymph nodes?
(A) Preaortic nodes
(B) Lumbar nodes
(C) External iliac nodes
(D) Superficial inguinal nodes
(E) Common iliac nodes

Answer 27

27. The answer is D. Superficial inguinal nodes

The superficial inguinal lymph nodes receive lymph from the scrotum, penis, buttocks, and lower part of the anal canal, and their efferent vessels enter primarily to the ex- ternal iliac nodes and ultimately to the lumbar (aortic) nodes. The deep inguinal nodes receive lymph from the testis and upper parts of the vagina and anal canal, and their efferent vessels enter the external iliac nodes.

Question 28

28. A patient with cirrhosis is scheduled for liver transplant surgery. During the operation rounds, the transplant physician explains to his residents that one of the reasons a surgeon must pay close attention to the anatomic location of the liver is that this organ:
    (A) Receives blood only from the hepatic arteries
    (B) Manufactures red blood cells in an adult
    (C) Drains bile from the quadrate lobe into the
    right hepatic duct
    (D) Drains venous blood into the hepatic veins
    (E) Functions to concentrate and store bile

Answer 28

28. The answer is D. Drains venous blood into the hepatic veins

The liver receives blood from the hepatic artery and portal vein and drains its venous blood into the hepatic veins. The liver manufactures red blood cells in the fetus. The liver plays important roles in bile production and secretion. The quadrate lobe drains bile into the left hepatic duct, not the right hepatic duct, whereas the caudate lobe drains bile into the right and left hepatic ducts. The gallbladder functions to concentrate and store bile.

Question 29

29. A 41-year-old woman is brought to the emergency department by her family because of acute onset of right upper quadrant pain, nausea, and vomiting. For this case, it is important to remember that the bile duct:
    (A) Drains bile into the second part of the duodenum
    (B) Can be blocked by cancer in the body of the pancreas
    (C) Joins the main pancreatic duct, which carries hormones
    (D) Is formed by union of the right and left hepatic duct
    (E) Lies posterior to the portal vein in the right free edge of the lesser omentum

Answer 29

29. The answer is A. Drains bile into the second part of the duodenum

The bile duct is formed by union of the common hepatic and cystic ducts, lies lateral to the proper hepatic artery and anterior to the portal vein in the right free margin of the lesser omentum, traverses the head of the pancreas, and drains bile into the second part of the duodenum at the greater papilla. The endocrine part of the pancreas secretes the hormones insulin and glucagon, which are transported through the bloodstream. The main pancreatic duct carries pancreatic juice containing enzymes secreted from the exocrine part of the pancreas.

Question 30

30. A patient with diverticulosis of the colon presents for follow-up to his primary care physician with ongoing complaints of left lower quadrant pain and occasionally bloody stools. His physician begins workup with appropriating test by recalling that the sigmoid colon:
    (A) Is drained by systemic veins
    (B) Is a retroperitoneal organ
    (C) Receives parasympathetic fibers from the vagus nerve
    (D) Receives its blood from the superior mesenteric artery
    (E) Has teniae coli and epiploic appendages

Answer 30

30. The answer is E. Has teniae coli and epiploic appendages
    The sigmoid colon has teniae coli and epiploic appendages. The sigmoid colon receives blood from the inferior mesenteric artery, drains its venous blood through the portal tributaries, has its own mesentery (sigmoid mesocolon, therefore, is not a retroperitoneal organ), and receives parasympathetic preganglionic fibers from the pelvic splanchnic nerve.

Question 31

31. A 19-year-old man with a ruptured appendix is sent to the emergency department for surgery. To cut off the blood supply to the appendix (if collateral circulation is dis- counted), a surgeon should ligate which of the following arteries?
(A) Middle colic artery
(B) Right colic artery
(C) Ileocolic artery
(D) Inferior mesenteric artery
(E) Common iliac artery

Answer 31

31. The answer is C. Ileocolic artery
    The appendicular artery is a branch of the ileocolic artery. The other arteries do not supply the appendix. The middle colic and right colic arteries are branches of the supe- rior mesenteric artery. The inferior mesenteric artery passes to the left behind the peritoneum and distributes to the descending and sigmoid colons and the upper portion of the rectum. The common iliac arteries are bifurcations from the aorta.

