Abdomen Clinical Cases

Question 1

clinical significance of fascia and fascial spaces of abdominal wall

Answer 1

-suture membranous layer of subcutaneous tissue separately bc of its strength
-between membranous layer and deep fascia -> potential space
-fluid accumulation cannot spread inferiorly into thigh bc membranous layer of subcutaneous tissue attaches to pubic bone and fuses with deep fascia of thigh (fascia lata) along a line inferior and parallel to inguinal ligament

Question 2

abdominal surgical incision

Answer 2

-splits muscle between their fibers during surgery to avoid transecting (necrosis)
-rectus abdominus can be transected bc its muscle fibers are short and nerves entering the lateral part of rectus sheath can be located and preserved
-overlapping areas of innervation between nerves in abdominal wall -> 1 or 2 small branches of nerves may be cut without noticeable loss of motor supply to muscles for loss of sensation to skin

Question 3

minimally invasive surgery

Answer 3

-endoscope
-tiny perforation into abdominal wall
-allow entry of remotely operated instruments
-potential for nerve injury, incisional hernia, or contamination of open wound and time required for healing are minimized

Question 4

protuberance of abdomen

Answer 4

-6 common cause of abdominal protrusion:
-food, fluid, fat, feces, flatus, fetus
-eversion of umbilicus may be sign of increased intraabdominal pressure, usually from ascites (abnormal accumulation of serous fluid into peritoneal cavity) OR large mass (tumor, fetus, enlarged organ)

Question 5

incisional hernia

Answer 5

-if muscular aponeurotic layers of abdomen do not heal properly -> hernia may occur through defect
-incisional hernia -> protrusion of omentum (fold of peritoneum) or organ through surgical incision or scar

Question 6

palpation of anterolateral abdominal wall

Answer 6

-warm hands!
-cold hands -> muscles tense -> involuntary spasms (guarding)
-intense guarding- occurs during palpation when organ is inflamed and itself constitutes sign of acute abdomen
-involuntary spasms attempt to protect inflamed viscera from pressure
-shared segmental nerve supply of organ and skin and muscles -> spasms
-pt should be supine, thighs and knees semiflexed -> relaxed
-deep fascia of thighs pulls membranous layer of abdominal subcutaneous tissue tensing the abdominal wall when legs are out straight

Question 7

reversal of venous flow and collateral pathways of superficial abdominal veins

Answer 7

-flow in superior or inferior vena cava obstructed -> anastomoses between tributaries of systemic veins (thoracoepigastric) -> provide collateral pathways
-bypass obstruction
-allow blood return to heart

Question 8

peritoneum and surgical procedures

Answer 8

-peritoneum is well innervated -> pain during surgery (laparotomy)
-high incidence of infection - peritonitis and adhesions post op involving opening peritoneal cavity
-avoid opening peritoneal always
-translumbar approach to kidneys
-great effort to avoid contamination if need be

Question 9

peritonitis and ascites

Answer 9

-bacteria contamination, gut penetrated or ruptured as result of infection/inflammation, allowing gas, fecal matter, bacteria to enter -> infection to peritoneum -> peritonitis
-exudation of serum, fibrin, cells, pus into peritoneal cavity
-pain overlying skin and increase in tone of overlying muscles
-generalized peritonitis- (widespread)- dangerous and sometimes lethal
-abdominal pain, tenderness, nausea, vomiting, fever, constipation
-excess fluid in peritoneum- ascitic fluid -> ascites
-ascites- also occurs with injury (blood), portal hypertension (venous congestion), widespread metastasis of cancer to abdominal viscera -> can be distended with liters of fluid and influence viscera movement
-paradoxical abdominothoracic rhythm (abdomen drawn in during inspiration) and muscle rigidity-> peritonitis or pneumonitis present
-lie with knees flexed to relax abdominal muscles, breathe shallow (rapid)

Question 10

peritoneal adhesions and adhesiotomy

Answer 10

-peritoneum damage (stab, infection) -> surface becomes inflamed -> sticky with fibrin
-fibrin may be replaced with fibrous tissue -> form abnormal attachments between visceral peritoneum and adjacent viscera or between visceral peritoneum of viscus and parietal peritoneum of adjacent abdominal wall
-common post op
-chronic pain
-intestinal obstruction when gut twists around adhesion (volvulus)
-adhesiotomy- surgical separation
-common in cadavers (spleen to diaphragm)

Question 11

abdominal paracentesis

Answer 11

-removal of ascitic fluid
-if infection -> large doses of antibiotics
-needle/trocar and cannula inserted into peritoneal cavity through linea alba
-inserted superiorly to the empty urinary bladder
-avoid inferior epigastric artery

