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Flashcards in The Abdomen - RR Deck (364):
1

What are the 3 fascia of the anterior abdominal wall?

1. Camper
2. Scarpa
3. Colles

2

What is the Scarpa fascia?

Deep layer of superficial fascia --> Membranous layer continuous with superficial fascia of penis, dartos layer of scrotum, and superficial perineal fascia (Colles).

3

What is the Colles fascia?

Superficial perineal fascia.

4

Scarpa fascia fuses laterally with what?

With fascia lata of the thigh.

5

Scarpa fascia forms what in lower midline?

Fundiform ligament of penis.

6

When incising the anterior abdominal wall lateral to rectus abdominis, the blade penetrares successively through which layers?

1. Superficial fascia
2. Deep fascia
3. External oblique
4. Internal oblique
5. Transversus abdominis
6. Transversalis fascia
7. Extraperitoneal connective tissue
8. Parietal peritoneum

7

Extravasated urine from a ruptured penile urethra may accumulate where?

Deep to Scarpa's fascia.

8

When suturing lower abdominal wall incisions, surgeons may include what for added strength?

The membranous layer of superficial fascia.

9

What are the muscles of the anterior abdominal wall?

Connect rib cage to hip bone as 3 large flat sheets:
1. External + Internal abdominal oblique
2. Transversus abdominis

10

What is the innervation of the muscles of the anterior abdominal wall?

1. Thoracoabdominal (intercostal T7-T11)
2. Subcostal (T12)
3. Iliohypogastric + Ilioinguinal nerves (L1)

11

What is the inguinal canal?

An oblique passage through the abdominal wall connecting the deep and superficial inguinal rings.

12

What does inguinal canal join and what is its role?

Deep and superficial inguinal rings above medial half of inguinal ligament --> Transmits spermatic cord in male and round ligament of uterus in female.

13

What may the inguinal canal contain in MALE that predisposes to indirect inguinal hernia?

Persistent processus vaginalis.

14

What may the inguinal canal contain in FEMALE that predisposes to indirect inguinal hernia?

Persistent processus vaginalis in female, termed the canal of Nuck.

15

What are the boundaries of the inguinal canal? (Roof, floor, anterior and posterior wall).

Roof --> Arching fibers of transversus abdominis and internal abdominal oblique muscles.
Floor --> Medial half of inguinal ligament and lacunar ligament
Anterior wall --> External oblique aponeurosis medially and internal oblique muscle fibers arising from inguinal ligament laterally.
Posterior wall --> Conjoint tendon medially and transversalis fascia laterally.

16

Where does the inguinal canal lie?

Posterior to superficial inguinal ring.

17

What forms the posterior wall of the inguinal triangle?

Transversalis fascia and conjoint tendon.

18

What is the clinical importance of the inguinal triangle?

Site where DIRECT inguinal hernia exits abdominal cavity.

19

What is the other name of the inguinal triangle?

Hesselbach triangle.

20

Give the general definition of hernia?

A hernia is a protrusion of a structure from the space it normally occupies through a weakness in the surrounding walls.

21

Besides small intestine what other structures in FEMALE might herniate?

Ovary and uterine tube.

22

What is the MC type of inguinal hernias?

INDIRECT inguinal hernia --> Much more frequent in men.

23

What are the main organs of the RUQ?

1. Liver (right lobe)
2. Gallbladder
3. Pylorus
4. Duodenum (parts 1-3)
5. Pancreas (head)
6. Right kidney + adrenal
7. Right colic (hepatic) flexure
8. Ascending colon (superior part)
9. Transverse colon (right half)

24

What are the organs of the RLQ?

1. Cecum
2. Appendix
3. Ascending colon (inferior part)
4. Right ovary + uterine tube
5. Right ureter
6. Right spermatic cord
7. Uterus (if enlarged)
8. Urinary bladder (if very full)

25

What are the organs of the LUQ?

1. Liver (left lobe)
2. Spleen
3. Stomach
4. Jejunum + proximal ileum
5. Pancreas (body + tail)
6. Left kidney + suprarenal gland
7. Left colic (splenic) flexure
8. Transverse colon (left half)
9. Descending colon (superior part)

26

What are the organs of the LLQ?

1. Sigmoid colon
2. Descending colon (inferior part)
3. Left ovary + uterine tube
4. Left ureter
5. Left spermatic cord
6. Uterus (if enlarged)
7. Urinary bladder (if very full)

27

What is the course of the herniating structure in INDIRECT inguinal hernia?

The herniating structure exits the abdominal cavity at the deep inguinal ring LATERAL to the inferior epigastric vessels --> Transverses the inguinal canal --> Exits the superficial inguinal ring to descend into the scrotum or labium majus.

28

What embyonic pathway does indirect inguinal hernia follow?

The path of descent of the embryonic testis --> It is due to persistence of a sac-like evagination of the peritoneal cavity --> The processus vaginalis, that normally is obliterated shortly after birth.

29

What is different about inguinal and femoral hernias?

Inguinal --> Superior to the pubic tubercle.
Femoral --> Inferior and lateral to the pubic tubercle.

30

What are the important structures of the inguinal region?

1. Superficial inguinal ring
2. Deep inguinal ring
3. Inguinal ligament
4. Lacunar ligament
5. Conjoint tendon
6. Pectineal ligament
7. Iliopubic tract

31

From where is superficial inguinal ring derived?

Aponeurosis of external abdominal oblique.

32

Where does the superficial inguinal ring lie?

Above and lateral to pubic tubercle.

33

What does superficial inguinal ring transmit?

Spermatic cord or round ligament.

34

From where does deep inguinal ring derived?

Oval defect in transversalis fascia.

35

Where does deep inguinal ring lie?

Lateral to inferior epigastric vessels + just above inguinal ligament.

36

From where is inguinal ligament derived?

Lower border of external oblique aponeurosis.

37

What is the course of the inguinal ligament?

Extends from anterior superior iliac spine to pubic tubercle --> Curves inward, forming shallow through that contains structures in inguinal canal.

38

From where is lacunar ligament derived?

Medial portion of inguinal ligament.

39

What is the course of the lacunar ligament?

Passes posteroinferiorly --> forming medial border of femoral ring.

40

From where is conjoint tendon derived?

Aponeuroses of transversus abdominis and internal abdominal oblique muscles.

41

What is the functional role of the conjoint tendon?

