Grays Review II: Abdomen Flashcards
1
Q
Perforation on the posterior wall of stomach - where will peritonitis develop first?
A
Omental bursa
2
Q
Where is the subhepatic space/pouch of Morison/ hepatorenal space?
A
Posterior to liver; anterior to the right kidney.
Would only accumulate stomach fluid in perforation if the patient was laying supine.
3
Q
Right subphrenic space - where is it?
A
Inferior to the diaphragm on the right. Would only accumulate stomach fluid in perforation if the patient was laying supine.
4
Q
If you accidentally inserted a scalpel posterior to the epiploic (omental) foramen and had profuse bleeding- what was likely hit?
A
The IVC, because the epiploic foramen is bounded posteriorly by the parietal peritoneum covering the IVC.
5
Q
If you expose the beginning of the jejunum without dissection, what relationship can you see?
A
The second part of the duodenum is crossed anteriorly by the attachment of the transverse mesocolon. can see this by lifting the transverse colon superiorly.
6
Q
Penetration to the fundus causes bleeding. What are the likely vessels that got hit?
A
Short gastric arteries pass from the area of the splenic hilum to the fundus, supplying anterior and posterior branches to it. Dorsal gastric arteries arising from the midportion of the splenic artery pass to the dorsal aspect of the fundus.
7
Q
What layers of peritoneum will have to be cut into to access the intestinal artery supplying the ileum?
A
Parietal peritoneum and mesentery. Parietal peritoneum lines the abdominal wall. Have to interrupt the visceral peritoneum of the mesentery covering the thromboses vessel.
8
Q
If you have a perforated peptic ulcer, where is fluid least likely to develop?
A
Greater sac. Morison’s pouch, the rectouterine pouch, right paracolic gutter, and the omental bursa are all dependent areas in the peritoneal sac, where fluid will collect if the patient is supine or standing.
9
Q
The descending colon is ___peritoneal
A
Retroperitoneal
10
Q
Where would you make an incision to separate the let and right rectus sheaths?
A
Linea alba; it contains the aponeuroses of the rectus abdominal muscles and is at the midline of the body.
11
Q
Midaxillary line
A
Vertical line inferior to the shoulder joint and axilla
12
Q
Arcuate line of douglas
A
Curved horizontal line that represents the lower edge of the posterior tendinous portion of the rectus abdominis sheath
13
Q
Semilunar line
A
an imaginary vertical line below the nipples; parallels the lateral edge of the rectus sheath
14
Q
Iliopubic tract
A
A reflective band of aponeurotic tissue of the origin of the transverse abdominus.
15
Q
What is the lateral border of the inguinal triangle of Hesselbach?
A
The inferior epigastric artery vein
16
Q
What is the lateral border of the femoral ring?
A
Femoral vein and connective tissue separating the vein from the femoral canal
17
Q
Lacunar ligament of Gimbernat attaches the inguinal ligament to the
A
Pectinal ligament
18
Q
Layers of anterior abdominal wall in the right lower quadrant:
A
Skin Camper’s fascia Scarpa’s fascia Ext oblique abdominus Int oblique abdominus Transversus abdominus Transversalis fascia Extra peritoneal fat Peritoneum
19
Q
Processus vaginalis is composed of? Difference in men and women
A
parietal peritoneum that precedes the testis as it migrates from upper lumbar wall to outside the abdomen. In men, this process usually obliterates, leaving only a distal portion that covers most of the testes and epididymis - the tunica vaginalis Females also have one that extends into the labia majus
20
Q
The distal portion of the processus vaginalis gives rise to the tunica vaginalis associated with the testis. If the intermediate portion of the processus persists, the pt will develop a _____. If the entire processus vaginalis persists, the pt will develop a ____.
A
Intermediate persists –> fills with fluid, creating a hydrocele Entire processus persists –> congenital inguinal hernia
21
Q
The cremaster muscle and fascia originate from the
A
Internal abdominal oblique muscle
22
Q
The external spermatic fascia is derived from
A
Aponeurosis and fascia of the external oblique muscle
23
Q
Internal spermatic fascia is derived from
A
Transversalis fascia
24
Q
The ___ is a retroperitoneal organ on the superomedial aspect of the right kidney, partially posterior to the IVC
A
Right adrenal gland
25
Adrenal medulla receives stimulation directly from \_\_ganglionic \_\_pathetic fibers carried by the ___ Chromaffin cells of the adrenal medulla are modified \_\_ganglionic, \_\_thetic neurons of neural crest origin that release epi and norepi into the ___ veins.
