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Gross Anatomy
Forum
Abdomen
Abdominal Viscera Small Group Questions/Cases A 45y/o accountant was admitted to the hospital after visiting the ER with complaints of severe abdominal pain and pain over his right shoulder. The H&P indicates a history of gastric ulcers controlled via Rx but he admits that recently he has not been taking his medication. The physician suspects a perforated gastric ulcer. Gastroscopy confirmed the diagnosis. During surgery, a small perforation was identified on the posterior region of the stomach body near the lesser curvature. The surgeon repaired the perforation, performed a vagotomy, and had to cut and ligate the left gastric artery during the procedure. 1. What structures are at risk in this perforation? A: Left gastric artery/vein, esophagus, and esophageal artery. Possibly the splenic artery, left gastric lymph nodes, anterior/posterior vagal trunk (nerves), diaphragm, right gastric artery/vein, right gastric lymph nodes, celiac branch and hepatic branch (of vagal nerve trunk), left lobe of liver, left kidney/suprarenal gland. 2. Why did the patient have shoulder pain? A: Irritation of the nearby diaphragm would agitate the phrenic nerve. This nerve has root values of C3-5 and referred pain would be felt at those dermatomes, which includes the shoulder. (However, due to the location of the lesser curvature in relation to the diaphragm, it is more likely that referred pain would come from the liver, gallbladder, or duodenum.) 3. What is a vagotomy and why was it performed? A: A vagotomy is the resection of part of the vagus nerve (CNX), which provides parasympathetic innervation to abdominal organs. Likely, the vagotomy was done to eliminate symptoms of gastro-esophageal reflux (GERD). However, this treatment is now obsolete. Improvements to the treatment included selecting only the branches innervating the stomach (highly selective vagotomy). This treatment was also used to reduce acid secretion to the stomach, prior to understanding ulcer disease was caused by H. pylori. 4. With the left gastric artery ligated, how will the stomach receive blood? A: The main anastamoses is from the right gastric artery, a branch off of the right hepatic artery. Other anatamoses include the right gastroepiploic artery (from right gastroduodenal) and possibly the left gastroepipolic artery (from splenic). 5. Celiac trunk branching is quite variable and therefore quite relevant to surgical work in this area. If the common hepatic artery originated from the left gastric artery in the patient above and the left gastric artery was ligated, how would this affect blood flow to the stomach? To other organs? A: In this situation, the common hepatic artery would not receive blood. This artery supplies the liver and pylorus. Without sufficient anastamoses, the pylorus of the stomach would die along with the liver possibly. The pancreas and duodenum would be supplied by the pancreaticoduodenal, assuming it has a direct connection to the celiac trunk.
Version: 09Apr2009
Page 1 of 7
Gross Anatomy
Forum
Abdomen
Hopefully, celiac arterial anastamoses would help keep the liver and pylorus alive. (See Image #1) 6. A 62y/o female professor who had a Hx of chronic duodenal ulcer was admitted to the ER with signs of internal hemorrhage. She was diagnosed with perforation of the posterior wall of the 1st part of the duodenum. a. What artery is most likely hemorrhaging? A: The gastroduodenal artery b. What structures are immediately at risk? A: The inferior vena cava, bile duct, and portal vein. Also, possibly the hepatic artery, pancreas and maybe the liver, gallbladder, and right kidney. (See Image #2) 7. A 23 y.o. medical student was involved in an MVA on the way to school. He was taken to the ER where exams indicated low BP and tenderness on the left mid-axillary line. X-rays indicated fracture of the angles of left ribs 9&10. The abdominal organ most likely injured by the fractures is? A: The spleen, which lies between ribs 9-11 on the left side. The spleen has blood flowing freely through it and a rupture would spill into the posterior left subphrenic space (if they’re lying down). 8. During emergency surgery, an ulcer was found to have perforated the posterior stomach wall eroding the large artery running in the vicinity. What artery was injured? A: The splenic artery. (See Image #1) If it were the pyloric region, it would be the aorta. 9. During surgery to repair hemorrhaging caused by arterial erosion from a duodenal ulcer, surgeons ligated the gastroduodenal artery near its origin. Assuming “normal anatomy” in what arteries would blood now flow retrograde from collateral sources to supply the stomach? To supply the pancreas/duodenum? A: For the stomach, it would be the left gastroepiploic (from the splenic). For the duodenum and pancreas, it would be the inferior pancreaticoduodenal artery (from SMA). (See Image #3) Also, anastamoses from dorsal and greater pancreatic arteries. 10. During a cholecystectomy, the surgical resident accidentally jabbed a scalpel into the area just posterior to the epiploic foramen. The surgical field immediately began to fill with blood. What was the source of the hemorrhage? A: The inferior vena cava. 11. A 5y/o. male patient with severe jaundice was diagnosed with pancreatic cancer. You suspect the tumor is located in which portion of the pancreas? A: The head of the pancreas, which contains the common bile duct (obstructive or posthepatic jaundice). Backup of the bile duct causes the blood levels of bilirubin to increase. When bilirubin reaches a certain level (>2-3mg/dL) in the blood, yellow skin coloration can be seen.