Reinforces posterior wall of superficial inguinal ring.

42

From where is pectineal ligament derived?

Lacunar ligament.

43

What is the clinical importance of pectineal ligament?

In inguinal hernia repair will hold sutures anchoring conjoint tendon.

44

From where is the iliopubic tract derived?

Thickened inferior margin of transversalis fascia.

45

What is the clinical importance of iliopubic tract?

Landmark on internal aspect of inguinal ligament on laparoscopic view.

46

What is the incidence of DIRECT inguinal hernia compared to indirect?

50% or less frequency of indirect inguinal hernias.

47

What is the target group of DIRECT inguinal hernias?

More common in males over 40.

48

What is the predisposing factor for indirect inguinal hernia?

Persistent processus vaginalis.

49

What are the predisposing factors for DIRECT inguinal hernia?

1. Weak or narrow conjoint tendon
2. Large superficial inguinal ring

50

What is the course of the DIRECT inguinal hernia?

Passes MEDIAL to inferior epigastric vessels through inguinal triangle and superficial inguinal ring --> rarely descends into scrotum.

51

What is the covering of herniating structure in indirect inguinal hernia?

Same 3 layers as spermatic cord:
1. External spermatic fascia
2. Cremasteric layer
3. Internal spermatic fascia

52

What is the covering of herniating structure in DIRECT inguinal hernia?

External spermatic fascia after pushing through superficial inguinal ring.

53

What are the complications of indirect inguinal hernia?

1. Prone to obstruction and strangulation of herniating intestine.
2. Surgical repair on diagnosis.

54

What are the complications of DIRECT inguinal hernia?

More easily reduced than INDIRECT hernias and less likely obstruction and strangulation.

55

On laparoscopic view, what is the site of indirect and direct inguinal hernia?

Indirect --> Lateral inguinal fossa.
Direct --> Medial inguinal fossa.

56

What is basically the spermatic cord?

A collection of structures that traverse inguinal canal passing to and from the testis.

57

What are the structures of the spermatic cord?

1. Ductus deferens
2. Artery of ductus deferens
3. Testicular artery
4. Pampiniform plexus coalescing to become single testicular vein
5. Cremasteric artery
6. Genital branch of genitofemoral nerve
7. Periarterial sympathetic plexus
8. Testicular lymph vessels

58

What is the processus vaginalis?

Saclike evagination of peritoneal cavity into inguinal canal and scrotum in fetus.

59

What is the fate of the processus vaginalis?

Normally disappears except for tunica vaginalis testis in male.

60

What is the gubernaculum?

A fibrous cord that guides the descent of the fetal testis or ovary.

61

What is the role of the gubernaculum?

Guides descent of the testis --> then remains as scrotal ligament (often still labeled as gubernaculum).

62

To what female structure is the gubernaculum homologous?

Homologous to female round ligament of uterus + ovarian ligament proper.

63

In cryptorchidism, where does the undescended testis usually lie?

In the inguinal canal (may lie anywhere along the path of the usual descent).

64

True or false? In cryptorchidism of one testis, there is not increased risk of testicular cancer for the other testis.

FALSE --> There is.

65

What situation usually leads to testicular torsion?

Frequently follows vigorous exercise in 10- to 20-year-olds.

66

Can testicular torsion be associated with congenital anomalies?

Yes :
1. Mobile, horizontally oriented testis (bell-clapper deformity)
2. Crryptorchidism

67

What is the innervation of cremaster muscle?

Genital branch of the genitofemoral nerve --> It is the EFFERENT limb of the cremasteric reflex (L1) --> It is tested by stroking the upper medial thigh.

68

In children, what does absence of the cremasteric reflex indicate?

Acute scrotal pain + swelling supports a diagnosis of torsion.

69

What is the dartos layer of the scrotum and what does it contain?

Membranous superficial fascia --> Containing smooth muscle thta elevates scrotum to conserve heat.

70

What is the scrotal septum?

An inward extension of dartos layer --> Divides dartos into right and left halves.

71

What is the cutaneous innervation of dartos layer?

Branches of:
1. Ilioinguinal
2. Genitofemoral
3. Pudendal
4. Posterior femoral cutaneous nerves

72

What is tunica albuginea?

Dense connective tissue capsule.

73

What is the tunica vaginalis?

Serous sac derived from fetal processus vaginalis.

74

What is the blood supply of the testes?

From abdominal aorta --> Testicular artery.

75

What is the vein drainage of the testes?

Pampiniform plexus via testicular vein drains to inferior vena cava on right and left renal artery on left.

76

Where does testicular cancer metastasize and where does scrotal cancer?

Testicular cancer --> Aortic lymph nodes.
Scrotal cancer --> Superficial inguinal lymph nodes.

77

What does varicocele on either side indicate?

Retroperitoneal malignancy or fibrosis obstructing testicular vein.

78

Where does a testicular hydrocele commonly form?

In tunical vaginalis testis or other remnants of the processus vaginalis --> May accumulate serous fluid (hydrocele) or blood (hematocele).

79

What is epididymis?

A convoluted tube that stores spermatozoa until transport into the ductus deferens.

80

What is a spermatocele?

A sperm-filled cyst that occurs near the head of the epididymis.

81

True or false? Spermatocele usually presents with symptoms.

FALSE --> Asymptomatic, discovered on routine physical examination.

82

What is a common cause of acute scrotal pain and swelling in young, sexually active males?

Epididymitis

83

What is the origin and the course of superior epigastric artery?

Terminal branch of internal thoracic artery --> descends in rectus sheath to anastomose with inferior epigastric artery.

84

What is the clinical importance of superior + inferior epigastric artery in postductal coarctation of the aorta?

Anastomoses between the superior and inferior epigastric arteries provide collateral circulation between the subclavian and external iliac arteries.

85

What is the origin and the source of inferior epigastric artery?

Arises from external iliac artery --> Ascends medial to deep inguinal ring to enter rectus sheath.

86

What is the clinical significance of inferior epigastric artery?

May be the source of aberrant obturator artery in danger during femoral hernia repair.

87

What other arteries of anterior abdominal wall anastomose with superior and inferior epigastric arteries?

1. Posterior intercostal (7-11)
2. Subcostal (12)
3. Lumbar segmental (1 and 2)

88

What is the clinical importance of collateral venous drainage of the anterior abdominal wall?

