Gray's Tract II

Question 1

Which lymph node is most likely to be involved in malignancy of the stomach?

Answer 1

Celiac nodes which then drain into the cisterna chyli

Question 2

Which vessel would be occluded if the hepatoduodenal ligament is clamped?

Answer 2

The proper hepatic artery is the only artery within the hepatoduodenal ligament. This ligament lies anterior to the omental foramen.

Question 3

Which venous tributaries to the portal system anastomoses with caval veins to cause esophageal varices?

Answer 3

The left gastric vein carries blood from the stomach to the portal vein. At the esophageal-gastric junction the left gastric vein (portal system) anastomoses with esophageal veins (caval system).

Question 4

Part of the bowel is being compressed between the abdominal aorta and the SMA (nutcracker syndrome). Which intestinal structure is being compressed?

Answer 4

The 3rd part of the duodenum goes anterior to the abdominal aorta and inferior to the SMA.

Question 5

If the gastroduodenal artery is ligated, a branch of which artery will continue to supply blood to the pancreas?

Answer 5

The SMA will supply the pancreas. Its first branches are the anterior and posterior inferior pancreaticoduodenal arteries which anastomose with the sup. pancreaticoduodenal arteries which came from the gastroduodenal branch of the celiac trunk.

Question 6

There is a 90% bloackage at the origin of the IMA from the aorta. Which artery would most likely provide collateral supply to the descending colon?

Answer 6

The middle colic artery. It is one of the first branches of the SMA and supplies the transverse colon. It provides collateral blood supply to both the ascending colon (anastomoses with the r. colic branch of the SMA) and descending colon (anastomoses with the l. colic branch of the IMA.

Question 7

Patient has esophageal varices. The varies are a result of the anastomoses between the left gastric vein and what other vessels?

Answer 7

Esophageal varices are dilated veins in the submucosa of the lower esophagus. They result from portal hypertension due to liver cirrhosis. The l. gastric vein and the esophgeal veins of the azygos system form a portal-caval anastomosis.

Question 8

Which anatomic feature helps to distinguish the jejunum from the ileum?

Answer 8

The jejunum has less mesenteric fat than the ileum. The jejunum has thicker walls, more villi and higher plicae circularis but this can’t be seen unless incised.

Question 9

The 3rd portion of the duodenum is being compressed by a large vessel. Which vessel is causing the compression?

Answer 9

The SMA descends across the 3rd part of the duodenum.

Question 10

Surgeon accidentally cut tissue immediately posterior to the epiploic (omental) foramen. Which vessel will bleed?

Answer 10

omental foramen has 4 boundaries

• superior: caudate lobe of liver
• inferior: 1st part of duodenum
• anterior: hepatoduodenal lig. (portal triad)
• posterior: IVC

Question 11

The left renal vein is being occluded by an arterial aneurysm where the vein crosses the aorta. The aneurysm is most likely located in which artery?

Answer 11

The SMA lies superior and anterior the left renal vein as the vein passes to its termination in the IVC.

Question 12

There is penetration of the fundic region of the stomach that resulted in bleeding. Which artery is the source of bleeding?

Answer 12

The short gastric artery supplies the fundus.

Question 13

There is penetration of the duodenal bulb by an ulcer that resulted in bleeding. Which artery is the source of bleeding?

Answer 13

The posterior superior pancreaticoduodenal a. arises from the gastroduodenal a. of the celiac trunk and travels behind the 1st part of the duodenum.

Question 14

There is large amounts of blood in the peritoneal cavity due to an injury to a vessel that occurred during appendectomy. Which vessel must be ligated to stop the bleeding?

Answer 14

The ileocolic artery directly supplies the appendix (gives off an appendicular branch).

The SMA gives origin to the ileocolic, right colic and middle colic arteries.

Question 15

There is diverticulosis of the lower portion of the descending colon. Which vessels and nerves will be cut to remove this part of the colon?

