Doctors Academy - Abdomen and Pelvis COPY Flashcards
What structures are found in the transpyloric plane?
- end of spinal cord
- L1 vertebral body
- origin of SMA (superior mesenteric artery)
- origin of portal vein
- neck of pancreas
- pylorus of stomach
- 2nd part of duodenum
- sphincter of oddi
- hylum of each kidney
- DJ flexure
- splenic flexure
- route of the transverse mesentery
- fundus of the gall bladder
- tips of 9th costal cartilages
- hilum of spleen
What structures are found in the Obturator Foreman?
- Obturator vein
- obturator artery
- obturator nerve
What structure divides the greater sciatic foremen in to two?
The Piriformis muscle
What structures pass through the greater sciatic foraman
Suprapiriform foramen:
- Superior gluteal artery, vein & nerve
Infrapiriform foramen: (PPIINNS)
- Pudendal nerve
- Posterior femoral cutaneous nerve
- Inferior gluteal vessels (artery and vein) and nerve
- Internal pudendal vessels (artery and vein)
- Nerve to obturator internus
- Nerve to quadratus femoris
- Sciatic nerve
What structures pass through the lesser sciatic foraman?
- Pudendal nerve
- Internal Pudendal Artery and Vein
- Nerve to obturator internus
- Tendon of the Obturator Inernus
PINT
Which structures pass through both the greater and lesser sciatic foraman?
- Pudendal nerve
- Internal pudendal artery
- Nerve to obturator internus
What structures are found within the pudendal canal?
- Inferior rectal nerve
- Perineal nerve
- dorsal nerve of the penis / clitoris
- pudendal artery
NB: these are all branches of the pudendal nerve
Diaphragm Openings
What structures pass through the diaphragm at T8
- IVC
- Right phrenic Nerve
Diaphragm Openings
What structures pass through the diaphragm at T10
- Oesophagus
- Posterior vagal trunk
- hemiazygous vein
- Lesser Splenic Artery
Diaphragm Openings
What structures pass through the diaphragm at T12
- Aorta
- Thoracic Duct
What is the blood supply to the diaphragm
- superior phrenic artery
- inferior phrenic artery
- pericardiophernic artery
- musculophernic artery
Where in the diaphragm are Bochdalek and Morgagni hernias found
Bochdalek:
- Left posterior diaphragm
Morgangni:
- Right anterior diaphragm
Hernia’s
Descibe the following hernias:
- Littres
- Spigelian
- Richters
- Panaloon
- Maydls
Littres - Contains a meckles diverticulum
Spigelian - found at the junction of the semilunaris
Richters - protrusion of the anti mesenteric small bowel
Pantaloon - both a direct and an indirect hernia on the same side
Maydls - Contains two loops of bowl and another loop of bowel on the inside
What abdominal layers would you go through in a pfannenstiel incision
- Skin
- subcutaneous fascia
- anterior rectus sheath
- rectus abdominis
- pyramidalis
- transversalis fascia
- pre and para vesical spaces
- peritoneum
what abdominal layers would you go through in a lanz incision
Skin, SC Fascia, external oblique, internal oblique, transverse abdominus, transversalis fascia, pre preitoneal fat, perioneum
where is the location of the deep inguinal ring
1.5cm above the mid point of the inguinal ligament
what is the hasslebachs triangle and what are its boarders
it is the weakest part of the abdominal wall as there is no rectus sheath.
Boarders:
Medially: Rectus abdominus
Laterally: Inferior epigastric vessels
Inferiorally: Inguinal Ligament
What are the boarders of the inguinal canal
The borders of the inguinal canal can be recalled using the mnemonic MALT:2
Roof (Muscles): Transversus abdominis muscle, internal oblique muscle
Anterior wall (Apeunerosis): Aponeurosis of the internal and external oblique muscle
Floor (Ligaments): Inguinal ligament, lacunar ligament
Postior wall (T’s): Conjoint tendon, transversalis fascia
What is the contents of the inguinal canal
- Ilioinguinal nerve
- Genital branch of the genitofemoral nerve
- The round ligament of the uterus (Females)
- Spermatic cord (Males)
Extra:
Spermatic Cord contents:
3 fascial layers: external spermatic fascia, cremasteric fascia/ muscle, internal spermatic fascia
3 arteries: artery to vas (ductus) deferens, cremasteric artery, testicular artery
3 nerves: ilioinguinal nerve, genital branch of genitofemoral, sympathetic and visceral afferent nerve fibres
3 other: pampiniform plexus, vas deferens, testicular lymphatics
which ligament supplies the most support to the uterus
Transverse Ligament
what is the innervation of the scrotal skin?