Provides collateral connections between superior and inferior vena caval systems --> when inferior vena cava is blocked by thrombus or by retroperitoneal tumor.

89

What is the role of the superior and inferior epigastric veins?

Connect brachiocephalic vein (superior vena cava) to external iliac vein (inferior vena cava).

90

What veins provide anastomoses to bypass vena caval obstruction?

1. Thoracoepigastric
2. Superior-Inferior epigastric veins.

91

What veins connect azygos system of veins (SVC) to inferior epigastric vein (IVC)?

1. Posterior intercostal veins (7-11)
2. Subcostal vein
3. Lumbar segmental veins (1 and 2)

92

What does thoracoepigastric vein connect?

Connects lateral thoracic vein (SVC) to superficial epigastric vein (IVC).

93

When may thoracoepigastric vein enlarge?

As part of collateral drainage accompanying portocaval anastomoses + caput medusae.

94

What is the innervation of the anterior abdominal wall?

Continue from anterior rami of spinal nerves T7-L1.
--> Provide motor innervation to muscles + Cutaneous innervation of anterior abdominal wall.

95

What is the peritoneum?

Serous sac lining abdominopelvic cavity and forming covering layer for viscera invaginating it from behind.

96

What does parietal peritoneum lie?

Walls of abdominopelvic cavity + inferior surface of respiratory diaphragm.

97

How is parietal peritoneum innervated?

By somatic nerves.

98

What does the visceral peritoneum cover?

Abdominal organs that have invaginated peritoneal sac.

99

What is the innervation of visceral peritoneum?

Innervated by GVA fibers in abdominal autonomic plexuses.

100

What is the role of peritoneal mesenteries and ligaments?

Suspend organs within abdominal cavity and transmit vessels and nerves between body wall and organs.

101

What is important to remember about the somatic pain from the parietal peritoneum and the visceral pain from the visceral peritoneum?

The first is sharp and localized + The second is diffuse and aching or cramping.

102

What are the intraperitoneal organs?

Invaginate peritoneal sac and receive coat of visceral peritoneum.

103

What are the retroperitoneal organs?

Lie within abdominal cavity behind posterior parietal peritoneum and were NEVER intraperitoneal during development.

104

What are the secondarily intraperitoneal organs?

Developed "intraperitoneally" but fused secondarily with posterior body wall, so they are covered only anteriorly by peritoneum.

105

What is the peritoneal cavity?

Potential space containing thin film of fluid to lubricate visceral movements and resist infection.

106

How can peritonitis occur?

From the introduction of sterile material or bacteria into the peritoneal cavity.

107

What sterile material can cause aseptic peritonitis?

For example, bile.

108

What is the septic peritonitis without bowel perforation?

Spontaneous bacterial peritonitis --> May occur when ascites is present in cirrhosis of the liver or the nephrotic syndrome --> Massive protein loss in the urine with decreased serum albumin.

109

Mention the major peritoneal ligaments and mesenteries.

1. Greater omentum --> Gastrosplenic + Gastrocolic + Splenorenal ligament.
2. Lesser omentum --> Hepatogastric + Hepatoduodenal ligament.
3. Falciform ligament
4. Mesentery proper
5. Transverse mesocolon
6. Sigmoid mesocolon
7. Mesoappendix

110

Mention the main INTRAperitoneal organs.

1. Duodenum (1st part)
2. Liver + Gallbladder
3. Pancreas (tail)
4. Stomach
5. Spleen
6. Jejunum
7. Ileum
8. Cecum
9. Appendix
10. Transverse colon
11. Sigmoid colon

111

Mention the main retroperitoneal organs?

1. Kidneys
2. Ureters
3. Suprarenal glands
4. Abdominal aorta
5. Inferior vena cava

112

Mention the main secondarily retroperitoneal organs.

1. Duodenum (2nd, 3rd, 4th part)
2. Ascending + Descending colon
3. Rectum
4. Pancreas (Head, neck, and body)

113

What is an important role of the greater omentum?

Can prevent spread of infection by adhering to and localizing areas of inflammation.

114

What does the gastrosplenic ligament contain?

Short gastric arteries and veins.

115

What does the gastrocolic ligament contain?

Gastroepiploic (gastro-omental) vessels.

116

What does the splenorenal ligament contain?

Tail of pancreas and splenic vessels.

117

What is the lesser omentum?

Ventral mesentery of stomach and anterior wall of lesser peritoneal sac.

118

What does the hepatogastric ligament contain?

Right and left gastric vessels along lesser curvature.

119

What does the hepatoduodenal ligament contain?

1. Common bile duct
2. Proper hepatic artery
3. Portal vein

120

What does falciform ligament contain in its free edge?

Ligamentum teres hepatis --> Remnant of left umbilical vein of fetus.

121

What does mesentery proper contain?

Vessels, nerves, and lymphatics supplying jejunum and ileum.

122

What does transverse mesocolon contain?

Middle colic vessels.

123

What does sigmoid mesocolon contain?

Sigmoidal arteries and veins.

124

What does the mesoappendix contain?

Transmits appendiicular artery and vein.

125

Mention some causes of ascites.

1. Cirrhosis
2. Peritoneal malignancy
3. RHF
4. Peritoneal TB

126

How is the peritoneal cavity subdivided?

Into greater and lesser peritoneal sacs connected by the omenta foramen.

127

What is the subphrenic recess?

Potential peritoneal space between liver and inferior surface of the diaphragm.

128

What is the clinical importance of subphrenic recess?

A liver abscess in the subphrenic recess may erode through the diaphragm into the thorax.
--> Cancer can spread quickly to adjacent organs.

129

What is the hepatorenal recess?

Potential space between right lobe of the liver and right kidney.

130

What is important to remember about the hepatorenal recess?

1. It is the lowest point of the peritoneal cavity in a supine patient.
2. May be infected from subphrenic recess or omenta bursa.

131

Where do the paracolic gutters lie?

Lateral to ascending and descending colons --> extend over pelvic brim into pelvis.

132

Where does fluid from the subphrenic recess or omental bursa collect?

In the hepatorenal recess in supine patients.

133

What is the clinical importance of paracolic gutters?

They are pathways for the spread of infection and cancer cells.

134

How do we put patients with peritonitis due to bacterial infections?

May be positioned sitting up to facilitate drainage into the pelvis, where absorption of toxins is slower.

