GI Flashcards

1
Q

GORD
- pathophysiology
- management
- reduce recurrence
- complications
- side-effects of long-term PPI treatment

A

In GORD, the resting tone of the lower oesophageal sphincter (LOS) is impaired, resulting in acid reflux.

Management: 4 to 8-week trial of proton pump inhibitors (PPIs) to act as both a diagnostic and therapeutic trial.
Perform oesophagogastroduodenoscopy (OGD) if no improvement.

Complications:
* Oesophageal ulcers
* Oesophageal stricture
* Barrett’s oesophagus—Pre-malignant damage
* Adenocarcinoma of the oesophagus incidence increases by 0.5% a year in those with Barrett’s oesophagus.

Side-effects of long-term PPI therapy:
- CAP
- Low magnesium
- B12 deficiency

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2
Q

Ulcerative Colitis
- Sx
- Extra-abdominal manifestations
- Investigations
- What size of the colon is colonoscopy contraindicated?
- Mx acute remission
- Barium enema XR findings
- Protective factor
- Complications

A

Ulcerative colitis often presents as continuous circumferential lesions in the distal rectum and colon with bloody diarrhoea, weight loss, bowel urgency, and fatigue.

Extra-abdominal manifestations:
* Erythema nodosum, pyoderma gangrenosum
* Anterior uveitis, episcleritis
* Arthritis, ankylosing spondylitis
* Primary sclerosing cholangitis (PSC)
* Cholangiocarcinoma

Investigations:
* Stool studies to exclude infective cause
* Faecal calprotectin elevated
* Full blood count: anaemia, leukocytosis, or thrombocytosis
* Variable elevation of ESR and CRP
* Abdominal X-ray showing dilated loops, assess for the presence of complications (e.g., megacolon, perforation)
* Colonoscopy for continuous ulcerative lesions
* Biopsy for crypt abscess and submucosal lesions

Colonoscopy is contraindicated in toxic megacolon (>6-cm diameter) due to the risk of perforation.

Mx of acute remission
<4 bowel motions/day: Rectal mesalazine (especially for distal disease), then oral 5-ASA, then oral prednisolone
* >6 bowel motions/day: IV corticosteroids for remission; infliximab in children
* Cyclosporin as adjunct
* Consider infliximab if cyclosporin is contraindicated.
* Surgery: Colectomy in patients with acute complications (e.g., megacolon, perforation) or who have failed to respond to medical therapy

The barium enema X-ray shows a classic lead pipe colon, indicative of chronic ulcerative colitis due to a loss of haustra.

Protective factor - smoking

Complications include colorectal cancer, toxic megacolon, and osteoporosis.

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3
Q

Crohns disease
- symptoms
- investigations
- gold standard test
- management

A

Sx:
* Chronic diarrhoea (normally not bloody)
* Abdominal pain (commonly ileitis in RIF)
* RIF mass (abscess)
* Constitutional symptoms (weight loss, fever, fatigue)
* Mouth ulcers
* Malabsorption

Investigations:
* FBC
* Serum B12
* Stool MCS (to rule out infection)
* AXR with oral contrast, which may show string sign (strictures) and skip lesions
* CT/MRI with oral contrast, which may show skip lesions, bowel thickening, inflammation, abscess, and fistulae

Gold standard test: colonoscopy, with terminal ileum biopsy showing transmural inflammation and granulomas

Management:
Lifestyle—Smoking cessation, NSAID avoidance
Medical:
a. Corticosteroids to induce acute remission
b. Aminosalicylates (5-ASA) with ileal or right-sided disease
c. Azathioprine or mercatopurine as add-on therapy
d. Methotrexate
e. Infliximab and adalimumab
Surgical: Bowel resection, ABSCESS DRAINAGE

Indications for surgery:
* Failure of medical treatment
* Severe complications
* Abscess/fistula formation
* Malignancy or high-grade dysplasia
* Malabsorption/failure to thrive (children)

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4
Q

IBS:
- criteria
- management

A

Criteria used is the Rome IV criteria in secondary care

Constipation Mx:
Prescribed laxatives: Any bulk-forming laxatives (e.g., macrogol) apart from lactulose; linaclotide or plecanatide if other laxatives are not tolerated.