Anterior:
- Ilioinguinal Nerve
- Genital nerve or the genitofemoral nerve
Posterior:
- Pudendal
which nerves are responsible for the cremasteric reflex (L1)
- Ilioinguinal Nerve
- Genital branch of the genitofemoral
list the retroperitoneal structures
SAD PUCKER
- Suprarenal (Adrenal) Glands
- Aorta
- Duodenum (parts 2/3)
- Pancreas (Appart from the tail, thats intraoperitoneal)
- Ureters
- Colon (Assecnding and descending)
- Kidneys
- Esophagus
- Rectum (Lower part)
what are the boarders of callots triangle and what does it contain
Boarders:
Superior: Livery
Medial: Common hepatic Duct
Lateral: Cystic Duct
Contents:
- Cystic Artery
- Right hepatic artery
- Sentinile lymph node
what is the blood supply of the CBD
- Gastroduodenal artery
- retroduodenal artery
- right hepatic artery
what are the layers of the scrotum? Also, these layers are continuation of abdominal fascia, for each name the abdominal fascia they are a continuation of.
Scrotal Layers (Abominal layers are in brackets):
Some Damn Englishman Called It the Testes
- Skin (N/A)
- Dartos (scarpas fascia)
- External Spermatic fascia (External Oblique)
- Cremastieric Spermatic Fascia (Internal Oblique)
- Internal Spermatic Fascia (Transversalis fascia )
- Tunica Vaginalis (Peritoneum)
- Tunica Alberginea
what nerves control acid secreition of the stomach
vagus nerve - causes acid secreion
Greater / lesser spanchlic nerves + hypogastric plexus - decrease acid secretion
What are some of the classic complications of a whipples?
- Delayed gastric emptying
- dumping syndrome
- brittle diabetes
- pancreatic fistula
Which part of the pancreas has the highest concentration of langerhans cells
The tail of the pancreas
which genetic mutation is associated with hereditory pancreatitis
SPINK1
which part of the gastrointestinal tract contains brunners glands
Duodenum
what types of mucosa are the most common in meckles diverticulum
Meckles are most commonly lined with ideal mucosa
they can also contain gastric and pancreatic mucosa
what cells line the epithelium of the majority of the GI tract and what are the exceptions
Most of the GI tract is columnar appart from Oesophagus and anal canal which is squamous
What are the branches of the SMA
- Iliocolic artery
- right colic
- middle colic artery
- inferior pancreatodudenum
- jejunal
- ileal
what are the branches of the IMA
- Left colic
- Sigmoid
- Superior rectal artery
What is the only structure the ureters cross?
RULE: the ureters are always crossed by other structures, appart from when it crosses the common ileac
what is the order of structures in the hilum of the kidney (anterior to postior)
Renal vein, renal artery, ureter
what structures join the IVC directly and what structures join the portal system
Join IVC:
- Renals (including suprarenals)
- gonadals
- Lumbar
- Left hepatic
- Right Hepatic
Join Portal System:
- SMV
- IMV
- Splenic Vein
- Gastric veins
- Hepatic portal vein (formed from Splenic, IMV, SMV and Gastric veins)
What is the blood supply and venous drainage of the adrenal glands?
Blood Supply:
- Superior suprarenal (inferior phrenic)
- middle suprarenal (aorta)
- inferior suprarenal (renal artery)
Venous drainage:
Right: Right adrenal vein (IVC)
Left: Left adrenal vein (left renal vein)
what is the blood suppply and venous drainage of the rectum?