Question 32

32. Because of an inflammatory bowel disease (Crohn disease) and a small bowel obstruction leading to bowel ischemia, an elderly woman requires bypass of her ileum and jejunum and is scheduled for a gastrocolostomy. The sur- geon will ligate all arteries that send branches to the stomach. Which of the following arteries may be spared?
(A) Splenic artery
(B) Gastroduodenal artery
(C) Inferior pancreaticoduodenal artery 
(D) Left gastroepiploic artery
(E) Proper hepatic artery

Answer 32

32. The answer is C. Inferior pancreaticoduodenal artery

The inferior pancreaticoduodenal artery does not supply the stomach. All of the other arteries supply the stomach. Gastrocolostomy is used to establish a communication between the stomach and colon, bypassing the small intestine when the patient has Crohn dis- ease (inflammation disease) and small bowel obstruction.

Question 33

33. A 38-year-old woman with peptic ulcer disease of the stomach experiences severe abdominal pain. Which of the following nervous structures is most likely involved?
(A) Greater splanchnic nerve
(B) Ventral roots of the spinal nerve 
(C) Lower intercostal nerve
(D) Vagus nerve
(E) Gray ramus communicans

Answer 33

33. The answer is A. Greater splanchnic nerve

The greater splanchnic nerve carries pain fibers from the upper GI tract. Neither the ventral roots of the spinal nerves nor the gray rami communicantes contain sensory nerve fibers. The vagus nerve contains sensory fibers associated with reflexes, but it does not contain pain fibers. The lower intercostal nerves carry general somatic afferent (GSA) pain fibers from the diaphragm, abdominal wall, and peritoneum but not GVA pain fibers from the GI tract.

Question 34

34. A 3-year-old boy is diagnosed as having a persistent processus vaginalis in its middle portion. Which of the following conditions is most likely to be associated with this developmental anomaly?
(A) Direct inguinal hernia
(B) Gubernaculum testis
(C) Hematocele
(D) Hydrocele
(E) Cryptorchidism

Answer 34

34. The answer is D. Hydrocele
    If a middle portion of the processus vaginalis persists, it forms a congenital hydrocele. If the entire processus vaginalis persists, it develops a congenital indirect inguinal hernia. Gubernaculum testis is the fetal ligament that connects the bottom of the fetal testis to the developing scrotum. Hematocele is an effusion of blood into the cavity of the tunica vagina- lis. Cryptorchidism is failure of the testis to descend from the abdomen to the scrotum.

Question 35

35. Examination of a 54-year-old man reveals an isolated tumor located at the porta hepatis. This tumor most likely compresses which of the following structures?
(A) Cystic duct
(B) Hepatic veins
(C) Common hepatic artery
(D) Left gastric artery
(E) Branches of the portal vein

Answer 35

35. The answer is E. Branches of the portal vein
    The porta hepatis is the transverse fissure (doorway) in the liver and contains the hepatic ducts, hepatic arteries, and branches of the portal vein. The other structures are not found in the porta hepatis.

Question 36

36. A patient is rushed to the operating room for an emergent cholecystectomy (resection of a gallbladder) because of cholecystitis. While locating landmarks before surgical resection of an infected gallbladder, the surgeon recalls a portal–caval anastomosis. Which of the following pairs of veins form a portal–caval anastomosis?
    (A) Hepatic veins and IVC
    (B) Superior and middle rectal vein
    (C) Left and right gastric vein
    (D) Inferior and superficial epigastric veins
    (E) Suprarenal and renal veins

Answer 36

36. The answer is B. Superior and middle rectal vein

Portal–caval anastomoses occur between the left gastric vein and esophageal vein of the azygos, the superior rectal and middle or inferior rectal veins, paraumbilical and superficial epigastric veins, and retrocolic veins and twigs of the renal vein. The hepatic veins and the IVC are systemic or caval veins. The left and right gastric veins belong to the portal venous system. The inferior and superficial epigastric veins and the suprarenal and renal veins are systemic veins.