Version: 09Apr2009
Page 2 of 7
Gross Anatomy
Forum
Abdomen
12. Your patient was admitted with symptoms of bowel obstruction. Tests revealed the obstruction was due to a nutcracker-like compression of the bowel between the superior mesenteric artery and the aorta. What portion of the bowel is most likely compressed? A: The duodenum, on the third portion. (See Image #4) 13. A 43y/o woman was diagnosed with pancreatitis due to reflux of bile in the pancreatic duct caused by a gallstone. Where is the gallstone most likely lodged? A: Near the major duodenal papilla. This would allow bile form the bile duct to enter the main pancreatic duct but no bile would enter into the duodenum, thus causing a reflux. (See Image #5) 14. What features would you use to distinguish small vs. large bowel? A: Small bowel has: Plicae circulares (jejunum), Peyer’s patches of lymph tissue (ileum), mobility, smaller caliber, a smooth external, and a mesentery that passes downward across the midline into the right iliac fossa. Large bowel has: epiploic appendices, haustra (sacculations), teniae coli, and a smooth mucous membrane inside. 15. During abdominal surgery following an MVA, the inferior mesenteric artery must be ligated. Why is it possible to ligate this major vessel without complications? A: Because sufficient anastamoses come from the SMA (middle colic branch than marginal sub-branches) and branches off of the left iliac (internal/external) artery. Mainly the inferior rectal from the left internal iliac. (See Image #6) 16. What are the regions of anastomosis between the SMA/IMA? Celiac trunk/SMA? A: SMA/IMA is at the middle colic artery and left colic artery. Celiac/SMA is at the superior pancreaticoduodenal artery and inferior pancreaticoduodenal artery. 17. Injury to the vagus nerve during abdominal surgery would not affect which part of the gut? A: The vagus nerve (CNX) gives parasympathetic innervation to the entire gut except for the suprarenal (adrenal) glands and the organs below the second segment of the transverse colon. 18. A purulent exudate in the right paracolic gutter would be situated beside what part of bowel? A: The ascending colon (and cecum). (See Image #7) Extra Question. A patient is stabbed on the right side, 12th rib. What organ is injured? What about left side, 12th rib? A: The liver. The spleen.
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Image #7 James Lamberg
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Abdominal Viscera Small Group Questions/Cases A 45y/o accountant was admitted to the hospital after visiting the ER with complaints of severe abdominal pain and pain over his right shoulder. The H&P indicates a history of gastric ulcers controlled via Rx but he admits that recently he has not been taking his medication. The physician suspects a perforated gastric ulcer. Gastroscopy confirmed the diagnosis. During surgery, a small perforation was identified on the posterior region of the stomach body near the lesser curvature. The surgeon repaired the perforation, performed a vagotomy, and had to cut and ligate the left gastric artery during the procedure. 1. What structures are at risk in this perforation? A: Left gastric artery/vein, esophagus, and esophageal artery. Possibly the splenic artery, left gastric lymph nodes, anterior/posterior vagal trunk (nerves), diaphragm, right gastric artery/vein, right gastric lymph nodes, celiac branch and hepatic branch (of vagal nerve trunk), left lobe of liver, left kidney/suprarenal gland. 2. Why did the patient have shoulder pain? A: Irritation of the nearby diaphragm would agitate the phrenic nerve. This nerve has root values of C3-5 and referred pain would be felt at those dermatomes, which includes the shoulder. (However, due to the location of the lesser curvature in relation to the diaphragm, it is more likely that referred pain would come from the liver, gallbladder, or duodenum.) 3. What is a vagotomy and why was it performed? A: A vagotomy is the resection of part of the vagus nerve (CNX), which provides parasympathetic innervation to abdominal organs. Likely, the vagotomy was done to eliminate symptoms of gastro-esophageal reflux (GERD). However, this treatment is now obsolete. Improvements to the treatment included selecting only the branches innervating the stomach (highly selective vagotomy). This treatment was also used to reduce acid secretion to the stomach, prior to understanding ulcer disease was caused by H. pylori. 4. With the left gastric artery ligated, how will the stomach receive blood? A: The main anastamoses is from the right gastric artery, a branch off of the right hepatic artery. Other anatamoses include the right gastroepiploic artery (from right gastroduodenal) and possibly the left gastroepipolic artery (from splenic). 5. Celiac trunk branching is quite variable and therefore quite relevant to surgical work in this area. If the common hepatic artery originated from the left gastric artery in the patient above and the left gastric artery was ligated, how would this affect blood flow to the stomach? To other organs? A: In this situation, the common hepatic artery would not receive blood. This artery supplies the liver and pylorus. Without sufficient anastamoses, the pylorus of the stomach would die along with the liver possibly. The pancreas and duodenum would be supplied by the pancreaticoduodenal, assuming it has a direct connection to the celiac trunk.