Arterial Supply:
- Superior rectal (IMA)
- Middle rectal (Internal Ileac)
- Inferior rectal (Internal pudendal, branch of the internal ileac)
Venous Supply:
- IMV
- Internal Ileac
what is the site of absorbtion of vitamin B12 and Folate in the GI tract
distal ileum
What do the following facia cover:
- Gerotas Fascia
- Waldeyers fascia
- colles fascia
- gallaudets fascia
- denovillers fascia
- sibsons fascia
- bucks fascia
- Gerotas = kidneys
- Waldeyers = pre sacral fascia (behind rectum - stopes infection spreading from the rectum to the spine)
- Colles = superficial fascia of the perineum
- Galleudets = deep peroneal fascia
- denovilliers - fascia between prostate and rectum
- sibsons - apex of lung
- bucks - deep fascia of the penis
at what anatomical location do the ureters enter the urinary bladder
posterolateral angles of the trigone of the bladder
which colonic polyps have the greatest malignant risk?
villous
What are the branches of the internal ileac?
- Inferior and superior vesical arteries (these give rise to artery to vas)
- Middle Rectal Artery
- Uterine artery
- Internal pudendal artery
- Obturator artery
- superior and inferior gluteal artery
- ileolumbar
- lateral sacral
Regions: buttock, inner leg, peroneum, bladder, uterus and rectum
What would be the cause of neurological signs + abdominal pain
Acute intermittent perforia or Lead poisoning
What is the urinary diagnostic marker for carcinoid syndrome?
5 hydroxidendolaecitic (5-HIAA)
What is SMA syndrome and what are the common symptoms?
This is where the 3rd part of the duodenum gets caught under the SMA
Symptoms:
- post prandial abdominal pain
- nausea and vommiting of partially digested food
- weight loss
- often relieved by lying prone or to the left
- high pitched bowel sounds
what is SMA stenosis and what are the common symptoms?
this is where you get calcification of the SMA.
Symptoms:
- hx of other vascular disease
- abdo pain about 1 hour after eating
What is the contents of the spermatic cord?
Spermatic Cord contents:
3 fascial layers: external spermatic fascia, cremasteric fascia/ muscle, internal spermatic fascia
3 arteries: artery to vas (ductus) deferens, cremasteric artery, testicular artery
3 nerves: ilioinguinal nerve, genital branch of genitofemoral, sympathetic and visceral afferent nerve fibres
3 other: pampiniform plexus, vas deferens, testicular lymphatics
What are the boarders of the femoral Triangle and what does it contain?
Boarders:
Roof: Fascia Lata
Floor: Pectineus, ileopsoas, adductor longus
Lateral: Sartorius
Medial: Adductor Longus
Superior: Inguinal Ligament
Contents:
- Femoral branch of the genitofemoral nerve
- femoral artery
- femoral vein
- femoral canal
What are the contents of the femoral canal?
lymphatics
What are the boarders of the Adductor canal?
Anteromedial: Sartorius.
Lateral: Vastus medialis.
Posterior: Adductor longus and adductor magnus.
What are the contents of the adductor canal?
- femoral artery
- femoral vein (posterior to the artery)
- nerve to the vastus medialis
- saphenous nerve
What are the boarders of the femoral canal?
Laterally: Femoral vein
Medially: Lacunar ligament
Anteriorly: Inguinal ligament
Posteriorly: Pectineal ligament
What is the gene associated with FAP Syndrome? and what are the symptoms?
Gene: APC gene
Features:
- Multiple Colonic polyps (adenoma)
- age of onset about 30 years old
What is the gene associated with Peuz-Jager syndrome? and what are the features?
Gene: STK11 gene
Features:
- Multiple benign harmatomas
- episodic obstruction and intersuseption
- increased risk of breast, ovarian, cervical,pancreatic and testicular cancer
What is the gene associated with Cowdan sydnrome? and what are the common features?
Gene: PTEN
Features:
- Multiple harmatomas + Trichlemmones (benign tumour from the outer root of the hair folicule)
- associated with breast and thryoid cancer.
What is the gene associated with Lynch syndrome? and what are the common features?