135

What is called omental bursa?

The lesser peritoneal sac.

136

Where does the lesser peritoneal sac lie?

Posterior to stomach, liver, and lesser omentum.

137

What is a pancreatic pseudocyst?

A fluid collection in acute pancreatitis, most frequently in the omental bursa.

138

What are the Grey-Turner sign and the Cullen sign?

Necrotizing pancreatitis:
Grey-Turner --> Blood may dissect along fascial planes to produce ecchymoses in the flank.
Cullen --> Or in the periumbilical region.

139

What are the boundaries of the epiploic foramen (omental foramen)?

Anteriorly --> Hepatoduodenal ligament
Posteriorly --> Inferior vena cava
Superiorly --> Caudate lobe of the liver
Inferiorly --> First part of the duodenum

140

What is interesting to remember about the epiploic foramen?

May be site of internal hernia.

141

What may obstruct the omental (epiploic) foramen?

Inflammation caused by acute pancreatitis or a perforated posterior gastric ulcer.
Rarely a loop of small intestine may become entrapped in the omental foramen as an internal hernia --> Danger of bowel obstruction + strangulation.

142

What are the 3 MCC of upper GI bleeding?

1. Peptic ulcers
2. Esophageal varices
3. Mallory-Weiss tears

143

Where does cardia of the stomach lie?

Adjacent to junction with esophagus and is related to physiological lower esophageal (cardiac) sphincter that prevents regurgitation into esophagus (gastroesophageal reflux).

144

To what is pylorus divided?

Into proximal pyloric antrum and distal pyloric canal --> And has smooth muscle pyloric sphincter that controls gastric emptying under vagal parasympathetic control.

145

How do we differentiate heartburn from GERD from the one of MI?

GERD heartburn is relieved by position change or antacids.

146

True or false? A paraesophageal hernia usually cause reflux.

FALSE --> Usually does not cause reflux.

147

What is a fatal complication of peptic ulcer?

Posterior gastric ulcer perforation --> May fatally erode the splenic artery.

148

What is the venous drainage of the stomach?

Accompanies arterial supply to ultimately end in portal vein.

149

How are the esophageal varices seen in portal HTN formed?

Anastomoses between the left gastric and the azygos veins form esophageal varices in portal HTN.

150

What is the lymphatic drainage of the stomach?

Accompanies arterial supply --> Ultimately ends in celiac nodes.

151

What is the duodenal bulb (duodenal cap)?

First 2cm of the 1st part of the duodenum --> Walls look smooth on radiograph using barium contrast.

152

What is the only intraperitoneal part of the duodenum?

The duodenal bulb.

153

How is duodenal bulb joined to liver?

By hepatoduodenal ligament.

154

What crosses the duodenal bulb posteriorly?

1. Portal vein
2. Bile duct
3. Gastroduodenal artery

155

What is the arterial supply of the stomach?

1. Left gastric artery
2. Right gastric artery
3. Left gastro-omental artery
4. Right gastro-omental artery
5. Short gastric arteries from the splenic artery.

156

What is the blood supply of the caudal foregut?

From the celiac artery.

157

What is the blood supply of the midgut?

From the superior mesenteric artery.

158

What is the blood supply of the hindgut?

From the inferior mesenteric artery.

159

What are the adult derivatives of the caudal foregut?

1. Liver parenchyma
2. Pancreas
3. Stomach
4. 1st part of the duodenum
5. Half of 2nd part of duodenum

160

What are the adult derivatives of the midgut?

1. 2nd part of duodenum.
2. 3rd and 4th parts of duodenum.
3. Jejunum + Ileum
4. Cecum + appendix
5. Ascending + Transverse colon.

161

What are the adult derivatives of hindgut?

1. Descending colon
2. Sigmoid
3. Rectum
4. Upper anal canal

162

What other structure that is NOT derived from caudal foregut is supplied by the celiac artery?

The spleen --> Origin from the mesoderm of the dorsal mesentery rather than the foregut.

163

What terminates at the 2nd (descending0 part of the duodenum?

1. Bile duct + main pancreatic duct at hepatopancreatic ampulla that opens at major duodenal papilla.
2. Accessory pancreatic duct at minor duodenal papilla.

164

What crosses anteriorly the 3rd part (transverse) of the duodenum?

Root of small intestine + Superior mesenteric vessels.

165

What crosses posteriorly the 3rd part (transverse) of the duodenum?

Inferior vena cava + Aorta anterior to vertebra L3.

166

What happens in superior mesenteric artery syndrome?

The SMA can compress the 3rd part of the duodenum against the aorta --> Causing life-threatening small bowel obstruction (SMA syndrome).

167

After what can SMA syndrome follow?

After rapid weight loss or scoliosis surgery.

168

Is SMA syndrome common?

No, it is rare.

169

What is the course of the 4th part of the duodenum (ascending part)?

Ascends to left side of L2 to end at duodenojejunal flexure --> Attached to right crus of diaphragm by suspensory muscle of duodenum (ligament of Treitz).

170

What may be associated with the 4th part of the duodenum?

Peritoneal recesses --> the superior and/or inferior peritoneal recesses --> Which can trap section of small intestine as an internal hernia.

171

What is ileus?

The temporary loss of peristalsis, MC following abdominal surgery.

172

What is the difference between ileus and mechanical bowel obstruction?

The absence of crampy abdominal pain and bowel sounds.

173

What is the blood supply of the pancreas?

1. Anterior/Posterior pancreaticoduodenal arteries.
2. Dorsal pancreatic artery.
3. Great pancreatic artery.
4. Caudal pancreatic arteries (from the splenic)
5. Inferior pancreatic artery

174

What is the venous drainage of the small intestine?

Duodenum --> Veins ending in portal vein or its tributaries.
Jejunum + Ileum --> Drained by SMA --> Which helps form the portal vein.

175

What is characteristic about the large intestine morphology?

1. Teniae coli
2. Haustra
3. Omental (epiploic) appendices

176

What is basically the cecum?

Blind pouch that receives ileocecal orifice and opening of appendix.

177

Is ileocecal valve a "real" valve?

No, it is rudimentary and does not prevent reflux into the ileum.

178

How can an unapparent appendix be found?

It may be found by tracing the convergence of the teniae coli at its base.

179

What are the teniae coli?

Three longitudinal bands of smooth muscle.

