Overview/Review of Abdominal Wall, GI Tract, and Peritoneum

Question 1

Abdominal aorta

Question 2

Celiac plexus neurolysis

Answer 2

Nerves on the celiac trunk that form a plexus; goes to all the thigns the celiac artery supplies.

Visceral afferents travel with them and can be teh source of a lot of pain (e.g. pancreatic cancer.)

Thus, neurolysis ( high conc alcohol) is used as an anesthetic to offer pain relief.

Question 3

Superior mesenteric artery

Question 4

Inferior mesenteric artery

Question 5

If a perforated ulcer reaches the posterior wall fo the duodenal bulb (1st part of duodenum), what large artery is at risk of injury/hemorrhage

Answer 5

Gastroduodenal

Question 6

If you lose the inferior mesenteri cartery in a repair of an abdominal aneurysym, what will supply the hindgut?

Question 7

Portal venous system- what veins are involved?

Answer 7

Venous blood from the gut goes to the liver for detoxification.

• Inferior mesenteric vein drains into splenic vein
• Splenic vein and superior mesenteric vein join to make the portal vein.
• Contributions from gastric veins and esophageal veins.

Question 8

Porto-systemic anastomoses & their significance in portal hypertension

Answer 8

Portal hypertension from cirrhosis –> high pressure in the liver sends blood from the portal system (which is valveless) to the systemic system (going backwards).

(1) GE junction: left gastric vein (p)+ esophageal vein of azygos system (s) -> esophageal varices
(2) Anorectal junction: superior rectal vein (p) + middle&inferior rectal vein (s) ->anorectval varices
(3) Ant abd wall around umbilicus: paraumbilical veins (p) + ant abd wall veins ->caput medusae

Question 9

Autonomic innervation of organs in the upper abdomen associated with the foregut - referred pain, administration of anesthesia, surgical procedures, cancer pain mgmt

Question 10

Spleen position, blood supply, surface markings, relations, and peritoneal attachments.

Answer 10

• Position: In development, it turns to the left upper quadrant
• Blood supply: splenic artery from celiac trunk
  
  • A CT scan will only see little pieces of it at a time because it’s torturous (distinguishes it form a splenic vein).
• Function: Spleen makes blood cells; filters blood
  
  • Can be enlarged in blood diseases
  • Protects against pneumococcus
• Embryo: Develops in teh dorsal mesoderm and dorsal mesogastrum, which evelops posteriorly and rotates to teh left and sits int eh left upper quadrant above the splenic flexure.
• Collateral blood supply: short gastric vessel from splenic artery

Question 11

Collateral blood flow to the spleen

Question 12

Spleen in trauma and hematopoietic disorders

Question 13

What part of the pancreas is NOT retroperitoneal?

Answer 13

Just the tail - attached to spleen.

Question 14

A patient has fever, chills, and severe abdominal pain. He has a posterior perforation of his stomach due to ulcerations. What structure is responsible for the movement of infected fluid from the perforation to the peritoneal cavity?

Answer 14

Omental foramen of Winslow

Question 15

A surgeon opens the lesser sac of the peritoneum to access the oragn located in the posterior aspect of the lesser sac. Which of the following structures is she most likely to locate?

Answer 15

She’s trying to get to the pancreas. The splenic artery and splenic vein go to the pancreas.

Question 16

What organ is on the anterior of the lesser sac? What organ is on the posterior?

Answer 16

Anterior- stomach

Posterior - Pancreas

Question 17

Where is the ligament of treitz?

Answer 17

A peritoneal attachment where the beginning of the jejunum and the end of the duodenum is fixed to the posterior abdominal wall. So if you looked under the transverse colon, you’d see it at the beginning of the jejunum.

Question 18

A surgeon had to ligate the gastroduodenal artery. How will the head of pancreas continue to receive blood?

Answer 18

Inferior pancreaticoduodenal artery.

The head of the pancreas has dual blood supply:

From the celiac trunk - gastrodudenal artery.

From the superior mesentery - inferior pancreaticoduodenal artery.