Gene: MMR / MSH2
Features:
- Fewer polyps
- Right sided colonic tumours
- Microsatallite instabilities
Associated with Endometrial, Gastric and pancreatic tumours
What is the gene associated with Li Fraumeni syndrome? and what are the common features?
Gene: P53
Features:
- asscoiated with sarcomas and leukemias + adrenal tumours
What are the features of gardeners sydnrome?
- Epidermoid cysts
- papillary thyroid cancers
- desmoid tumours
- osteomas and fibromas
A 34 year old lady undergoes an elective cholecystectomy for attacks of recurrent cholecystitis due to gallstones. Microscopic assessment of the gallbladder is most likely to show what?
Aschoff-Rokitansky sinuses
What symptoms do you get in plummer vincent syndrome?
- Iron deficient anemia
- Oesophageal webs
- dysphasia
From what cells do almost all pancreatic cancers arise?
Ductal epithelium
what is the blood supply of the pancreas
Head is supplied by the Pancreatoduodenal artery
Tail is supplied by the splenic artery
If you are presented with a child with abdominal pain, who has a high pitched screem and is drawing their legs up, what is your main differential?
Intersusseption
what are the two main differential diagnosis for painful PR Bleeding?
Anal fissure and rectal ulcer syndrome (here you will have an abraision)
if the question mentions Melanosis coli is present, what is this a sign of?
Laxitive abuse
What are some of the histological features of UC?
- Crypt Abcesses
- Pseudopolps
- mucosal islands
*
What is the surgical treatment for UC?
Panproctocolectomy + Ileostomy
where do the majority of gall bladder cancers arise?
in the fundus
what is the most common type of pancreatic cancer?
adenocarcinoma
what vaccinations are reuired post splenctomy?
- Haemopholis Influenza type B
- Menigiococal B
- Pneumococcal
- Influenza
what strucutres are at risk during caecal mobilisation?
gonadal vessels and ureters are most at risk of damge
What is the blood supply and venous drainage of the pancreas?
Arterial supply
Head: pancreaticoduodenal artery
Rest: splenic artery
Venous drainage
Head: superior mesenteric vein
Body and tail: splenic vein
What are the structures of the porta hepatis?
Portal vein
Hepatic artery
Common hepatic duct
what are the constrictions of the oesophagus?
Constrictions of the oesophagus : ABCD
A- Arch of the Aorta
B- Left main Bronchus
C- Cricoid Cartilage
D- Diaphragmatic Hiatus
What is the first line treatment for a muconium ileus?
The first line treatment for uncomplicated cases is enemas of either dilute gastrograffin or N-acetyl cysteine.
what is the lymphatic drainage of the prostate?
internal ileac nodes
what is the blood supply to the prostate?
inferior vesical
What are the common features of carcinoid syndrome?
CARCinoid:
- Cutaneous flushing
- Asthmatic wheezing
- Right sided valvular heart lesions
- Cramping and diarhorrea
in a male Where is the first site of resistance to be encountered on inserting the catheter?
The membrenous urethra
What is the longest part of the male urethra?
Spongy urethra
What composition of renal stone is most common in staghorn calculi
Stuvate
What composition of renal stone is most common in malignancy
uric acid
What is the most common composition of renal stone
Calcium oxalate
What composition renal stones are radio-opaque
Calcium Oxalate
Calcium Pyrophosphate
Cystine
What composition of renal stone is most common in renal tubular acidosis
Calcium pyrophosphate
What tumour markers are raised in seminomas and non seminomatous testicular cancers?
Seminomas = HCG raised in 10%. AFP normal
Non seminometous = AFP raised. HCG raised in 40%
what is the treatment of testicular cancer?
Inguinal orchidectomy + post operative chemotherapy
What is the treatment of adrenal adnenomas?
- <2-4cm and non functioning: dishcarge
- 4-6cm and non functioning: discuss possible removal
- 4-6cm and functioning: laparoscopic removal
- If >6cm: remove open
What are the histological features / endoscopic feature of Crohns?
- Non caseating granulomas
- Goblet cells
- transmural inflamation
- cobblestone appearence
What is the main blood supply to the omentum?
Gastroepiploic artery
Which vessels provides the greatest contribution to the arterial supply of the breast?