180

What is the usual location of the appendix?

Retrocecal.

181

Compare the diameter of jejunum and ileum.

Jejunum --> Slightly larger.

182

Compare the wall thickness of the jejunum and ileum.

Jejunum --> Slightly thicker.

183

Compare the blood supply of the jejunum and ileum.

Jejunum --> Fewer arcades, longer vasa recta, fewer anastomoses.

184

Compare the amount of fat of jejunum and ileum.

Jejunum --> Less.

185

Compare the plicae circulares between jejunum and ileum.

Jejunum --> Numerous.

186

Compare the Peyer patches between jejunum and ileum.

Jejunum --> Few.

187

To what does a mobile ascending colon predispose?

To volvulus.

188

What is volvulus?

Twisting around its mesentery.

189

What is the blood supply of the large intestine?

1. Ileocolic artery
2. Right colic artery
3. Middle colic artery
4. Left colic artery
5. Sigmoid arteries
6. Superior rectal artery

190

For what conditions is the sigmoid colon the most frequent location?

For volvulus and diverticulosis.

191

How is the marginal artery of the large intestine formed?

Along the inner margin of the large intestine from the ileocolic to the rectosigmoid junction by anastomosing branches of the superior and inferior mesenteric arteries.

192

What is the clinical importance of the marginal artery?

May allow safe ligation of the inferior mesenteric artery, if it provides sufficient collateral circulation.

193

What may obstruct the omental (epiploic) foramen?

Inflammation caused by acute pancreatitis or a perforated posterior gastric ulcer.
Rarely a loop of small intestine may become entrapped in the omental foramen as an internal hernia --> Danger of bowel obstruction + strangulation.

194

What are the 3 MCC of upper GI bleeding?

1. Peptic ulcers
2. Esophageal varices
3. Mallory-Weiss tears

195

Where does cardia of the stomach lie?

Adjacent to junction with esophagus and is related to physiological lower esophageal (cardiac) sphincter that prevents regurgitation into esophagus (gastroesophageal reflux).

196

To what is pylorus divided?

Into proximal pyloric antrum and distal pyloric canal --> And has smooth muscle pyloric sphincter that controls gastric emptying under vagal parasympathetic control.

197

How do we differentiate heartburn from GERD from the one of MI?

GERD heartburn is relieved by position change or antacids.

198

True or false? A paraesophageal hernia usually cause reflux.

FALSE --> Usually does not cause reflux.

199

What is a fatal complication of peptic ulcer?

Posterior gastric ulcer perforation --> May fatally erode the splenic artery.

200

What is the venous drainage of the stomach?

Accompanies arterial supply to ultimately end in portal vein.

201

How are the esophageal varices seen in portal HTN formed?

Anastomoses between the left gastric and the azygos veins form esophageal varices in portal HTN.

202

What is the lymphatic drainage of the stomach?

Accompanies arterial supply --> Ultimately ends in celiac nodes.

203

What is the duodenal bulb (duodenal cap)?

First 2cm of the 1st part of the duodenum --> Walls look smooth on radiograph using barium contrast.

204

What is the only intraperitoneal part of the duodenum?

The duodenal bulb.

205

How is duodenal bulb joined to liver?

By hepatoduodenal ligament.

206

What crosses the duodenal bulb posteriorly?

1. Portal vein
2. Bile duct
3. Gastroduodenal artery

207

What is the arterial supply of the stomach?

1. Left gastric artery
2. Right gastric artery
3. Left gastro-omental artery
4. Right gastro-omental artery
5. Short gastric arteries from the splenic artery.

208

What is the blood supply of the caudal foregut?

From the celiac artery.

209

What is the blood supply of the midgut?

From the superior mesenteric artery.

210

What is the blood supply of the hindgut?

From the inferior mesenteric artery.

211

What are the adult derivatives of the caudal foregut?

1. Liver parenchyma
2. Pancreas
3. Stomach
4. 1st part of the duodenum
5. Half of 2nd part of duodenum

212

What are the adult derivatives of the midgut?

1. 2nd part of duodenum.
2. 3rd and 4th parts of duodenum.
3. Jejunum + Ileum
4. Cecum + appendix
5. Ascending + Transverse colon.

213

What are the adult derivatives of hindgut?

1. Descending colon
2. Sigmoid
3. Rectum
4. Upper anal canal

214

What other structure that is NOT derived from caudal foregut is supplied by the celiac artery?

The spleen --> Origin from the mesoderm of the dorsal mesentery rather than the foregut.

215

What terminates at the 2nd (descending0 part of the duodenum?

1. Bile duct + main pancreatic duct at hepatopancreatic ampulla that opens at major duodenal papilla.
2. Accessory pancreatic duct at minor duodenal papilla.

216

What crosses anteriorly the 3rd part (transverse) of the duodenum?

Root of small intestine + Superior mesenteric vessels.

217

What crosses posteriorly the 3rd part (transverse) of the duodenum?

Inferior vena cava + Aorta anterior to vertebra L3.

218

What happens in superior mesenteric artery syndrome?

The SMA can compress the 3rd part of the duodenum against the aorta --> Causing life-threatening small bowel obstruction (SMA syndrome).

219

After what can SMA syndrome follow?

After rapid weight loss or scoliosis surgery.

220

Is SMA syndrome common?

No, it is rare.

221

What is the course of the 4th part of the duodenum (ascending part)?

Ascends to left side of L2 to end at duodenojejunal flexure --> Attached to right crus of diaphragm by suspensory muscle of duodenum (ligament of Treitz).

222

What may be associated with the 4th part of the duodenum?

Peritoneal recesses --> the superior and/or inferior peritoneal recesses --> Which can trap section of small intestine as an internal hernia.

223

What is ileus?

The temporary loss of peristalsis, MC following abdominal surgery.

224

What is the difference between ileus and mechanical bowel obstruction?

The absence of crampy abdominal pain and bowel sounds.

225

What is the blood supply of the pancreas?

1. Anterior/Posterior pancreaticoduodenal arteries.
2. Dorsal pancreatic artery.
3. Great pancreatic artery.
4. Caudal pancreatic arteries (from the splenic)
5. Inferior pancreatic artery

226

What is the venous drainage of the small intestine?

Duodenum --> Veins ending in portal vein or its tributaries.
Jejunum + Ileum --> Drained by SMA --> Which helps form the portal vein.