Question 37

37. Mrs. Jones is undergoing a routine colonos- copy for colon cancer prevention. The gastroen- terologist finds a Meckel diverticulum. Which of the following statements is true about the diverticulum?
    (A) It is found 2 ft distal to the ileocecal junction
    (B) It is located on the mesenteric side of the ileum
    (C) It occurs in approximately 20% of the population
    (D) It is a persistent remnant of the embryonic yolk stalk
    (E) It may contain renal and suprarenal tissues

Answer 37

37. The answer is D. It is a persistent remnant of the embryonic yolk stalk

The Meckel diverticulum is a persistent remnant of the yolk stalk (vitelline duct) and located 2 ft proximal to the ileocecal junction on the antimesenteric border of the ileum. It is approximately 2 in. long, occurs in approximately 2% of the population, and contains two types of mucosal (gastric and pancreatic) tissues in its wall.

Question 38

38. A 54-year-old man comes to a hospital with abdominal pain, jaundice, loss of appetite, and weight loss. On examination of his radiograms and CT scans, a physician finds a slowly growing tumor in the uncinate process of the pancreas. Which of the following structures is
most likely compressed by this tumor?
(A) Main pancreatic duct
(B) Splenic artery
(C) Portal vein
(D) Superior mesenteric artery
(E) Superior pancreaticoduodenal artery

Answer 38

38. The answer is D. Superior mesenteric artery

The uncinate process of the pancreas is a projection of the lower part of its head to the left behind the superior mesenteric vessels. The superior pancreaticoduodenal artery runs between the duodenum and the head of the pancreas. The main pancreatic duct runs transversely through the entire pancreas superior to the uncinate process. The splenic artery runs along the superior border of the pancreas. The portal vein runs behind the neck of the pancreas

Question 39

39. A 6-year-old boy comes to his pediatrician with a lump in the groin near the thigh and pain in the groin. On examination, the physician makes a diagnosis of a direct inguinal hernia because the herniated tissue:
    (A) Enters the deep inguinal ring
    (B) Lies lateral to the inferior epigastric artery
    (C) Is covered by spermatic fasciae
    (D) Descends into the scrotum
    (E) Develops after birth

Answer 39

39. The answer is E. Develops after birth
    A direct hernia is acquired (develops after birth), whereas an indirect inguinal hernia is congenital. The direct hernia does not enter the deep inguinal ring but occurs through the posterior wall of the inguinal canal, lies medial to the inferior epigastric artery, is covered only by peritoneum, and does not descend into the scrotum.

Question 40

40. A 21-year-old man developed a hernia after lifting heavy boxes while moving into his new house. During the repair of his resulting hernia, the urologist recalls that the genitofemoral nerve:
    (A) Runs in front of the quadratus lumborum (B) Is a branch of the femoral nerve
    (C) Supplies the testis
    (D) Passes through the deep inguinal ring
    (E) Gives rise to an anterior scrotal branch

Answer 40

40. The answer is D. Passes through the deep inguinal ring

The genitofemoral nerve descends on the anterior surface of the psoas muscle and gives rise to a genital branch, which enters the inguinal canal through the deep inguinal ring to supply the cremaster muscle, and a femoral branch, which supplies the skin of the femoral triangle. The genitofemoral nerve is not a branch of the femoral nerve but arises from the lumbar plexus and does not supply the testis. It is the ilioinguinal nerve that gives rise to an anterior scrotal branch.

Question 41

41. An oncologist is reviewing a CT scan of a 74-year-old man with newly diagnosed hepa- tocellular carcinoma. He locates the affected quadrate lobe of the liver that:
    (A) Lies between the IVC and ligamentum venosum
    (B) Receives blood from the right hepatic artery
    (C) Drains bile into the left hepatic duct
    (D) Is a medial superior segment
    (E) Is functionally a part of the right lobe

Answer 41

41. The answer is C. Drains bile into the left hepatic duct

The quadrate lobe of the liver drains bile into the left hepatic duct and receives blood from the left hepatic artery. It lies between the gallbladder fossa and the ligamentum teres hepatic, is a medial inferior segment, and is a part of the left lobe.

Question 42

42. A 58-year-old man is presented with edema of the lower limb and enlarged superficial veins of the abdominal wall. Examination of radiographs and angiograms reveals obstruction of the IVC just proximal
    to the entrance of the renal vein. This venous blockage may result in dilation of which of the following veins?
    (A) Left suprarenal vein
    (B) Right inferior phrenic vein
    (C) Right hepatic vein
    (D) Left gastric vein
    (E) Portal vein

Answer 42

42. The answer is A. Left suprarenal vein

The veins distal to obstruction are dilated, but the veins proximal to obstruction are not dilated but have low blood pressure. The suprarenal vein drains into the left renal vein and thus is dilated because of high pressure. The right phrenic and right hepatic veins drain into the IVC above the obstruction. The left gastric vein joins the portal vein, which enters the liver.