Question 12

function of greater omentum

Answer 12

-large fat laden
-prevents visceral peritoneum from adhering to parietal peritoneum
-high mobility and moves around peritoneal cavity with peristaltic movements of viscera
-forms adhesions adjacent to inflamed organ (appendix) -> protects other viscera from it

Question 13

spread of pathological fluids

Answer 13

-peritoneal recesses determine extent and direction of spread of fluids that may enter peritoneal cavity when an organ is diseased or injured
-pus, fluid, product of inflammation

Question 14

overview of embryological rotation of midgut

Answer 14

-primordial gut consists of foregut (esophagus, stomach, pancreas, duodenum, liver, biliary ducts), midgut (small intestine distal to bile duct, cecum, appendix, ascending colon, and most of transverse colon), hindgut (distal transverse colon, descending and sigmoid colon, and rectum)
-for 4 weeks- rapidly growing midgut supplied by SMA -> herniated into proximal part of umbilical cord
-it is attached to umbilical vesicle (yolk sac) by omphaloenteric duct (yolk stalk)
-midgut rotates 270 degrees around axis of SMA as it returns to abdominal cavity
-mesenteries shorten and/or disappear
-malrotation of midgut results in several congenital anomalies such as volvulus (twisting) of intestine

Question 15

hiatal hernia

Answer 15

-protrusion of part of stomach into mediastinum through esophageal hiatus of diaphragm
-after middle age -> weakening of muscular part of diaphragm and widening of esophageal hiatus
-2 main types- paraesophageal and sliding
-paraesophageal- cardia remains in normal position but pouch of peritoneum (often containing fundus) extends through esophageal hiatus anterior to esophagus -> usually no regurgitation of gastric contents bc cardiac orifice is in normal place
-sliding- abdominal part of esophagus, cardia, and parts of fundus slide superiorly through esophageal hiatus into thorax (especially when lying down and bending over) -> some regurgitation bc clamping action of right crus of diaphragm on inferior end of esophagus is weak

sliding
-cardiac portion of stomach come up into chest
-gaining weight -> pressure -> moves things up
-slides back and forth
-reflux

paraesophageal
-herniate through diaphragm
-next to esophagus
-need repair often
-size dependent
-painful

Question 16

carcinoma of stomach and gastrectomy

Answer 16

-body or pyloric part of stomach contains a malignant tumor -> mass may be palpable
-gastroscopy- inspect lining of air-inflated stomach -> observe gastric lesions and take biopsies
-1 or more arteries may be ligated without seriously affecting blood supply to remaining stomach bc
-Partial gastrectomy (remove part of stomach) to remove carcinoma
-1 or more arteries may be ligated without seriously affecting blood supply to remaining stomach bc anastomoses
-partial gastrectomy requires removal of all lymph nodes -> cancer frequently occurs in the pyloric region -> removal of pyloric and gastroomental lymph nodes
-as cancer progresses malignant cells go to celiac lymph nodes where all gastric nodes drain

Question 17

gastric ulcers, peptic ulcers, helicobacter pylori, and vagotomy

Answer 17

-Gastric ulcers- open lesions of mucosa in stomach
-peptic ulcers- lesions of mucosa of pyloric canal or duodenum
-associated Helicobacter pylori infection -> high acid level in stomach and duodenum overwhelms bicarbonate normally produced by duodenum -> reduces effectiveness of mucous lining -> vulnerable to H. pylori
-bacteria erode protective mucous lining of stomach -> inflame mucosa -> make it vulnerable to gastric acid and digestive enzymes (pepsin) in stomach
-If the ulcer erodes into gastric arteries -> life-threatening bleeding
-secretion of acid by parietal cells of stomach controlled by vagus nerves -> vagotomy for people with chronic or recurring ulcers
-posterior gastric ulcer may erode through stomach wall into pancreas-> referred pain to back-> erosion of splenic artery -> severe hemorrhage into the peritoneal cavity

Question 18

appendicitis

Answer 18

-Acute inflammation of appendix -> acute abdomen (severe sudden pain
-McBurney point- maximum abdominal tenderness with pressure
-starts as vague pain in periumbilical area bc fibers enter spinal cord at T10
-Later -> pain in RLQ from irritation of posterior parietal peritoneum

Question 19

appendectomy

Answer 19

-inflate peritoneal cavity with CO2 -> distends -> view and working space
-laparoscope near or through umbilicus
-may be performed through transverse or gridiron (muscle splitting) incision centered at McBurney point in RLQ if indicated
-malrotation of intestine- failure of descent of cecum -> when cecum is high (subhepatic cecum -> appendix in right hypochondriac region