Internal Mammary Artery
Which nerve is the primary source of innervation to the scrotal skin?
- Anterior skin: Illioinguinal nerve + small contribution from genital branch of the genitofemoral nerve
- Posterior Skin: Pudendal nerve
What type of liver pathology is common in patients who have worked in a PVC factory?
Angiosarcoma (or Hepatocellular carcinoma)
What cancers is BRACA1 gene associated with?
Breast and ovarian cancer
A 46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash of erythematous blisters involving the abdomen and buttocks. The blisters have an irregular border and both intact and ruptured vesicles. What is the most likely diagnosis?
glucagonoma - these are associated with necrolytic erythema
Which organ is affected by a Klatskin tumour
bile ducts
at what anatomical site does anatomical sites does dormant tuberculosis most frequently reactivate?
apex of the lung
If a patient has portal hypertension or varices what can be given to reduce the portal pressure?
Turlopressin
What can increase gastric emptying post vagotomy
Erythromycin (Metoclopermides effects are decreased)
What is goodsals rule with regards to fistula in ano?
Anterior fistulae will tend to have an internal opening opposite the external opening.
Posterior fistulae will tend to have a curved track that passes towards the midline.
what is the normal size of the CBD?
less than 6mm
where in the body is the most water reabsorbed?
Jejunum
what agent can increase the rate of empyting in a vagotamised stomach
erythromycin
what are the branches of the external iliac artery
inferior epigastric, deep circumflex iliac and femoral arteries (profunda femoris is a branch of the femoral)
what structures are contained within the hepatoduodenal ligament
- bile duct
- portal vein
- hepatic artery
*
what is the blood supply of the omentum
gastroepiploic artery
Which sign is commonly present in a patient with retroperitoneal haemorrage?
grey turners sign
which sign would you commonly see in a patient with an intraperitoneal haemorrage or pancreatitis?
cullens sign
where are gastrinomas most commonly found
duodenum (50%)
Pancreas (20%) - these are commonly solitary and display malignant behaviour
what is zollinger elison syndrome composed of
- Non beta islet cell tumours of the pancreas
- Hypergastrinaemia
- Severe ulcer disease
what percentage of patients with colorectal cancer have a synchronus cancer?
5%
what are the Extraintestinal manifestation of inflammatory bowel disease?
- Aphthous ulcers
- Pyoderma gangrenosum
- Iritis
- Erythema nodosum
- Sclerosing cholangitis
- Arthritis
- Clubbing
what hepatobiliary disorders are most classically associated with ulcerative colitis?
Primary sclerosing cholangiits
which portion of the pancreas lies between the aorta and the SMA
uncinate process
what are the most common benign tumour of the oesophagus
leiomyoma’s
where are peyers patches most commonly found?
ileum
how common are parastomal hernias
they occur in 10% of colostomies
what is the common position of the inferior epigastric vessels to direct hernias
direct hernias are most common in hasslebachs triangle. Here the epigastric vessels would be lateal to the hernia
what is a krunkenburg tumour
A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract
what is the order of structures from anterior to posterior in the porta hepatis
common hepatic duct, hepatic artery and the portal vein (most posterior)
At what anatomical level does the aorta bifurcate?
L4
what is the most common cause of intersusception in children?
- Hypertrophic Peyers patches (80%)
- Meckles diverticulum (10%)
what are peyers patches and where are they found
these are aggregates of lymphoid tissue found in the small bowel
Which hernias are found in the following positions:
- below and lateral to the pubic tubercle
- above and medial to pubic tubercle
- below and lateral to the pubic tubercle - femoral hernia
- above and medial to pubic tubercle - inguinal hernia
Splenectomy increases your risk of infection to which organisms?