227

What is characteristic about the large intestine morphology?

1. Teniae coli
2. Haustra
3. Omental (epiploic) appendices

228

What is basically the cecum?

Blind pouch that receives ileocecal orifice and opening of appendix.

229

Is ileocecal valve a "real" valve?

No, it is rudimentary and does not prevent reflux into the ileum.

230

How can an unapparent appendix be found?

It may be found by tracing the convergence of the teniae coli at its base.

231

What are the teniae coli?

Three longitudinal bands of smooth muscle.

232

What is the usual location of the appendix?

Retrocecal.

233

Compare the diameter of jejunum and ileum.

Jejunum --> Slightly larger.

234

Compare the wall thickness of the jejunum and ileum.

Jejunum --> Slightly thicker.

235

Compare the blood supply of the jejunum and ileum.

Jejunum --> Fewer arcades, longer vasa recta, fewer anastomoses.

236

Compare the amount of fat of jejunum and ileum.

Jejunum --> Less.

237

Compare the plicae circulares between jejunum and ileum.

Jejunum --> Numerous.

238

Compare the Peyer patches between jejunum and ileum.

Jejunum --> Few.

239

To what does a mobile ascending colon predispose?

To volvulus.

240

What is volvulus?

Twisting around its mesentery.

241

What is the blood supply of the large intestine?

1. Ileocolic artery
2. Right colic artery
3. Middle colic artery
4. Left colic artery
5. Sigmoid arteries
6. Superior rectal artery

242

For what conditions is the sigmoid colon the most frequent location?

For volvulus and diverticulosis.

243

How is the marginal artery of the large intestine formed?

Along the inner margin of the large intestine from the ileocolic to the rectosigmoid junction by anastomosing branches of the superior and inferior mesenteric arteries.

244

What is the clinical importance of the marginal artery?

May allow safe ligation of the inferior mesenteric artery, if it provides sufficient collateral circulation.

245

What does the inferior mesenteric artery supply?

1. Descending + sigmoid colons.
2. Proximal rectum
3. Upper 1/2 of anal canal.

246

What is the function of the marginal artery?

Provides collateral circulation between adjacent branches of superior and inferior mesenteric arteries.

247

What is the venous drainage of the cecum, appendix, ascending + transverse colon?

To the superior mesenteric vein.

248

What is the venous drainage of descending and sigmoid colons?

To inferior mesenteric vein and then to splenic vein or superior mesenteric vein --> Which join to form portal vein.

249

What is the lymphatic drainage of cecum, appendix, ascending + transverse colons?

Drainage is via regional nodes to superior mesenteric nodes and through intestinal lymph trunk to cisterna chyli.

250

What is the lymphatic drainage of descending and sigmoid colons?

Drainage is via regional nodes to inferior mesenteric nodes and through the intestinal lymph trunk to cisterna chyli.

251

What is the omphalocele?

The failure of the embryonic midgut to return to the abdominal cavity.

252

What is gastroschisis?

A herniation through an abdominal wall defect.

253

What occurs with anterior abdominal wall defects?

High amniotic AFP levels.

254

What is the situs inversus?

Mirror-image reversal of thoracic and abdominal viscera due to anomalous determination of right and left sidedness during gastrulation.

255

If inherited, what is the inheritance pattern of situs inversus?

AR

256

What part of the liver is NOT covered with peritoneum (visceral peritoneum)?

Except where it directly contacts the diaphragm.

257

True or false? Liver is relatively larges in adult than in the newborn.

FALSE --> It is relatively larger in newborn and child than in adult.

258

What does double-bubble sign on newborn radiograph or ultrasound indicate?

Duodenal atresia or anular pancreas.

259

Where exactly is the needle inserted during a liver biopsy? (under ultrasound guidance)

Through the thoracic wall at a lower intercostal space (7-10) in the right midaxillary line.

260

What are the layers needed to be passed to reach the liver parenchyma?

1. Skin
2. Superficial fascia
3. Intercostal muscles
4. Endothoracic fascia
5. Costal pleura
6. Costodiaphragmatic recess
7. Diaphragmatic pleura
8. Diaphragm
9. Diaphragmatic peritoneum
10. Subphrenic recess
11. Visceral peritoneum on the liver

261

What are the potential complications of a liver biopsy?

1. Hemorrhage
2. Bile peritonitis
3. Pneumothorax/hemothorax

262

When is transjugular liver biopsy indicated?

In patients with severe coagulopathy.

263

What is special about the diaphragmatic surface of the liver?

It has a bare area that directly contacts diaphragm with no intervening peritoneum.

264

Mention some causes of enlarged liver.

1. Cirrhosis
2. Space-occupying lesions (e.g. tumors, abscesses)
3. Biliary tract obstruction
4. RHF

265

What do we see on the visceral surface of the liver?

1. Porta hepatis
2. Groove for inferior vena cava
3. Fissure for ligamentum venosum
4. Fissure for ligamentum teres hepatis (round ligament of the liver), remnant of umbilical vein.

266

What do the paraumbilical veins do?

Paralleling the ligamentum teres in the falciform ligament connect the portal vein and superficial (systemic) veins around the umbilicus.
--> In portal HTN --> Dilation of the superficial veins radiating from the umbilicus may produce caput medusae.

267

What is the blood supply of the liver?

20% from the proper hepatic artery (celiac trunk).
80% portal vein.
Drainage from liver is by hepatic veins.

268

What is interesting to remember about the right hepatic artery?

May arise as aberrant branch of SMA.

269

How is the portal vein formed?

By the union of superior mesenteric and splenic veins POSTERIOR TO THE NECK OF THE PANCREAS.

270

What is interesting to keep in mind about left hepatic artery?

May arise as aberrant branch of left gastric artery.

271

Through which ligament does the portal vein reach the liver?

Hepatoduodenal ligament.

272

What major veins drain into the portal vein?

1. Middle colic
2. Right colic
3. Ileocolic
4. Jejunal and ileal + right gastro-omental vein
1-4 --> SMV

5. Esophageal vein
6. Right/Left gastric vein
7. Splenic vein --> Short gastric veins + Left gastro-omental vein.
8. IMV

273

What is the gallbladder?

Pear-shaped sac on visceral surface of the liver that stores + concentrates bile.

274

What are the main parts of the gallbladder?

