Tieman - Clinical Correlations CIS II

Question 1

Course of arterial supply of the appendix (starting from aorta)?

Answer 1

SMA to ileocolic to appendicular branch/artery

Question 2

Why is the early pain of appendicitis vague and periumbilical and the later pain specific to the right lower quadrant?

Answer 2

Initially it inflames the viscera then continues to become inflamed until it comes into contact with the parietal peritoneum, where it elicits somatic nociceptive fibers

Question 3

What lays adjacent to the appendix?

Answer 3

Ureter in both male and female
Female:
Male:

Question 4

What inflamed structures can mimic appendicitis?

Answer 4

Ureters, …

Question 5

What are the various locations of the appendix relative to the cecum?

Answer 5

Appendix can either be behind the cecum, medial (free peritoneal cavity), lateral along the pelvis, near the obturator nerve, right along the right psoas m., etc. (see variation illustration in Netter’s)

Question 6

Know variations in position of the vermiform appendix

Answer 6

You can see RUQ pain in a pregnant women that actually has appendicitis

Question 7

Gangrenous appendicitis

Answer 7

Necrotic; blackish in color

Question 8

Abd pain with movement?

Answer 8

Peritonitis

Question 9

“Scalloping” of the bowel…

Answer 9

Edema of the bowel and probably colitis

Ligation of IMA (due to AAA repair) can create ischemic colitis

Question 10

AAA and ischemic colitis

Answer 10

“Important questions related to anatomy”

Question 11

Which major artery must be ligated or reimplanted into the graft?

Answer 11

IMA

Question 12

If the IMA is ligated, how is blood supplied to the distal 1/3 of transverse artery / descending colon?

Answer 12

Marginal artery

Question 13

What vein runs posterior to the ligament of Treitz (suspensatory ligament of the duodenum)?

Answer 13

Inferior mesenteric vein

Question 14

How could the patient in case II become paraplegic post surgery?

Answer 14

Anterior spinal artery laceration

Question 15

Idiopathic thrombocytopenic purpura

Answer 15

splenectomy

Question 16

Trace the blood supply to and from the spleen, beginning at the aorta and ending in the liver:

Answer 16

Celiac trunk comes off aorta, one of the three branches of the celiac trunk is the splenic artery, this runs just superior to the pancreas, gives off vessels that supply pancreatic head and tail, goes to hilum of the spleen, before this it gives off short gastric which supplies fundus of stomach; splenic vein is joined by inferior mesenteric vein, joins superior mesenteric vein to form the portal vein, which goes on to the liver

Question 17

What are the two true ligaments of the spleen?

Answer 17

Gastrosplenic (fundus of stomach to spleen), splenorenal (lienorenal; fascia of superior kidney to spleen); sits on “shelf” of phrenicocolic ligament

Question 18

Which vessels travel through the gastrosplenic ligament and which vessels do they originate from/drain into?

Answer 18

short gastric, arise from splenic

Question 19

Esophageal varices vs. gastric varices

Answer 19

coronary veins drain into esophageal veins in order to get back to the azygos veins…but in a person who abuses EtOH, you can get gastric varices… how can this be? With several episodes of pancreatitis, you can get a splenic vein thrombosis (due to recurrent inflammation) and pressure backs up into the spleen and into the short gastric vessels which lead to the fundus of the stomach…problem with drainage out of the spleen which causes gastric varices.

Question 20

In ligating the splenic artery and vein, which adjacent organ must we identify and be careful not to injure?

Answer 20

Pancreas?

Question 21

If the splenic vein were thrombosed (obstructed), which veins would become dilated (varicose)?

Answer 21

short gastric and splenic