Version: 09Apr2009
Page 1 of 7
Gross Anatomy
Forum
Abdomen
Hopefully, celiac arterial anastamoses would help keep the liver and pylorus alive. (See Image #1) 6. A 62y/o female professor who had a Hx of chronic duodenal ulcer was admitted to the ER with signs of internal hemorrhage. She was diagnosed with perforation of the posterior wall of the 1st part of the duodenum. a. What artery is most likely hemorrhaging? A: The gastroduodenal artery b. What structures are immediately at risk? A: The inferior vena cava, bile duct, and portal vein. Also, possibly the hepatic artery, pancreas and maybe the liver, gallbladder, and right kidney. (See Image #2) 7. A 23 y.o. medical student was involved in an MVA on the way to school. He was taken to the ER where exams indicated low BP and tenderness on the left mid-axillary line. X-rays indicated fracture of the angles of left ribs 9&10. The abdominal organ most likely injured by the fractures is? A: The spleen, which lies between ribs 9-11 on the left side. The spleen has blood flowing freely through it and a rupture would spill into the posterior left subphrenic space (if they’re lying down). 8. During emergency surgery, an ulcer was found to have perforated the posterior stomach wall eroding the large artery running in the vicinity. What artery was injured? A: The splenic artery. (See Image #1) If it were the pyloric region, it would be the aorta. 9. During surgery to repair hemorrhaging caused by arterial erosion from a duodenal ulcer, surgeons ligated the gastroduodenal artery near its origin. Assuming “normal anatomy” in what arteries would blood now flow retrograde from collateral sources to supply the stomach? To supply the pancreas/duodenum? A: For the stomach, it would be the left gastroepiploic (from the splenic). For the duodenum and pancreas, it would be the inferior pancreaticoduodenal artery (from SMA). (See Image #3) Also, anastamoses from dorsal and greater pancreatic arteries. 10. During a cholecystectomy, the surgical resident accidentally jabbed a scalpel into the area just posterior to the epiploic foramen. The surgical field immediately began to fill with blood. What was the source of the hemorrhage? A: The inferior vena cava. 11. A 5y/o. male patient with severe jaundice was diagnosed with pancreatic cancer. You suspect the tumor is located in which portion of the pancreas? A: The head of the pancreas, which contains the common bile duct (obstructive or posthepatic jaundice). Backup of the bile duct causes the blood levels of bilirubin to increase. When bilirubin reaches a certain level (>2-3mg/dL) in the blood, yellow skin coloration can be seen.
Version: 09Apr2009
Page 2 of 7
Gross Anatomy
Forum
Abdomen
12. Your patient was admitted with symptoms of bowel obstruction. Tests revealed the obstruction was due to a nutcracker-like compression of the bowel between the superior mesenteric artery and the aorta. What portion of the bowel is most likely compressed? A: The duodenum, on the third portion. (See Image #4) 13. A 43y/o woman was diagnosed with pancreatitis due to reflux of bile in the pancreatic duct caused by a gallstone. Where is the gallstone most likely lodged? A: Near the major duodenal papilla. This would allow bile form the bile duct to enter the main pancreatic duct but no bile would enter into the duodenum, thus causing a reflux. (See Image #5) 14. What features would you use to distinguish small vs. large bowel? A: Small bowel has: Plicae circulares (jejunum), Peyer’s patches of lymph tissue (ileum), mobility, smaller caliber, a smooth external, and a mesentery that passes downward across the midline into the right iliac fossa. Large bowel has: epiploic appendices, haustra (sacculations), teniae coli, and a smooth mucous membrane inside. 15. During abdominal surgery following an MVA, the inferior mesenteric artery must be ligated. Why is it possible to ligate this major vessel without complications? A: Because sufficient anastamoses come from the SMA (middle colic branch than marginal sub-branches) and branches off of the left iliac (internal/external) artery. Mainly the inferior rectal from the left internal iliac. (See Image #6) 16. What are the regions of anastomosis between the SMA/IMA? Celiac trunk/SMA? A: SMA/IMA is at the middle colic artery and left colic artery. Celiac/SMA is at the superior pancreaticoduodenal artery and inferior pancreaticoduodenal artery. 17. Injury to the vagus nerve during abdominal surgery would not affect which part of the gut? A: The vagus nerve (CNX) gives parasympathetic innervation to the entire gut except for the suprarenal (adrenal) glands and the organs below the second segment of the transverse colon. 18. A purulent exudate in the right paracolic gutter would be situated beside what part of bowel? A: The ascending colon (and cecum). (See Image #7) Extra Question. A patient is stabbed on the right side, 12th rib. What organ is injured? What about left side, 12th rib? A: The liver. The spleen.
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Image #7 James Lamberg
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