Adrenal medulla receives stimulation from preganglionic, sympathetic fibers carried by the thoracic splanchnic nerves. Modified postganglionic, sympathetic neurons Releases epi and norepi into the adrenal/suprarenal veins
26
What causes an imperforate hymen?
Failure of canalization of the vaginal plate, which arises from sinovaginal bulbs. If it doesn't canalize, then you have a persistent vaginal plate and thus imperforate hymen (mucous membrane that covers the opening of the vaginal canal). Would come with amenorrhea.
27
A patient has a kidney stone on his right ureter. We find that he has a second ureter on his right side. What caused that?
Early splitting of the uteric bud, which is responsible for the development of the ureter.
28
The urorectal septum is a section of tissue of ___ origin that develops between the ___ and \_\_\_.
Mesenchymal origin Between allantois and hindgut
29
A young boy has a large fluid collection around a normally developed testis. What developed wrong?
Persistent processus vaginalis allows peritoneal fluid passing through the abdominal end into the scrotum forming a hydrocele of the testis.
30
A young boy only has one testis- what condition is this?
Cryptochordism: failure of descent of one or both testes into scrotum.
31
Chordee
congenital ventral or dorsal curvature of the penis
32
Differentiate between hermaphroditism and pseudophermaphroditism.
Hermaphroditism: presence of both testicular and ovarian tissue Pseudohermaphroditism: errors in sexual differentiation creates contrasting phenotypes
33
If this artery was blocked, it would lead to extremely low sperm count.
Testicular artery. It originates from the abdominal aorta and travels with the spermatic cord to supply testes.
34
Congenital inguinal hernias occur when __ is patent, so that a loop of intestine herniates into the \_\_\_.
Processus vaginalis; herniation into the inguinal canal.
35
A 3-year-old girl has a palpable right inguinal mass. A sac of peritoneum is protruding from the internal ring. What is the origin of this structure?
Patent processus vaginalis/canal of Nuck. The processus vaginalis is formed as the parietal peritoneum layer of the abdominal wall (inguinal region) evaginates through the deep inguinal ring and continues through the superficial inguinal ring; however, it's supposed to be obliterated during development. If it doesn't close off, a cyst can develop in the processus.
36
Where would you see swelling in a woman with a congenital hydrocele?
In the labium majus because the congenital hydrocele would present at the base of the canal.
37
Which nerve is responsible for groin pain in an indirect inguinal hernia?
Ilioinguinal nerve (from L1). It pierces the internal oblique muscle & goes through superficial inguinal ring to provide sensation to... \> skin of upper & medial thigh \> root of penis and upper scrotum in men, and mons pubis & labum majus in women.
38
Patient feels severe pain inferior to the 12th rib and is paralyzed at the right internal oblique & transverse abdominal muscles. What nerve got compressed by the tumor?
Iliohypogastric innervates the skin over the posterolateral gluteal and pubic regions.
39
Woman has numbness over the anterior part of her right labium. What nerve got messed up?
Ilioinguinal nerve.
40
Woman has pain in her right side that radiates to the suprapubic region. She has hematuria and UTIs. What nerve conveys the pain to the CNS?
Iliohypogastric nerve receives sensations from the capsule of the kidney
41
\_\_\_\_ nerve innervates the dermatome OVER the pubic symphysis. ___ nerve innervates the dermatome BELOW the pubic symphysis
Iliohypogastric nerve - over Ilioinguinal nerve - below
42
Tumor in the head of the pancreas likely obstruct what structure?
Common bile duct
43
If you ligate the gastroduodenal artery, what will supply blood to the pancreas?
Superior mesenteric artery. It branches into the anterior and posterior inferior pancreaticoduodenal arteries -\> anastomose with superior pancreaticoduodenal arteries --\> supplies pancreas
44
A woman comes in with nausea and intermittent, acute pain in the right upper abdomen. She has jaundice and a history of gallstones. What is a gallstone obstructing?
The common bile duct. Obstructing the common bile duct allows no collateral pathway for drainage of bile into the duodenum .
45
A tumor at the tail of the pancreas will compromise blood supply to what organ?
Blood supply of the spleen can be affected because its splenic artery is adjacent to the superior border of the pancreas.
46
Tumor at the head of the pancreas that involves the uncinate process may occlude which vessel?
The superior mesenteric artery, because it crosses the uncinate process and third part of duodenum.