Contraindicated laxative: Lactulose due to bloating

Diarrhoea Mx:
Antispasmodics (mebeverine hydrochloride, alverine citrate, and peppermint oil) to reduce smooth muscle wall spasms

Loperamide

Amitriptyline used as a second-line agent after FODMAP and antispasmodics and laxatives (depending on predominant symptoms)

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5
Q

Acute diarrhoea causes
a. Daycare outbreaks
b. Winter outbreaks
c. Raw eggs and poultry
d. Immunosuppression—
e. Travel to Asia
f. Contaminated shellfish and water
g. HUS complications
h. Reheated rice
i. After antibiotic use
j. Faecally contaminated water in travel

A

a. Daycare outbreaks—Rotavirus
b. Winter outbreaks—Norovirus
c. Raw eggs and poultry—Salmonella
d. Immunosuppression—CMV
e. Travel to Asia—Campylobacter
f. Contaminated shellfish and water—Vibrio cholerae
g. HUS complications—E. coli O157 or Shigella
h. Reheated rice—Bacillus cereus
i. After antibiotic use—Clostridium difficile
j. Faecally contaminated water in travel—Giardia, Entamoeba

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6
Q

LFTs
a. ALP>3 x ALT
b. ALT >3 x ALP
c. AST:ALT >2.5
d. AST:ALT<1

What conditions raise ALT, AST, ALP and GGT?

A

a. ALP >3 × ALT = gallstones or malignancy
b. ALT >3 × ALP = hepatocellular damage
c. AST:ALT >2.5 = alcoholic liver disease
d. AST:ALT <1 = hepatitis or paracetamol toxicity

ALT = Hepatocellular damage
AST = Cellular damage; raised significantly in alcoholic liver disease
ALP = Cholestasis
GGT = Cholestasis (most sensitive); recent alcohol use

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7
Q

Acute liver failure
- Sx
- Causes
- Mx
- Criteria for transplant

A
  • Confusion, jaundice, scleral icterus, xanthoma

Causes:
* Viral: Hepatitis A, B, D, E; CMV; HSV
* Drugs and toxins, most commonly paracetamol and alcohol
* Ischaemia, with hypoperfused and then ischaemic liver
* Vascular (Budd–Chiari syndrome)
* Autoimmune hepatitis

Initial management:
* ABCDE assessment
* Early IV access and fluid resuscitation
* N-acetylcysteine IV (indicated for all ALF patients, not just paracetamol toxicity)
* Treatment of underlying cause (e.g., steroids for autoimmune hepatitis, antivirals for viral hepatitis)
* Vitamin supplementation (vitamin K or thiamine)
* ICU transfer and discussion with local organ transplant centre

Kings College Criteria for liver transplant:
* Paracetamol:
-pH <7.3 or
- Hepatic encephalopathy grade 3 (creatinine >300, INR >6.5)
* Non-paracetamol:
- INR >6 or
- Three of the following: age <10 years or >40 years, unfavourable aetiology, not hyper-ALF, INR >3.5, bilirubin >300

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8
Q

Primary biliary cholangitis (PBC)
- Sx
- Investigations
- Mx

A

Sx - fatigue, hyperpigmentation, intense pruritus, jaundice, dark urine, light stool, hepatosplenomegaly

Investigations:
Serology - AMA and ANAs
Liver biopsy - bile duct lesions, portal tract inflammation, and granuloma formation
LFTs raised including ALP and GGT

Mx:
* Ursodeoxycholic acid, which helps prevent or delay hepatic damage if taken in the early stages; will not improve fatigue or pruritus
* Cholestyramine, which lowers cholesterol levels in the blood and removes bile acids, thus reducing pruritus

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9
Q

Primary sclerosing cholangitis (PSC)
- Sx
- Investigations
- Mx

A

Sx: RUQ pain, pruritus and fatigue (Hx of IBD)

Investigations
- MRCP
- LFTs: ALP and GGT

Mx:
Treatment protocol of PSC for an early-stage diagnosis:
* Lifestyle changes
* Ursodeoxycholic acid
* Cholestyramine (pruritus relief)

Treatment for a late-stage: Liver transplant

Regular colonoscopies due to increase risk of colorectal cancer

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10
Q

Autoimmune hepatitis
- Investigations
- Mangement

A

Investigations:
* LFT—↑ ALT/AST (ALP only mildly to moderately increased), ↑ bilirubin, ↑ gamma-GT
* ↓ Albumin
* ↑ PT/INR, ↑ IgG
* Positive ANAs, anti–smooth muscle antibodies (ASMAs), anti–liver/kidney microsomal-1 (LKM) antibodies, anti–liver cytosol (LC) antibodies, perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCAs)
* Liver biopsy

Management:
* Medical: Corticosteroids, azathioprine (plus other immunosuppressive agents if first-line medications do not work)
* Surgical: Liver transplant, which is only indicated in acute severe AIH with acute liver failure

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11
Q

Hepatocellular carcinoma (HCC)
- associations
- Sx
- investigations

A

Associations - chronic hepatitis B, hepatitis C and haemochromatosis

Sx:
* Decompensated symptoms and worsening LFTs
* Weight loss, RUQ pain, and hepatomegaly may also be present.