Question 20

diverticulosis

Answer 20

-disorder
-multiple false diverticula (external evaginations or outpocketing of mucosa) develop along intestine
-middle aged and elderly
-sigmoid colon
-subject to infection and rupture -> diverticulitis

Question 21

Ileal diverticulum

Answer 21

-congenital
-1-2%
-severe inflammation and ulceration of colon and rectum
-colectomy- terminal ileum, colon, rectum and anal canal are removed in some cases
->ileostomy- constructed to establish artificial cutaneous opening between ileum and skin of abdominal wall
-partial colectomy -> colostomy or sigmoidostomy -> create artificial cutaneous opening for terminal part of colon

Question 22

colonoscopy

Answer 22

-long fiberoptic endoscope (colonoscope)
-inserted into colon through anus and rectum
-minor procedures- bx or removal of polyps
-most tumors of large intestine occur in rectum
-only stretch and visceral pain

Question 23

subphrenic abscesses

Answer 23

-peritonitis can cause abscesses (localized pus)
-common site- subphrenic recesses
-more common right side bc frequency of ruptured appendices and perforated duodenal ulcers
-right and left subphrenic recesses are continuous with hepatorenal recess -> pus may drain into it especially when bedridden
-subphrenic abscess is often drained by incision inferior to 12th rib

Question 24

liver biopsy

Answer 24

-needle puncture through right 10th intercostal space in midaxillary line
-before biopsy pt is asking to hold their breath in full expiration to reduce costodiaphragmatic recess and lessen possibility of damaging lung and contaminating pleural cavity

Question 25

rupture of liver

Answer 25

-less vulnerable to rupture than spleen but still at risk due to large size, fixed position, and friability
-torn by fractured rib that perforates the diaphragm
-vascularity and friability -> laceration causes considerable hemorrhage and right upper qaud pain

Question 26

cirrhosis of liver

Answer 26

-hepatocytes destroyed and replaced by fibrous tissue
-this happens on tissue surrounding intrahepatic blood vessels and biliary ducts
-makes liver firm and impeding circulation of blood through it
-most common cause of portal hypertension (there are many causes)
-frequent of chronic alcohol
-ovarian cancer
-ascites needs to be drained
-U/S

Question 27

hepatic lobectomies and segmentectomy

Answer 27

-right and left hepatic arteries, ducts, branches of right and left portal veins -> do not communicate significantly
-hepatic lobectomies are possible!
-removal of right or left part of liver without significant bleeding
-segmentectomy- removal of segment affected by injury/cancer
-intersegmental hepatic veins guide interlobular planes

Question 28

gallstones

Answer 28

-concretions in cystic duct, hepatic ducts, bile duct
-distal end of hepatopancreatic ampulla is narrowest part of biliary passage -> common site for impaction of gallstone
-gallstones can produce biliary colic (pain in epigastric region)
-gallbladder relaxation -> stone in cystic duct may pass back into gallbladder
-cholecystitis- stone blocks gallbladder causing inflammation -> bile accumulation causes enlargement
-pain develops in epigastric region and shifts to right hypochondriac region at junction of 9th costal cartilage and lateral border of rectus sheath
-inflammation of gallbladder -> can cause posterior thoracic wall or right shoulder pain due to irritation of diaphragm
-if bile cant leave gallbladder -> enters blood -> obstructive jaundice

Question 29

cholecystectomy

Answer 29

-biliary colic -> gallbladder removal
-laparoscopic cholecystectomy
-cystic artery arises from right hepatic artery in cystohepatic triangle (calot triangle)
-cystohepatic triangle- inferiorly cystic duct, medially common hepatic duct, superiorly inferior surface of liver
-dissection of cystohepatic triangle early during cholecystectomy -> safeguards important structures

Question 30

visceral referred pain

Answer 30

-poorly localized visceral pain
-dull to severe
-radiates to dermatome level that receives visceral sensory fibers from organ concerned
-t10- umbilical

Question 31

section of a phrenic nerve

Answer 31

-complete paralysis
-eventual atrophy of muscular part of corresponding diaphragm half
-recognized radiographically by permanent elevation and paradoxical movement

Question 32

referred pain from diaphragm

Answer 32

-diaphragmatic pleura or peritoneum
-referred to shoulder area
-area of skin supplied by C3-C5 -> also contribute anterior rami to phrenic nerves
-peripheral regions of diaphragm innervated by inferior intercostal nerves -> this pain is referred to skin over costal margins