47
Cholecystitis (inflamed gallbladder) pain and jaundice indicates
Blockage of release of bile into the duodenum --\> common bile duct is likely occluded
48
A man with severe weight loss has a tumor that's causing portal hypertension. The patient has fatty stool, malnutrition, and liver hypoxia. Where is the tumor most likely located?
Porta hepatis. It transmits the proper hepatic artery, portal vein, common hepatic duct, autonomic nerves, and lymph vessels. Thus, a tumor here could obstruct all of these vessels.
49
In a laproscopic cholecystectomy, what artery has to be clamped to safely remove the gallbladder?
Cystic artery- it goes directly to the gallbladder.
50
A woman had trauma to the ninth and tenth rib, resulting in intrabadominal bleeding, hypovolemic shock, and progressive hypotension. What organ was likely injured?
Spleen - it's always 9, 10, and 11
51
A woman has abdominal pain around her umbilicus and can't stop vomiting. She has numerous gallstones and air accumulation in the gallbladder and biliary tree. Where are we likely to find an obstructive stone?: -Jejunum -Terminal ileum -Common bile duct -Duodenum -Hepatic duct
Terminal ileum. Large intestine pain is referred to the umbilical region. The gallstone probably ulcerated through the gallbladder fundus wall and entered the transverse colon, or through the gallbladder bodyw all and entered the duodenum. At this ileocecal junction, it causes intestinal obstruction. "Clear biliary tree" -\> can't be common bile duct or hepatic duct
52
An obstruction at the ____ would cause referred pain to the scapula and jaundice.
Hepatopancreatic ampulla of vater
53
An obstruction at ____ would cause pain that mimics appendicitis and bowel sounds will be exaggerated.
Ileocecal region. Ex) Gallstone ileus: gallstone ulcerates through body of the gallbladder into the duodenum.
54
Intense radiating pain to the top of the left shoulder after a trauma indicates...
Spleen rupture (Kerh's sign)
55
A woman has gallbladder stones and it's difficult to insert a catheter into the gallbladder- what structure is likely interfering with passage of the catheter into the cystic duct?
Spiral valve of Heister is in the duct; it maintains the patency of the duct but could also be a point of constriction.
56
A pancreatic pseudocyst would formed be in the greater/lesser sac
The floor of the omental bursa because it's directly anterior to the pancreas.
57
A man has a tumor- ductus adenocarcinoma- at the neck of the pancreas. What structure will receive metastatic cells first? What vessel could be obstructed?
Liver would receive the metastatic cells first because they'd flow through the portal venous system from the pancreas to the liver. The portal vein is the most likely structure to be occluded by a large tumor at the pancreas neck because it's nearby; the pancreas is drained via the splenic vein and empties into the portal vein.
58
A woman has jaundice and epigastric pain migrating towards the patient's right side and posteriorly toward the scapula. Which is the most likely site for a gallstone to lodge? Common bile duct Hepatopancreatic ampulla of Vater Left hepatic duct Pancreatic duct
The ampulla of vater at the junction of the pancreatic duct and common bile duct is the narrowest part of the biliary duct system.
59
Pain that starts in the epigastrium and moves to the right hypogastrium; fever; and positive Murphy's sign indicate
Cholecystitis
60
A woman had pain from the epigastrium that moved to the right hypochondrium region. She has a tender abdomen, positive murphy sign, thickened gallbladder wall, and elevated bilirubin. What structure is most likely obstructed?
Common bile duct obstruction - Causes cholecystitis bc backflow to gallbladder - Causes increased serum bilirubin bc backflow to liver
61
The third part of the duodenum
Inferior part; longest and crosses over the IVC, aorta, and vertebral column.
62
In a cholecystectomy, you have to ligate the \_\_\_, which is located within Calot's triangle (cystic duct + liver + common hepatic duct)
Cystic artery
63
A neurectomy is performed to interrupt the neural pathway carrying pain from the pancreas. Which structure was severed?
Foregut -\> Celiac ganglion. Nerve cell bodies of these visceral afferent fibers are located in the DRG of T5-T9
64
If you cut the cystic artery, what branch of the nervous system traveling along with the artery is also cut?
Foregut -\> Celiac plexus
65
Patient has gallstones. He has cramping midabdominal pain, abdominal distention, and vomiting. There's air in the gallbladder and biliary tree. No jaundice, biliary colic, or cholangitis. Where is a gallstone lodged?
Air in the biliary tree rules out common bile duct or hepatic duct because gallstones there would fill the tree with bile.