Investigations:
* Ultrasound imaging of the liver is the first line of investigation for HCC screening; however, only tumours up to 2 cm can be detected.
* CT of the chest, abdomen, and pelvis is often performed to detect distant metastasis.
* When there is uncertainty about a diagnosis, a liver MRI can provide better quality images.

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12
Q

C.difficile management

A

First episode:
- oral vancomycin 10 days
- 2nd line: oral fidaxomicin
- 3rd line: oral vanc +/- IV metronidazole

Recurrent episode:
- within 12 weeks of Sx resolution: oral fidaxomicin
- after 12 weeks of Sx resolution: oral vanc or oral fidax

Life-threatening:
Oral vancomycin AND IV metronidazole

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13
Q

Liver cirrhosis
- symptoms
- diagnosis

A

Sx - portal HTN symptoms (splenomegaly, upper GI bleeds, varies, ascites, caput-medusae)
Diagnosis - transient elastography (fibroscan)

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14
Q

Dyspepsia referrals

A

Urgent:
- all patients with dysphagia
- all patients with an upper abdo mass
- patients =>55 with weight loss and upper abdo pain, reflux or dyspepsia

Non-urgent:
- pt with haematemesis
- pt aged >=55 with treatment resistant dyspepsia, upper abdo pain w low Hb levels, raised platelet count or nausea and vomiting

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15
Q

Small intestinal bacterial overgrowth (SIBO)
- Sx
- investigations
- Mx

A

Disturbances of the normal gut flora

Sx: abdo pain, belching, bloating, diarrhoea, distension, flatulance, indigestion

Investigation:
Hydrogen breath test
Gold standerd - small intestinal fluid aspirate (>105)

Mx: ABX (2 week course), metronidazole, ciprofloxacin, polyoils

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16
Q

Spontaneous bacterial peritonitis
- Sx
- Diagnosis
- Mx

A

Sx - ascites, abdo pain, fever

Diagnosis - paracentesis (neutrophil count >250), most common organism is E.Coli

Mx - IV cefotaxime

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17
Q

Boerhaave syndrome
- the triad

A
  1. vomiting
  2. thoracic pain
  3. subcutaneous emphysema

Typically presents in middle aged men with a background of alcohol abuse

18
Q

Achalasia
- Sx
- Investigations
- Mx

A

Symptoms:
- dysphasia to both solids and liquids
- weight loss
- intermittent sx
- retrosternal chest pain

Investigations
Barium study - ‘birds beak’

Management
Calcium channel blockers or nitrates before food
Surgery - endoscopic balloon dilation or Hellers cardiomyotomy

19
Q

Wilsons disease
- features
- investigation
- management

A

Excessive COPPER deposition in tissues

Features
- liver: hepatitis, cirrhosis
- neuro: speech, behaviour, asterixis
- Kayser-Fleischer rings
- Renal tubular acidosis (Faconi syndrome)
- Haemolysis
- Blue nails

Investigation
- slit lamp
- reduced serum caeruloplasmin
- reduced total serum copper
- increased 24h urinary copper excretion

Management:
- penicillamine

20
Q

Hepatitis B serology
HBsAg
Anti-HBs.
Anti-HBc
HbeAg

A

HBsAg - ongoing infection (>6mo chronic)
Anti-HBs - immunity (exposure or immunisation)
Anti-HBc - ‘caught’ i.e. negative if immunised
HbeAg - marker of infectivity

21
Q

Where is the prostate located in the digital rectal examination?

A

Anterior rectal tissue

22
Q

Management of constipation in adults

A

first-line laxative: bulk-forming laxative first-line, such as ispaghula

second-line: osmotic laxative, such as a macrogol

23
Q

Variceal bleeding:
Acute management
Long-term management

A

Acute:
A-E
Correct clotting
Give terlipressin and ABX
1st line: endoscopy with variceal band ligation (EVL)
2nd line: Sengstaken-Blakemore tube if uncontrolled haemorrhage
3rd line: transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail

Long-term management:
Propanolol
EVL or TIPSS

TIPS procedure connects the hepatic and portal vein !!!!