1. Blunt-ended fundus
2. Body
3. Narrow S-shaped neck

275

What part of the gallbladder may be palpable and where exactly?

The gallbladder fundus --> it projects below the liver at the right costal margin (9th costal cartilage) --> Near the lateral border of the rectus abdominis.

276

What is the Hartman pouch?

An abnormal sacculation may develop at the junction of the neck of the gallbladder and cystic duct --> Harbor gallstones.

277

How is the common hepatic duct formed and where?

By union of right and left hepatic ducts --> Near porta hepatis.

278

What accompanies common hepatic duct?

Portal vein and proper hepatic artery.

279

What lines the cystic duct and how is it arranged inside?

Lined by mucous membrane organized into spirally arranged folds (spiral valve) --> Keep the lumen open.

280

What is caused by cystic duct obstruction?

Acute cholecystitis with Murphy sign.

281

Discuss the referred pain pathway of foregut derivatives supplied by celiac trunk.

Visceral Afferent Pathway --> Greater splanchnic nerve.
Spinal Cord Level of Termination --> T5-T9.
Areas of referral --> Epigastric region and T5-T9 dermatomes of back.

282

Discuss the referred pain pathway of midgut derivatives.

Visceral Afferent Pathway --> Greater and Lesser splanchnic nerves.
Spinal cord levels of termination --> T8-T11.
Areas of referral --> Umbilical region.

283

Discuss the referred pain pathways from hindgut derivatives.

Visceral Afferent Pathway --> Least and lumbar splanchnic nerves.
Spinal cord levels of termination --> T12-L2.
Areas of Referral --> Hypogastric region, Inguinal Region, and flanks.

284

What is the Murphy sign seen in acute cholecystitis?

Patient shows a sudden catch in breath on deep inspiration as the examiner's fingers contact the area over the fundus of the inflamed gallbladder.

285

What is the cystohepatic triangle?

1. Cystic duct
2. Common hepatic duct
3. Liver

286

What is a key landmark for cholecystectomy?

The cystic artery often arises from the right hepatic artery in the hepatocystic triangle.

287

How is the common bile duct formed?

By union of common hepatic and cystic ducts.

288

What is the course of the common bile duct?

Descends in hepatoduodenal ligament to RIGHT of proper hepatic artery + ANTERIOR to portal vein --> Passes behind first part of the duodenum --> Pierces head of the pancreas + Joins main pancreatic duct to form hepatopancreatic ampulla.

289

Where may gallbladder pain be referred?

To the right shoulder.

290

Where does pancreas lie?

In bed of stomach behind parietal peritoneum except for tail.

291

Where does the hooklike uncinate process of the head of the pancreas lie?

Posterior to superior mesenteric vessels.

292

What is the 4th leading cause of cancer deaths in the USA?

Pancreatic cancer.

293

What is a contraindication for pancreatic cancer surgery?

SMA involvement.

294

What passes behind the neck of the pancreas?

Neck is constricted where it is crossed posteriorly by superior mesenteric vessels + origin of portal vein.

295

What does the body of the pancreas overlie?

1. Aorta
2. Left renal vein
3. Splenic vein
4. Termination of inferior mesenteric vein

296

What is the location of the tail of the pancreas?

Enters splenorenal ligament --> ends at hilum of spleen.

297

What does the accessory pancreatic duct drain?

Uncinate process and lower part of head.

298

Where does the accessory pancreatic duct open?

Independently at minor duodenal papilla --> 2nd part of duodenum.

299

Where does spleen lie?

Posterior to midaxillary line in left hypochondriac region deep to ribs 9-11 with long axis along rib 10 --> Separated from ribs by diaphragm and pleura.

300

Where is pain from the spleen may be referred?

To the left shoulder via the phrenic nerve.

301

What is the most frequently injured abdominal organ?

The spleen.

302

True or false? Accessory spleens may be present near splenic hilum.

True

303

In what persons do we usually see splenic artery aneurysms?

In pregnant patients --> fatal in 70% if rupture.

304

What is the lymphatic drainage of liver, biliary system, pancreas and spleen?

From regional nodes to celiac nodes --> intestinal lymph trunk --> Cisterna chyli.

305

From where does liver parenchyma develop?

From foregut endoderm --> supporting cells arise from septum transversum mesoderm.

306

What does the septum transversum form?

1. Central tendon of the diaphragm
2. Lesser omentum
3. Falciform ligament

307

What is a possible complication of anular pancreas?

May cause duodenal obstruction.

308

What does the lumbar plexus supply?

Extensor and adductor compartments of thigh.

309

Where is the lumbar plexus formed?

Formed within psoas major muscle by anterior rami of spinal nerves L1-L4.

310

True or false? Lumbar plexus is the upper part of larger Lumbosacral plexus.

True

311

Where does the kidney lie?

Retroperitoneal organ --> Lying at vertebral levels T12-L3.
--> Usually lies lower in right side than left to accommodate large right lobe of liver.

312

Where does superior pole of kidney extend?

To rib 12 on the right and to rib 11 on the left.

313

What passes through the renal hilum?

Renal vessels + Renal pelvis + Autonomic nerves.

314

What is the renal pelvis?

Funnel-shaped expansion of upper end of ureter.

315

What is the course of the ureter?

Descends retroperitoneally on anterior surface of psoas major.

316

What is the blood supply of the ureter?

1. Renal
2. Gonadal
3. Common iliac
4. Vesicular arteries

317

What is the innervation of the ureter?

From autonomic and afferent fibers derived from renal, aortic, and superior hypogastric plexuses.

318

What is the usual site of ureter obstruction?

1. Ureteropelvic junction
2. Pelvic brim
3. Bladder wall

319

What is the renal fascia?

Membranous condensation of connective tissue that surrounds kidney and suprarenal gland --> Divides fat into two regions.

320

What is the clinical importance of the renal fascia?

Because the renal fascia is open inferiorly along the ureter, it provides a path for infection between the kidney and the pelvis.

321

Discuss the obstructive lesions of the urinary tract that may cause hydroureter and hydronephrosis.

Pelvis --> Calculi, tumors, Ureteropelvic stricture
Ureter-intrinsic --> Calculi, tumors, clots, sloughed papillae, inflammation.
Ureter-extrinsic --> Pregnancy, tumors (e.g., cervix), retroperitoneal fibrosis.
Bladder --> Calculi, tumors, functional (e.g., neurogenic)
Prostate --> Hyperplasia, Carcinoma, Prostatitis
Urethra --> Posterior valve stricture, tumors (rare)

322

What is the perirenal and pararenal fat?