He probably has gallstone ileus -\> Ileum
66
Blockage at the inferior mesenteric artery. What artery can provide collateral to the descending colon?
Middle colic artery.
67
Patient has cirrhosis of the liver. He most likely has enlarge anastomoses between which of the following pairs of veins? -Inferior & superior phrenic -Left & middle colic -Left gastric & esophageal -Lumbar & renal -Sigmoid & superior rectal
Left gastric & esophageal. Cirrhosis -\> blood backs up into systemic circulation --\> drains into IVC, with pooling at portal-caval anastomoses.
68
A man has bleeding from his esophageal varices. Which surgical venous anastomoses is most commonly used to relieve his symptoms? -Left gastric to splenic vein -Right gastric to left gastric vein -Splenic to left renal vein -Superior mesenteric to inferior mesenteric vein
Splenic to renal vein. Need to alleviate symptoms by connecting a large portal vein to a large systemic vein. The other options are all in the portal venous system.
69
Duodenal ulcer to the first portion of the duodenum causes profuse bleeding. What artery got hit?
Posterior superior pancreaticoduodenal artery from the gastroduodenal artery feeds the first part of the duodenum.
70
A man has hypertension, poor appetite, and pulsation in his epigastric region. Which diagnosis is most likely?: -Hiatal hernia -Splenomegaly -Cirrhosis -Aortic aneurysm -Kidney stone
Aortic aneurysm btwn L3-L4 would cause the epigastric pulsation and hypertension. The others are associated with referred pain and no htn.
71
A man has hepatomegaly and esophageal varices. He is also jaundiced and has caput medusae on his anterior abdominal wall. Which is most likely obstructed for development of caput medusae? -Portal vein -IVC -Lateral thoracic vein -Superficial epigastric vein
Portal vein- the central connection of anastomoses.
72
What vessels provide collateral between the celiac trunk and superior mesenteric artery?
Superior and inferior pancreaticoduodenal. Blood supply from inferior pancreaticoduodenal artery via the SMA can provide collateral to teh head of the pancreas and first part of duodenum when celiac trunk is occluded.
73
Severe portal htn causes caput medusae. What is it?
Anastomoses between veins that accompany the ligamentum teres hepatis (within the falciform ligament) with veins of the anterior abdominal body wall. Umbilical veins are expanded.
74
A man has caput medusae. The blood vessel obstructed in this patient is formed by the union of what vessels?
The portal vein is formed by superior mesenteric & splenic veins.
75
A man has vomiting, postprandial epigastric pain, distended abdomen, and high pitched bowel sounds. The angle between his SMA and the aorta is severely decreased. What structure is most likely to be obstructed by the artery? -Ascending duodenum -Descending duodenum -Duodenal bulb -Duodenojejunal flexure -Transverse duodenum
The transverse duodenum is at L3 between the aorta and SMA.
76
A patient has pain in the back and left shoulder as well as an abscess in the left kidney. What got inflamed?
Abscess inflammation may have spread to the diaphragm to cause referred shoulder pain since the diaphragm is near by the superior poles of the kidneys. The phrenic nerves that innervate the diaphragm come form C3,4,5, which is where somatic afferents from the back enter.
77
What vessel is at risk of being compressed by the SMA?
Left renal vein. This could cause occlusion of any veins that empty into the left renal vein, such as the left testicular vein --\> testicle pain
78
How do you distinguish between a sliding and a paraesophageal hiatal hernia?
In sliding hiatal hernias, the gastroesophageal junction is displaced anteriorly into the mediastinum.
79
What vessel crosses the ureter just lateral to the cervix of the uterus?
**Uterine artery.**
80
A woman has pain radiating from her lower back toward and above her pubic symphysis. She has a kidney stone partially obstructing her right ureter. What nerve is most likely responsible for conducting the sensation of pain?
**Ilioinguinal nerve** receives fibers from L1 and innervates the skin from the iliac crest to the upper portions of the labia.
81
After swallowing a bone, a patient has perforation of the intraabdominal portion of the esophageal wall. Which of these arteries was most likely injured?
* Branches of left gastric
* Bronchial
* Thoracic intercostal
* Branches of right gastric
* Right inferior phrenic
Branches of left gastric.
## Footnote
The **bronchial artery** supplies only a small par tof the esophagus right below the carina.
The **inferior phrenic** supplies the portion of the esophagus just inferior to the diaphragm
The **left gastric artery** supplies the lowest part of the esophagus below the diaphragm.
.
82
The pancreas and liver are at teh level of T\_\_ and below.