Answer 15

Pelvic splanchnic nerves and the left colic artery supply the descending colon.

Question 16

Patient has chronic diverticulitis and bleeding from the descending colon. Which artery is the most likely source of the bleeding?

Answer 16

Left colic artery from the IMA.

Question 17

There is an abnormal mass of tissue in the rectum below the pectinate line. Which lymph nodes would first receive this lymph?

Answer 17

Below pectinate line = Superficial (horizontal) inguinal nodes.

Above pectinate line = internal iliac

Question 18

There is a tumor from an area superior to the external anal sphincter, superior the pectinate line. Which lymph nodes would first receive this lymph?

Answer 18

The lymphatics of the inferior rectum above the pectinate line drain into the internal iliac nodes.

Question 19

Palpable mass on right groin. The lymph node in this region is enlarged. Which location would be the source of this carcinoma?

Answer 19

Right groin lymph node = superficial (horizontal) inguinal lymph node

Question 20

Massive tumor originates from the 3rd part of the duodenum. Which structure is compressed by the tumor?

Answer 20

The SMA traverses inferiorly across the anterior surface of the 3rd part of the duodenum.

Question 21

There are numerous stones and air accumulation in the gallbladder . Which place will an obstructive stone most likely be found?

Answer 21

The stone is most likely entrapped at the ileocecal junction. The biliary trees are clear (indicated by the presence of air) and rules out the common bile duct or hepatic duct as potential sites of gallstone obstruction.

Question 22

There is penetration of an anterior duodenal ulcer. Which condition will most likely occur?

Answer 22

A perforating ulcer in the anterior wall of the duodenum is most likely to cause peritonitis. The duodenum is covered anteriorly by a layer of peritoneum and an erosion would allow intestinal contents into the greater peritoneal sac.

Question 23

Which structure is used as a landmark to determine the position of the duodenojejunal junction?

Answer 23

The suspensory ligament of the duodenum, ligament of Treitz, is attached to the 4th part of the duodenum at the duodenojejunal junction.

Question 24

Which vessels provide collateral channels between the celiac trunk and the SMA?

Answer 24

Blood supply from the inf. pancreaticoduodenal a. via the SMA can provide collateral blood supply to the head of the pancreas and the 1st part of the duodenum in situations where the celiac trunk is occluded (the sup. pancreaticoduodenal a.)

Question 25

Diverticulosis of the transverse colon. Which arterial supply needs to be ligated?

Answer 25

The middle colic artery is the principal source of arterial supply to the transverse colon.

Question 26

There is an ulcer in the posterior wall of the duodenal cap. Which structures will most likely be affected if the ulcer perforates?

Answer 26

The duodenal cap and the 1st part of the duodenum are supplied by the gastroduodenal artery which arises from the common hepatic artery.

The gastroduodenal has 2 branches: right gastro-omental a. and superior pancreaticoduodenal a.

Question 27

There is a laceration of the body of the pancreas with hemorrhage around the vessel traveling along the superior border of the pancreas. Which vessel is this?

Answer 27

The splenic artery takes a tortuous course to the left along the superior border of the pancreas and gives off branches to the neck, body and tail.

Question 28

The anastomosis of which portal system vein with the esophageal veins can result in hematemesis?

Answer 28

The left gastric vein anastomose with the esophageal branches of the azygos vein. Distension of this network in cases of obstruction results in esophageal varices at lower esophagus.

Question 29

The gastroduodenal artery is ligated. A branch of which artery will continue to supply blood to the duodenum?

Answer 29

The inferior pancreaticoduodenal artery will continue to supply the pancreas (head of the pancreas). This artery is a branch of the SMA.

Question 30

A neurectomy is performed to interrupt the neural pathway carrying pain from the pancreas. Which structure was severed?

Answer 30

Postganglionic sympathetic nerves to the foregut, including the pancreas, are located in the celiac ganglion.