24
Q

Gastric cancer
- Sx
- Diagnosis
- Mx

A

Sx:
abdominal pain
weight loss and anorexia
nausea and vomiting
dysphagia: particularly if the cancer arises in the proximal stomach
overt upper gastrointestinal bleeding is seen only in a minority of patients
if lymphatic spread:
- left supraclavicular lymph node (Virchow’s node)
- periumbilical nodule (Sister Mary Joseph’s node)

Diagnosis
- oesophago-gastro-duodenoscopy with biopsy
signet ring cells may be seen in gastric cancer
- CT for staging

Mx:
surgical options depend on the extent and side but include:
- endoscopic mucosal resection
- partial gastrectomy
- total gastrectomy
chemotherapy

25
Q

Haemorrhoids:
- symptoms
- subtypes
- grades
- management
- acuteley thrombosed external haemorrhoids

A

Symptoms:
- painless rectal bleeding
- pruitus
- soiling (3rd/4th degree)

Types:
1. external: below the dentate line, prone to thrombosis, may be painful
2. internal: above the dentate line, do not cause pain

Grading:
I - do not prolapse out of anal canal
II - prolapse on defecation but reduce spontaneously
III - can be manually reduced
IV - cannot be reduced

Mx:
- soften stool: diet
- topical local anaesthetics & steroids
- outpatient: rubber band ligation
- surgery: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Acutely thrombosed external haemorrhoids
- significant pain
- if within 72h referral for excision.
- Sx settle in 10 days

25
Q

Anal fissures:
- risk factors
- symptoms
- management

A

Risk factors: constipation, STI, IBD

Sx: bright red rectal bleeding (majority in the posterior midline)

Mx:
Acute (<1 week)
- soften stool: dietary advise, bulk forming laxatives
- lubricants before defecation
- topical anaesthetics
- analgesia

Chronic
- first line: GTN
- if it doesn’t work after 8 weeks referral should be considered for surgery (sphincterotomy) or botulinum toxin

26
Q

Colorectal cancer:
- risks
- Sx
- referral
- investigations
- staging
- managemet

A

**Risks: **
- genetic: HNPCC and FAP
- lifestyle: low fibre diet, obesity, smoking
- medical: IBD, acromegaly, DM

**Features: **
- change in bowel habit
- rectal bleeding
- abdo pain, bloating
- tenesmus
- unexplained weight loss
- fatigue/breathlessness

Referral - perform a FIT test on anyone with:
Change in bowel habit
Abdominal mass
Iron deficiency anaemia
Age >40 with unexplained weight loss and abdominal pain
Age <50 with rectal bleeding and abdominal pain or weight loss
Age >50 with unexplained rectal bleeding, abdominal pain or weight loss
Age >60 with anaemia

If the FIT is positive (>10 micrograms of haemoglobin/gram of faeces), the patient should be referred on an urgent suspected cancer (two-week wait) referral pathway.

**Investigations: **
Colonoscopy is gold standard test (if rectal bleeding a flexible sigmoidoscopy is offered)

**Staging - TNM system **
Tumour: degree of intestinal wall invasion
Nodes: lymph node involvement
Metastasis: presence of distant metastases

Mx: surgery, radiotherapy, chemo

27
Q

Femoral hernia
- what is it?
- Sx
- diagnosis
- complications
- management

A

A femoral hernia is when a section of the bowl passes into the femoral canal via the femoral ring.

Sx: lump in the groin which is inferolateral to the pubic tubercle.
- typically non-reducible
- cough impulse is often absent

Diagnosis:
- more common in women (esp if been pregnant)
- mostly clinical diagnosis
- USS for differentials

Complication:
- incarceration: tissue cannot be recue
- strangulation - medical emergency
- bowel obstruction & ischaemia

Mx:
- surgical repair due to risk of strangulation (laparoscoptic or laparotomy)
- hernia support belts
- emergency = laparotomy

28
Q

Inguinal hernia:
- what is it?
- features
- management
- subtypes

A

Sx:
- groin lump superior and medial to the pubic tubercle
- dissappears on pressure
- strangulation is rare

Subtypes:
1. indirect: hernia through the inguinal canal
2. direct: through the posterior wall of the inguinal canal

Mx:
- treat medically fit patients even if asymptomati
- mesh repair

29
Q

Hiatus hernia
- subtypes
- risk factors
- Sx
- investigation
- Mx

A

Subtypes:
1. Sliding - 95% of hiatus hernias. GO junction moves above diaphragm
2. rolling - GO remains below disaphrgan but separate part of stomach herniates through