Question 33

rupture of diaphragm and herniation of viscera

Answer 33

-can result from sudden large increase in intrathoracic or intraabdominal pressure
-commonly caused by severe trauma to thorax or abdomen during MVA
-most on left side (95%) bc substantial mass of liver being very close with diaphragm -> physical barrier
-lumbocostal triangle- non-muscular area between costal and lumbar parts of diaphragm -> normally formed only by fusion of superior and inferior fascias of diaphragm
-traumatic diaphragmatic hernia -> stomach, small intestine, mesentery, transverse colon, and spleen may herniate through this area into thorax
-hiatal/hiatus hernia- protrusion of part of stomach into thorax through esophageal hiatus
-structures that pass through esophageal hiatus (vagal trunks, left inferior phrenic vessels, esophageal branches of left gastric vessels) may be injured in surgical procedures on esophageal hiatus (repairs of hiatus hernia)

Question 34

congenital diaphragmatic hernia

Answer 34

-congenital diaphragmatic hernia (CDH)- part of stomach and intestine herniate through large posterolateral defect (foramen of Bochdalek) in region of lumbocostal trigone of diaphragm
-almost always on left bc liver on the right
-hernia results from complex development of diaphragm
-posteriolateral defect of diaphragm- only relatively common congenital anomaly -> abdominal viscera in prenatal pulmonary cavity -> 1 lung (usually left) does not have room to develop or inflate after birth
-pulmonary hypoplasia results (undersized lungs) -> mortality rate is high (76%)

Question 35

rectal examination

Answer 35

-palpate through its walls
-prostate and seminal glands in males and cervix in female
-pelvic surfaces of sacrum and coccyx can be palpated
-enlarged internal iliac lymph nodes, thickening of ureters, swellings in ischioanal fossae, abnormal contents in rectovesical pouch in male or pouch in female
-ischial spines and tuberosities
-inflamed appendix if descends into lesser pelvis (pararectal fossa)

Question 36

resection of rectum

Answer 36

-cancer treatment
-males- the plane of rectovesical septum is located so that the prostates and urethra can be separated from rectum
-avoids damage of these organs

Question 37

ischioanal abscesses

Answer 37

-ischioanal fossae can become infected -> formation of ischioanal abscesses
-collections of pus are painful
-S&S- fullness and tenderness between anus and ischial tuberosity
-perianal abscess may rupture spontaneously -> opening into anal canal, rectum, or perianal skin

Question 38

internal hemorrhoids

Answer 38

-piles
-prolapses of rectal mucosa containing normally dilated veins of internal rectal venous plexus
-result from breakdown of muscularis mucosae (smooth muscle layer deep to mucosa)
-ones that prolapse through anal canal -> compressed by contracted sphincter -> impede blood flow -> Strangulate and ulcerate
-presence of abundant arteriovenous anastomoses
-bleeding is bright red
-commonly occur in absence of portal hypertension

Question 39

external hemorrhoids

Answer 39

-thrombi in veins of external rectal venous plexus
-covered by skin
-predisposing factors- pregnancy, chronic constipation, disorder that impedes venous return, increased pressure
-anastomoses among superior, middle, and inferior rectal veins form communications between portal and systemic venous systems
-superior rectal vein drains into inferior mesenteric vein
-middle and inferior rectal veins drain through systemic system into inferior vena cava
-increase in pressure in portal veins -> enlargement of superior rectal veins -> increase blood flow or stasis in internal rectal venous plexus
-portal hypertension- portocaval anastomosis among superior, middle, and inferior rectal veins along with protocaval anastomoses elsewhere -> may become varicose
-veins of rectal plexuses normally appear varicose

Question 40

portal hypertension

Answer 40

-divert blood from portal venous system to systemic venous system
-liver transplants, sometimes preceded by transjugular intrahepatic portosystemic shunt (TIPS) procedure while donor liver is procured
-previously portal veins was connected to IVC or splenic and left renal veins connected (outdated)

Question 41

gastroparesis

Answer 41

-excessive canabis use, certain medications
-vagus nerve damaged
-nausea and bloating
-younger
-pyloric sphincter closed due to vagus nerve

Question 41

diverticular disease

Answer 41

-holes and pouching’s
-where vasa recta penetrate circular layer of colon wall
-area of weakness
-occur where vessel enters -> erosion -> arterial bleed -> massive
-painless bleed -> shocking
-pocket infection- diverticulitis -> IV antibiotics
-abscess complications may need to be drained
-high fiber diet prevents this

Question 41

ischemic colitis

Answer 41

-