The kidneys are at the level of what vertebra range?
Pancreas & liver: T12 and below
Kidneys: T12 - L3
83
Perinephric fat, renal fascia, and paranephric fat
84
If someone has a perinephric abscess, where is the fluid?
Between the renal capsule and the renal fascia.
85
Ureter is normal size, but the renal pelvis is enlarged and the renal calyces were rounded/blunted. Where is the kidney stone most likely lodged?
* Ureter at uretero-vesical junction
* Ureter at pelvic brim
* Ureter at the uretero-pelvic junction
Uretero-pelvic junction because it's the only one where the ureters are normal size.
86
A patient has pain from the lowerback towards her pubic symphysis due to a kidney stone obstructing the lower part of her right ureter. The stone is probably lodged where the ureter crosses which structure?
The common iliac artery
## Footnote
The lower part of the ureter is narrowed at the point where it crosses the common iliac artery where it opens into the bladder at the vesicoureteric junction.
87
88
Gastroschisis results from failure of proper formation of which?
* Head fold
* Tail fold
* Neural folds
* Lateral folds
* Amnion
It's due to a defect in the anterior abdominal wall muscles, so lateral folds.
89
The left vagus nerve on the stomach rotates ___ degrees to become the ___ vagal trunk
90 degrees to become the anterior
90
An infant has an umbilical hernia and another organ is attached to the inner surface of the hernia. What portion of the GI tract is most likely to be attached to the inner surface of the umbilical hernia?
This is Meckel's diverticulum (persistent vitelline duct), so it's ileum
91
A woman has bloody stool and a lesion of the ileum intestinal wall that contains gastric mucosa. What's the diagnosis?
Meckel's diverticulum
92
A male fetus has viscera protruding into the amniotic cavity due a defect on his right side, lateral to the medial plane. Which of the following conditions explains this?
* Nonrotation of midgut
* Patent urachus
* Abdominal contents have not returned from the umbilical cord
* Incomplete closure of the lateral folds
* Persistent cloacal membrane
Gastroschisis results from incomplete closure of lateral folds due to a defect in the medial plane of the abdominal wall --\> epigastric hernia with viscera protruding int othe amniotic cavity withou ta peritoneal covering.
93
A baby vomits stomach contents and bile. He also can't pass meconium. What is the most common cause of this condition?
* Infarction of fetal bowel due to volvulus
* Incomplete closur eof lateral folds
* Failure of recanalization of the ileum
* Remnant of the proximal portion of hte omphaloenteric duct
* Nonrotation of the mdigut
Infarction of fetal bowel due to volvulus
94
A baby has anal stenosis. What's the cuase?
Dorsal deviation of the urachal septum
95
A 21 yo man has periumbilical pain. He has internal bleeding about 2 feet proximal to the ielocecal junction. What is the most likely diagnosis?
* Ruptured appendix
* Volvulus
* Diverticulosis
* Ileal (Meckel's) diverticulum
* Borborygmi
Ileal (Meckel's) diverticulum - if the diverticulum (remnant of vitelline duct) gets infected, it produces pain in the umbilical region fo the abdomen and can cause bleeding.
96
There is urine draining from the umbilicus of a newborn infant. Which developmental defect is most likely to explain this finding?
* Obliterated distal end of urachus
* Obliterated proximal end of the urachus
* Completely patent urachus
* Patent urachus at one point alogn its length
* Completely obliterated urachus
Completely patent urachus.
## Footnote
The urachus is a remnant of the allantois, which connected the bladder to the umbilicus in the fetus to excrete waste in the mrbyo.
97
Abnormal patent connection between ileum and umbilicus
Omphaloenteric/vitelline fistula
98
A newborn girl with Down's starts vomiting afte rher first feeding and the vomitus is stained with bile. Which condition is most likely?
* Atresia of the third part of the duodenum
* Atresia of the first part of the duodenum
* Congenital hypertrophic pyloric stenosis
* Esophageal estenosis
* Tracheoesophageal fistula
Down's is associated with duodenal atresia, btu to get bile in the vomit, it has to be past the first part of the duodenum --\> atresia of third part of duodenum
99
If you give a woman relaxin to relax the sacroiliac joint and pubic symphysis, which of the following would most likely be UNaffected?
* Transverse diameter
* Interspinous distance
* True conjugate diameter
* Diagonal conjugate
* Oblique diameter
True conjugate diameter (antero-posterior) is not altered by relaxation of the pelvic joints.