Question 43

43. A physical fitness trainer for a young Hollywood movie star explains the reasons for
    100 stomach crunches a day. The young star,
    a medical student before ‘hitting it big,’ reaffirms to his trainer that the lateral margin of the rectus abdominis, the muscle responsible for a washboard stomach, defines which of the following structures?
    (A) Linea alba
    (B) Linea semilunaris
    (C) Linea semicircularis
    (D) Transversalis fascia
    (E) Falx inguinalis

Answer 43

43. The answer is B. Linea semilunaris

The linea semilunaris is a curved line along the lateral border of the rectus abdominis. The linea alba is a tendinous median raphe between the two rectus abdominis muscles. The linea semicircularis is an arcuate line of the rectus sheath, which is the lower limit of the posterior layer of the rectus sheath. The falx inguinalis (conjoint tendon) is formed by aponeuroses of the internal oblique and transverse abdominal muscles (otherwise known as the transversalis fascia).

Question 44

44. During surgical treatment of portal hypertension in a 59-year-old man with liver cirrhosis, a surgeon inadvertently lacerates the dilated paraumbilical veins. The veins must be repaired to allow collateral flow. Which of the following ligaments is most likely severed?
(A) Lienorenal ligament
(B) Lienogastric ligament
(C) Gastrophrenic ligament
(D) Ligamentum teres hepatis
(E) Ligamentum venosum

Answer 44

44. The answer is D. Ligamentum teres hepatis

The paraumbilical veins and the ligamentum teres hepatis are contained in the free margin of the falciform ligament. The lienorenal ligament contains the splenic vessels and a small portion of the tail of the pancreas. The lienogastric ligament contains the left gastroepiploic and short gastric vessels. The gastrophrenic ligament contains no named structures. The hepatoduodenal ligament, a part of the lesser omentum, contains the bile duct, proper hepatic artery, and portal vein in its free margin.

Question 45

45. A 43-year-old woman is admitted to the hospital because of deep abdominal pain in her epigastric region. On examination, it is observed that a retroperitoneal infection erodes an artery that runs along the superior border of the pancreas. Which of the following arteries is likely injured?
(A) Right gastric artery
(B) Left gastroepiploic artery
(C) Splenic artery
(D) Gastroduodenal artery
(E) Dorsal pancreatic artery

Answer 45

45. The answer is C. Splenic artery

The splenic artery arises from the celiac trunk, runs along the superior border of the pancreas, and enters the spleen through the lienorenal ligament and the hilus of the spleen. The right gastric artery runs along the lesser curvature of the stomach, and the left gastroepiploic artery runs along the greater curvature of the stomach. The gastroduodenal artery runs behind the first part of the duodenum. The dorsal pancreatic artery descends behind the neck of the pancreas and divides into right and left branches to supply the pancreas.

Question 46

46. A 19-year-old young woman with a long history of irritable bowel syndrome presents for the possibility of surgical resection of the gastrointestinal (GI) tract where the vagal parasympathetic innervation terminates. Which of the following sites is most appropriate for surgical resection?
(A) Duodenojejunal junction
(B) Ileocecal junction
(C) Right colic flexure
(D) Left colic flexure
(E) Anorectal junction

Answer 46

46. The answer is D. Left colic flexure

The vagus nerve supplies parasympathetic nerve fibers to the GI tract and terminates approximately at the left colic flexure (junction of the transverse colon and the descending colon). The duodenojejunal junction, ileocecal junction, and right colic flexure are supplied by the vagus nerve. The descending colon, sigmoid colon, rectum, anal canal, and anorectal junction are supplied by the pelvic splanchnic nerve for parasympathetic innervation.

Question 47

47. A 58-year-old man is admitted to the hospital with severe abdominal pain, nausea, and vomiting resulting in dehydration. Emergency CT scan reveals a tumor located between the celiac trunk and the superior mesenteric artery. Which of the following structures is likely compressed by this tumor?
(A) Fundus of the stomach
(B) Neck of the pancreas
(C) Transverse colon
(D) Hepatopancreatic ampulla 
(E) Duodenojejunal junction

Answer 47

47. The answer is B. Neck of the pancreas
    The pyloric canal and the neck of the pancreas are situated anterior to the abdominal aorta between the origin of the celiac trunk and the superior mesenteric artery. The transverse colon passes anterior to the superior mesenteric artery and the third part of the duodenum. The other structures are not located in front of the aorta.