Question 19

A surgeon uses a transverse incision just inferior to the arcuate line to acccess organs in the pelvis. All of these abdominal wall layers will be encountered during the incision except the:

• Anterior rectus sheath
• Posterior rectus sheath
• Rectus abdominis muscle
• Skin and subcutaneous tissue
• Transversalis fascia, extraperitoneal fat, and peritoneum

Answer 19

Posterior rectus sheath, because there is no posterior rectus sheath below the arcuate line.

Question 20

What is the name of the region between the two rectus sheaths?

Answer 20

The linea alba.

Question 21

A hernia is located with a small knuckle of intestine projected through the abdominal wall just above the inguinal ligament and lateral to the epigastric vessels. What kind of hernia is this?

Answer 21

Indirect inguinal hernia because lateral to the epigastric vessels.

Question 22

Which of the following structures passes through the deep inguinal ring?

• Iliohypogastric nerve
• Ilioinguinal nerve
• Inferior epigastric artery
• Medial umbilical ligament
• Round ligament of the tuerus

Answer 22

Round ligament of the uterus is in the canal- remember that the gonads in the posterior wall get pulled down through the canal by the gubernaculum.

The ilioinguinal nerve does go to the inguinal canal and leaves through the superficial ring, but it enters through the side- not the deep ring.

The hypogastric nerve runs between the int oblique & transversus abdominus, piercing the int oblique at the anterior superior iliac spine and travelign deep to just the external oblique.

Inferior epigastric is in the lateral fold

Question 23

The deep inguinal ring is an opening in which of the following structures?

• Ext abdominal oblique
• Falx inguinalis
• Internal abdominal oblique
• Scarpa’s fascia
• Transversalis fascia

Answer 23

Transversalis fascia.

The external abdominal oblique is responsible for the superificial ring!

Question 24

Occlusion of the inferior mesenteric artery is seldom symptomatic because its territory may be supplied by the branches of the

Answer 24

Middle colic.

SMA > middle >marginal > left side of the colon.

Question 25

The inferior mesenteric artery is often occluded without symptoms; its nromal area of distribution therefore must be mainly supplied by collateral blood flow between which arteries?

• Ileocolic & right colic
• Left & middle colic
• Left colic & sigmoidal
• Right & middle colic
• Sigmoidal & superior rectal

Answer 25

Left and middle colic arteries shunt blood are collaterals for the IMA.

Question 26

Visceral pain is often referred to a site on the body wall that is innervated by the same spinal cord segment that innervates the visceral organ involved.

Pain of appendicitis is often first felt around the umbilicus, indicating that the appendix gets its visceral afferents from which spinal cord segment?

Answer 26

T10

Question 27

The spleen usually doesn’t descend below the costal margin, but it will push downward and medially when pathologically enlarged. What structure limits the straight vertical downward movement of the spleen?

• Left colic flexure
• Left suprarenal gland
• Ligament of Treitz
• Pancreas
• Stomach

Answer 27

Left colic flexure/splenic flexure is right below the spleen; it is a continuation of the transverse and descending colon.

Question 28

What keeps the splenic flexure from moving?

Answer 28

The colicophrenic ligament attaches the splenic flexure up to the diaphragm and to the back wall; it also prevents infection from moving up past the pelvis. The right side doesn’t have it.

Question 29

The artery of the midgut

Answer 29

SMA

Question 30

A patient is diagnosed with a bleeding ulcer of the lesser curvature of the stomach. Which artery is most likely involved?

Answer 30

Left gastric

Question 31

Which of the following structures does not lie at least partially in the retroperitoneum?

• Adrenal gland
• Duodenum
• Kidney
• Pancreas
• Spleen

Answer 31

Spleen

SADPUCKER: Suprarenal(adrenal glands); Aorta; Duodenum(2-4); Pancreas; Ureters; Colon (descending and ascending); Kidney; Esophagus; Rectum

Question 32

Why are varices from portal hypertension dangerous?

Answer 32

They are prone to bleeding -> vomiting or pooping blood