Perirenal --> Surrounds kidney inside renal fascia.
Pararenal --> Lies outside the renal fascia.

323

How are the renal arteries divided?

At the hilum into anterior and posterior branches that give rise to segmental arteries --> One to each of five kidney segments.

324

What are the accessory renal arteries?

Segmental arteries that do not pass through renal hilum to enter kidney.

325

What is important to remember about accessory renal arteries?

They are at risk during renal surgery --> May compress the ureteropelvic junction to obstruct urine outflow.

326

What is the location of the renal veins compared to the renal arteries?

Each passes anterior to renal artery and renal pelvis at hilum.

327

What is the course of the left renal vein?

Passes anterior to aorta just below the origin of SMA.

328

What veins does the left renal vein receive?

1. Left suprarenal
2. Left gonadal
3. Communicates with ascending lumbar vein
Providing collateral drainage if ligated.

329

Why may the LEFT renal vein be compressed?

LEFT renal vein crosses toward the IVC through the angle between the SMA and the aorta --> Renal vein entrapment syndrome --> Nutcracker syndrome.

330

What is the main difference between the renal vein entrapment syndrome and the SMA syndrome?

In SMA syndrome --> The 3rd part of the duodenum is compressed.

331

Renal vein passes posterior to what?

2nd part of duodenum and head of pancreas.

332

What is the lymphatic drainage of the kidney?

To aortic nodes.

333

Is the adrenal easily separated from the kidney?

Yes, besides the fact that it is enclosed by perirenal fat --> Because of intervening renal fascial septum.

334

What is the cellular component of the adrenal medulla?

Consists of modified postganglionic SNS neurons known as chromaffin cells --> secrete epinephrine and NE.

335

What is the blood supply of the adrenals?

Supplied by:
1. Superior suprarenal arteries (inferior phrenic artery)
2. Middle suprarenal artery (abdominal aorta)
3. Inferior suprarenal artery (renal artery)

336

What is the vein drainage of adrenals?

Single suprarenal vein that terminates on right in inferior vena cava and on left in left renal vein.

337

What is the embryologic origin of kidney and adrenal?

Kidney + Adrenal cortex --> Mesoderm.
Adrenal medulla --> Neural crest cells.

338

What is metanephros?

The last of the 3 embryonic kidneys --> Forms the permanent kidney.

339

Is unilateral renal agenesis common?

Relatively, yes --> Usually involving left kidney in males.
Compensated for by hypertrophy of other kidney.

340

Is bilateral renal agenesis compatible with life?

No.

341

What is the Potter sequence?

Neonates with:
1. Flattened face
2. Hypoplastic lungs
3. Limb deformities
4. Other defects

342

At what level does the aorta enter the abdomen?

Through aortic hiatus of diaphragm anterior to body of T12 vertebra.

343

At what level does the aorta bifurcate?

Over L4 (supracristal plane near level of umbilicus).

344

In order to control pelvic or lower-extremity bleeding, what can be done to the abdominal aorta?

May be compressed against L4 in children and thin adults.

345

What are the 3 routes of collateral venous return in IVC obstruction?

Via:
1. Ascending lumbar - Azygos
2. Superior - Inferior epigastric
3. Thoracoepigastric veins.

346

Where is portal vein formed?

Union of superior mesenteric + splenic veins --> BEHIND THE NECK OF PANCREAS.

347

What is the course of portal vein?

Ascends behind 1st part of duodenum --> Reaches liver within hepatoduodenal ligament.

348

What is the course of the splenic vein?

Forms within the hilum of spleen and enters splenorenal ligament --> Courses posterior to pancreas to join superior mesenteric vein.

349

What does inferior mesenteric vein receive?

Terminations of:
1. Left colic
2. Sigmoidal
3. Superior rectal veins
Usually drains into splenic or superior mesenteric vein.

350

How else do we call the left gastric vein?

Coronary vein.

351

What anastomoses does left gastric vein have?

Has esophageal tributaries anastomosing with those of azygos system of veins.

352

What are the portocaval (portosystemic) anastomoses?

Anastomoses between tributaries of portal vein and superior/inferior vena cava.

353

Mention some important portocaval anastomoses.

1. Lower end of esophagus between esophageal tributaries of left gastric vein (portal) and azygos system (systemic) --> Engorgement of these veins causes esophageal varices.
2. Anal canal between superior rectal (portal) and inferior rectal (systemic) veins --> Engorgement of these veins causes hemorrhoids.
3. Umbilicus between paraumbilical veins (portal) and superficial veins of anterior abdominal wall (systemic) --> Caput medusae.

354

Until what point do the vagus nerves supply PNS innervation to GI tract?

As far as distally as left colic flexure.

355

What is the course of the vagus nerves inside the abdomen?

Enter abdomen on esophagus as anterior + posterior vagal trunks --> Distributed through celiac and superior mesenteric plexuses.

356

How is the GI tract distal to the left colic flexure innervated by the PNS?

By the PELVIC splanchnic nerves.

357

What is the course of the lumbar sympathetic trunk?

Descends from thorax behind medial arcuate ligament of diaphragm and lies on bodies of lumbar vertebrae.

358

How many segmentally arranged ganglia does the lumbar sympathetic trunk have?

Typically has 4.

359

At which ganglia do the 3 THORACIC splanchnic nerves terminate?

Greater splanchnic --> Celiac ganglion.
Lesser splanchnic --> Superior mesenteric ganglion + Aorticorenal ganglion.
Least splanchnic --> Aorticorenal ganglion.

360

What is the course of the LUMBAR splanchnic nerves?

Arise from L1 and L2 sympathetic ganglia --> End in superior mesenteric + inferior mesenteric ganglia.

361

How does pain from abdominal viscera travel?

On GVA fibers --> accompanying sympathetic fibers.

362

How can visceral pain occur?

Results from distention, spasm, inflammation, or ischemia of walls of hollow abdominal viscera --> Or of stretched capsules of solid abdominal organs.

363

Why GI visceral pain may start in the midline?

Because of the original embryonic position of the organs.

364

What is the Camper fascia?

Superficial layer of Superficial fascia --> Fatty layer continuous with superficial fascia of thorax and thigh.