Question 48

48. An emergent hernia repair is scheduled. As the attending physician is driving to the hospital, the medical student assisting on the case quickly reviews his anatomy atlas and is trying to commit to memory that the internal oblique abdominis muscle contributes to the formation of which of the following structures?
(A) Inguinal ligament
(B) Deep inguinal ring
(C) Falx inguinalis (conjoint tendon) 
(D) Internal spermatic fascia
(E) Reflected inguinal ligament

Answer 48

48. The answer is C. Falx inguinalis (conjoint tendon)

The falx inguinalis (conjoint tendon) is formed by the aponeuroses of the internal oblique and transverse muscles of the abdomen. The inguinal ligament is formed by aponeurosis of the external oblique abdominal muscle, and the reflected inguinal ligament is formed by certain fibers of the inguinal ligament reflected from the pubic tubercle upward towards the linea alba. The deep inguinal ring lies in the transversalis fascia, and the internal sper- matic fascia is formed by the transversalis fascia

Question 49

49. A 9-year-old girl has crashed into her neighbor’s brick fence while riding her bike and is brought to the emergency department with a great deal of abdominal pain. Her radiogram and angiogram show laceration of the superior mesenteric artery immediately distal to the origin of the middle colic artery. If collateral circulation is discounted, which of the following organs may become ischemic?
(A) Descending colon 
(B) Duodenum
(C) Pancreas
(D) Ascending colon 
(E) Transverse colon

Answer 49

49. The answer is D. Ascending colon
    The right colic and ileocolic arteries arise from the superior mesenteric artery distal to the origin of the middle colic artery. The right colic artery may arise from the ileocolic artery and supplies the ascending colon. The duodenum and pancreas receive blood from the inferior pancreaticoduodenal artery and superior pancreaticoduodenal artery. The pancreas
    is also supplied by the splenic artery of the celiac trunk. The transverse colon receives blood from the middle colic artery. The descending colon is supplied by the left colic artery, which is a branch of the inferior mesenteric artery.

Question 50

50. A 53-year-old woman with known kidney disease presents to a hospital because her pain has become increasingly more severe. A physician performing kidney surgery must remember that:
    (A) The left kidney lies a bit lower than the right one
    (B) The perirenal fat lies external to the renal fascia
    (C) The renal fascia does not surround the suprarenal gland
    (D) The left renal vein runs anterior to both the aorta and the left renal artery
    (E) The right renal artery is shorter than the left renal artery

Answer 50

50. The answer is D. The left renal vein runs anterior to both the aorta and the left renal artery

The left renal vein runs anterior to both the aorta and the left renal artery. The renal fascia lies external to the perirenal fat and internal to the pararenal fat, and it also sur- rounds the suprarenal gland. The right renal artery runs behind the IVC and is longer than the left renal artery. Because of the large size of the right lobe of the liver, the right kidney lies a little lower than the left kidney

Question 51

51. A neonatal baby was born with diabetes mellitus due to an inadequate production of insulin. Cells in the endocrine portion of the pancreas that secrete insulin, glucagon, and somatostatin are derived from which of the following?
(A) Ectoderm
(B) Mesoderm
(C) Endoderm
(D) Proctodeum
(E) Neural crest cells

Answer 51

51. Answer is C. Endoderm
    Cells in the islets of Langerhans, an endocrine portion of the pancreas, are de- rived from the endoderm of the caudal foregut (from the liver diverticulum). Proctodeum is an invagination of the ectoderm of the terminal part of the hindgut.

Question 52

52. During development, the midgut artery appears to be markedly narrowed at its origin. Which of the following structures is derived from the midgut and may receive inadequate blood supply?
(A) Gallbladder
(B) Stomach
(C) Descending colon
(D) Ascending colon
(E) Rectum

Answer 52

52. Answer is D. Ascending colon
    The ascending colon is derived from the midgut. The gallbladder and stomach are
    derived from the foregut, and the descending colon and rectum are derived from the hindgut.