- Pneumococcus
- Meningococcus
- H. Influenza
What is the most common composition of gallstones in a patient with crohns
Cholesterol
descibribe the differences between the ileum and the jejunan in terms of:
- Site
- Lumen
- Arcades
- Vasa recta
Jejunum:
- Site - Left
- Lumen - wide lumen and thick walled
- Arcades: Less Arcades
- Vasa recta: Long vasa recta
Ileum:
- Site - Right
- Lumen - Narrow and thin walled
- Arcades: more arcades
- Vasa recta: short vasa recta
If there was a tumour in the transverse colon, which structure should be ligated close to its origin to maximise clearance of the tumour
Middle colic artery
What is the treatment of a carcinoid tumour
- Smaller than 1 cm and asymptomatic – local excision
- Bigger than 2 cm – small-bowel resection and lymphatic clearance
- Carcinoid syndrome (by definition metastatic) and other advanced disease – palliative
Where does fluid from a perforated peptic ulcer normally collect
Right paracollic gutter
Stimulation from which nerve causes gall bladder contraction
Vagus nerve
What is the blood supply of the gall bladder
Cystic artery (from the right hepatic artery)
What is the management of splenic lacerations
Grade 1 - laceration <1cm + <10% haematoma. Treatment = Conservative
Grade 2 - Laceration 1-2cm + 10-80% haematoma. Treatment = Conservative
Grade 3 - Grade 2 + intraparencymal bleed. Treatemnt if stable = observe. If undsatble = IR or pack
Grade 4 - Grade 3 + hilar injury. Treatment = IR
Grade 5 - shattered spleen. Treatment = Splenectomy
What is the blood supply to the omentum
Gastroepiploic arteries
What is the treatment of NEC?
Most are treated conservatively. If they dont settle conservatively you may have to undertake a laparotomy
What is the most common viral infection a patient gets following a solid organ transplant
Cytomegalovirus
What is the treatment for anal cancer
- Chemoradiotherapy
- APER
What is the treatment for a toxic mega colon
Subtotal collectomy + end ileostomy
What is an annular pancreas
This is a pancreas that wraps round the second part of the duodenum
From which muscle does the conjoint tendon arise
the internal oblique
which portion of the ascending and descending colon is retroperitoneal
the posterior surface
what macroscopic change is noted at the transition point of the sigmoid colon and the upper rectum?
at this point the teniae fuse
Where does the Foregut, Midgut and Hindgut begin / end
Foregut: Stomach and 1st part of the duodenum
Midgut: 2nd part of the duodenum to ⅔ the way along the transverse colon
Hindgut: distal ⅓ of the transverse colon to the anus
Where does the middle colic vein and the inferior mesenteric vein drain to
Middle colic drains to the Superior Mesenteric vein → Portal vein →SVC
Inferior mesenteric vein drains to the Splenic vein → portal vein → SVC
what two arteries does the marginal artery connect
the SMA and the IMA
What is the nervous innervation of the internal and external anal sphincter
internal sphincter → Sympathetic nerves
external sphincter → S2,3,4
Where do the testicular arteries arise from and where do the testicular veins drain to
Arteries: Arise from the aorta
Veins:
- Left drains in to the left renal veins
- right drains to the IVC
What is found in the red and white pulp of the spleen?
White pulp - contains immune cells + Central trabecular artery.
red pulp - contains vessels
What is the blood supply of the right and left lobe of the liver
Right → Right hepatic artery
Left → left hepatic artery
How many liver lobes are there?
Right lobe (Segments 5,6,7,8)
Left Lobe (2, 3)
Quadrate lobe (segment 4 - anatomically part of the right lobe but functionally part of the left lobe)
Caudate Lobe (segment 1 - part of the left lobe)
how many liver segments are there and in which lobe are these segments found?
There are 8 segments of the liver
Right lobe: 5-8 +/- segment 1
Left Lobe: 2-4 +/- Segment 1
Segment 1 is the Caudate Lobe
Segment 4 includes the quadrate lobe
How many ligaments are there in the liver?
5 ligmaments:
Falciform Ligment - divides left and right lobes
Round ligament - fibrous cord at the free edge of the falciform ligament
Coronary Ligament - connects liver to the diaphragm superiorly
Left Triangular ligament - connects left corner of the liver ot the diaphragm
Right triangular ligament - connects the right corner of the liver to the diaphragm
What is the ligament teres in the liver?
This is a cord like ligmaent found in the falciform ligament that is a remnant of the umbilical vein
what is the ligament venous
a remnant of the ductus venosus