Risks: obesity, increased intraabdominal pressure

Features: heartburn, dysphagia, regurgitation, chest pain

Investigation:
- barium swallow
- lots of people have endoscopy first line where it is found incidentally

Management:
- weight loss
- medical: PPI
- surgical: only really has a role in symptomatic paraesophageal hernias

30
Q

Oesophageal cancer:
- subtypes & differences
- features
- diagnosis
- treatment

A

Features:
- dysphagia
- anorexia & weight loss
- vomiting
- other possible features include: odynophagia, hoarseness, melaena, cough

Diagnosis:
- upper GI endoscopy with biopsy

Mx:
- operable disease (T1N0M0) is managed with surgical resection

31
Q

Perianal abscess
- what is it?
- features
- causes
- investigations
- associations
- management

A

A perianal abscess is a collection of pus within the subcutaneous tissue of the anus that has tracked from the tissue surrounding the anal sphincter.

Features:
- pain around anus, worse on sitting
- hardened tissue in anal region
- pus-like discharge
- may be long standing

Causes: E.coli or staph aureus

Investigation:
- PR exam
- colonoscopy, cultures and inflam markers
- MRI and transperineal USS

Associations: IBD, DM

Mx:
- incision & drainage, packing or left open for 3-4 weeks
- ABX

32
Q

Acute pancreatitis:
- causes
- features
- investigations
- scoring
- management

A

Causes: GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Features - epigastric pain radiating to back, vomiting, Cullens sign (periumbilical discolouration) or Grey-Turners sign (flank discolouration)

Investigations:
- amylase >3 x the upper limit of normal: does not show severity
- serum lipase more sensitive
- USS

Scoring: APACHE II
Common factors indicating severity:
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST

Management - supportive

33
Q

Ascending cholangitis
- cause
- features (triad)
- investigation
- Mx

A

Cause: e.coli

Features:
Charcots triad
1. RUQ pain
2. fever
3. jaundice

Investigation - USS

Mx: IV ABX and ERCP to relieve obstruction of gallstones

34
Q

Diverticular disease
- symptoms
- management

A

Sx: altered bowel habit, rectal bleed, abdo pain

Management: increase dietary intake
- Mild attacks of diverticulitis may be managed conservatively with antibiotics.
- Peri colonic abscesses should be drained either surgically or radiologically.
- Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection.
- Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma.

35
Q

Ischaemic colitis
- what is it?
- investigations
- management

A

Compromise to blood flow in large bowel leading to inflammation, ulceration and haemorrhage

More likely to occur in ‘watershed’ areas such as the splenic flexure

Invesitgation - ‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage

Management: laparotomy

36
Q

Mesenteric ischaemia
- chronic triad of features
- risk factors
- diagnosis
- chronic management
- acute management

A

Triad:
1. colicky abdo pain after food
2. weight loss
3. abdominal bruit

Risks - age, FH, smoking, diabetes, HTN, raised cholesterol

Diagnosis - CT angio

Chronic Mx:
- Reducing modifiable risk factors (e.g., stop smoking)
- Secondary prevention (e.g., statins and antiplatelet medications)
- Revascularisation to improve the blood flow to the intestines

Acute Mx:
- removal of necrotic bowl
- remove thrombus

37
Q

Bowel obstruction:
- top 3 causes
- presentation
- abdo X-ray normal diameters
- initial management
- surgical management

A

Causes:
1. adhesions
2. hernias
3. malignancy

Sx:
- Vomiting (particularly green bilious vomiting)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence
- “Tinkling” bowel sounds may be heard in early bowel obstruction

Abdo XR:
3 cm small bowel
6 cm colon
9 cm caecum

Initial management:
- NBM
- IV fluids
- NG tube

Surgical Mx:
Exploratory surgery in patients with an unclear underlying cause
Adhesiolysis to treat adhesions
Hernia repair
Emergency resection of the obstructing tumour

38
Q

Colorectal surgery:
- right hemicolectomy
- left hemicolectomy
- high anterior resection
- low anterior resection
- abdominal perineal resection
- Hartmanns procedure

A
  • Right hemicolectomy involves removal of the caecum, ascending and proximal transverse colon.
  • Left hemicolectomy involves removal of the distal transverse and descending colon.
  • High anterior resection involves removing the sigmoid colon (may be called a sigmoid colectomy).
  • Low anterior resection involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.
  • Abdomino-perineal resection (APR) involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.
  • Hartmann’s procedure is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.
39
Q

Duodenal ulcers

A

Arise fron the gastroduodenal artery, a branch of the hepatic artery, travels posteroinferior to first part of duodenum.

40
Q
A