Question 53

53. A 3-year-old boy is admitted to the children’s hospital with complaints of restlessness, abdominal pain, and fever. An MRI examination reveals that he has a double ureter. Which of the following embryonic structures is most likely failed to develop normally?
(A) Mesonephric (Wolffian) duct
(B) Paramesonephric (Müllerian) duct
(C) Ureteric bud
(D) Metanephros
(E) Pronephros

Answer 53

53. Answer is C. Ureteric bud

The ureteric bud is an outgrowth of the mesonephric duct and develops into the ureter, renal pelvis, calyces, and collecting tubules. However, a bifurcated ureteric bud results in a partial duplication (bifid) of the ureter, whereas two separate ureteric buds result in a complete duplication. Mesonephric duct forms efferent ductules, epididymal duct, ductus deferens, ejaculatory duct, and seminal vesicles. Paramesonephric duct regress and its vestigial remnants form the appendix testis. Metanephros develops into the adult kidney. Pronephros degenerates and never forms functional nephrons.

Question 54

54. A neonate has a small reducible protrusion through a defined ring at the umbilicus. His pediatrician indicates to the parents that this will likely close spontaneously. Which of the following congenital malformations is present?
(A) Umbilical hernia
(B) Symptomatic patent urachus
(C) Patent omphalomesenteric duct
(D) Omphalocele
(E) Gastroschisis

Answer 54

54. The answer is A. Umbilical hernia

In most case, an umbilical hernia closes spontaneously by age 4 and requires no surgery unless there is incarceration. A symptomatic patent urachus (drainage of urine at the umbilicus) is typically surgically excised. A patent omphalomesenteric duct (Meckel diverticulum) is promptly repaired to minimize the potential for intestinal obstruction or prolapse. Omphalocele and gastroschisis are defects that require surgical repair.

Question 55

55. Which structure is hematopoietic in early life and later destroys worn-out red blood cells?

Answer 55

55. The answer is E.
    The spleen lies in the left hypochondriac region, is hematopoietic in early life, and later functions in worn-out red blood cell destruction. It filters blood, stores red blood cells, and produces lymphocytes and antibodies.

Question 56

56. Which structure runs along the superior border of the pancreas and enters the lienorenal ligament?

Answer 56

56. The answer is D.
    The splenic artery is a branch of the celiac trunk, follows a tortuous course along the superior border of the pancreas, and divides into several branches that run through the lienorenal ligament.

Question 57

57. Which structure is divided into the proper hepatic and gastroduodenal arteries?

Answer 57

57. The answer is A.

The common hepatic artery is divided into the proper hepatic and gastroduodenal arteries.

Question 58

58. Which structure provides an attachment of the suspensory muscle of the duodenum (ligament of Treitz)?

Answer 58

58. The answer is B.
    The duodenojejunal flexure is supported by a fibromuscular band called the suspensory ligament of the duodenum (ligament of Treitz), which is attached to the right crus of the diaphragm.

Question 59

59. Which structure is retroperitoneal in position and receives blood from the splenic artery?

Answer 59

59. The answer is C.
    The pancreas is an endocrine and exocrine gland; is retroperitoneal in position; and receives blood from the splenic, gastroduodenal, and superior mesenteric arteries.

Question 60

60. Which structure is a direct branch of the aorta and supplies blood to the ascending and transverse colons?

Answer 60

60. The answer is D.

The superior mesenteric artery, a direct branch of the aorta, supplies blood to the ascending and transverse colons.

Question 61

61. Which structure receives blood from the liver and kidney and enters the thorax by pierc- ing the central tendon of the diaphragm?

Answer 61

61. The answer is B.
    The IVC, which receives blood from the liver, kidneys, and other abdominal structures, enters the thorax through the vena caval foramen to empty into the right atrium.

Question 62

62. Which structure receives bile, concentrates it by absorbing water and salt, and stores it?

Answer 62

62. The answer is A.

The gallbladder receives bile, concentrates it by absorbing water and salt, and stores it.

Question 63

63. Which structure receives blood from the left gonad and suprarenal gland?

Answer 63

63. The answer is E.
    The left renal vein runs anterior to the aorta but posterior to the superior mes- enteric artery and receives blood from the gonad and suprarenal gland.

Question 64

64. Which structure receives blood from the portal vein?

Answer 64

64. The answer is C.

The liver receives venous blood from the portal vein and arterial blood from the hepatic arteries.