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Abdomen Board Review Cases


Case 1. You are having a busy day in the ER – two patients come in at the same time complaining of pain, constipation, and bloating. The first patient is a 14 y.o. boy with a discernable bulge in his left inguinal region and scrotum. The second patient is a 60 y.o. man with a small reducible lump in his left groin region. Using the information you have at this time, what type of hernia do you suspect that each of your patients has? After receiving the contrast films that you ordered, you discover that the boy’s hernia is contained within the layers of the spermatic cord, while the man’s hernia is not. Did the films confirm your suspicions? Where would each of the above hernias pass with respect to the inferior epigastric vessels?


Case 2. Your patient has a history of alcoholism and has been diagnosed with liver cirrhosis. He comes to your office with complaints of hemorrhoids. What are hemorrhoids? How could they be caused by liver cirrhosis? What other types of varices could be caused by your patient’s condition? Your patient also has an enlarged spleen. Explain how this could be due to his disease.


Case 3. Your patient develops a gastric ulcer that erodes away the posterior wall of his stomach. As gastric juices and stomach contents leak out of the stomach, where would they accumulate? What are the borders of this area? The ulcer then erodes the area posterior to the stomach. What organ would be damaged by the stomach acid? You perform a vagotomy (sectioning of the vagal trunks) to improve the situation. How could this procedure reduce your patient’s symptoms? Would the functioning of the descending colon be affected by this procedure?


Case 4. While performing surgery, you accidentally cut the celiac trunk. Review all the branches of the celiac trunk and name the organs that are normally supplied by this artery.


Case 5. Your patient has cancer in her liver and right kidney. Explain how cancer could spread from these locations to the venous system via the lymphatic system.


Case 6. Your patient has localized pain at the tip of the 9th costal cartilage. How would you locate this landmark using surface landmarks and/or abdominal planes? What is the tip of the 9th costal cartilage a landmark for? You decide that it is necessary to perform a laparoscopic cholecystectomy. During surgery, you accidentally cut the hepatoduodenal ligament and arterial blood fills the area. What artery did you cut? You also severed sympathetic GVE fibers and GVA pain fibers that were travelling on the artery. Which splanchnic nerve are the sympathetic fibers branches of? Are they preganglionic or postganglionic? Where did/will they synapse? Generally, where would pain from the gallbladder be referred to? Explain how it is possible for gallbladder pain to be referred to the patient’s shoulder.



Practice questions

1. Your patient has diffuse periumbilical pain. Which of the following conditions could NOT be responsible for your patient’s pain?

A. Meckel’s diverticulum
B. gastric ulcer
C. diverticulitis of the descending colon
D. appendicitis

2. Your patient has a retroperitoneal infection. Which of the following organs would most likely be susceptible to the infection:

A. spleen
B. jejunum
C. duodenum
D. sigmoid colon

3. Which of the following is NOT derived from the ventral mesentery:

A. hepatoduodenal ligament
B. falciform ligament
C. hepatogastric ligament
D. greater omentum

4. An excited 2nd year med student (EBSP, passed her boards) is performing her first urethral catheterization on a male patient. Unfortunately, she fails to negotiate the curves in the spongy urethra and punctures the urethra within the bulb of the penis. Urine from the ruptured urethra could spread into all of the following locations EXCEPT:

A. abdominal wall (deep to the membranous layer of superficial fascia)
B. scrotum
C. thigh
D. penis

5. Your patient is trying to pass a kidney stone and it gets stuck in the ureter. Pain from the ureter could be referred to all of the following EXCEPT:

A. epigastric region
B. genitals
C. lumbar region
D. medial thigh


Abdomen Board Review Answers


Case 1. The key information that will help you determine the type of hernia is the age of the patient and the “characteristics” of the lump (i.e. location and reducibility). The young age of the first patient hints indirect (indirect are often congenital; direct are uncommon in children) and the fact that it is in the scrotum also hints indirect (direct don’t often extend that far). The age of the second patient hints direct (often occur in older men whose abdominal muscles are weak – “beer guts”) as well as the reducibility (harder to push an indirect back in since it is usually along the length of the inguinal canal and/or strangulated at the deep ring; direct are usually just sitting posterior to the external oblique and can be pushed back in). The films did indeed confirm the suspicions above because only an indirect hernia can be surrounded by layers of the spermatic cord (the only way to become surrounded by the layers is to follow the path of the spermatic cord through the deep ring). Indirect hernias pass lateral to the inferior epigastric vessels while direct pass medial.


Case 2. Hemorrhoids are dilated rectal veins. Liver disease would cause backup of blood in the portal system (portal hypertension) – therefore any tributaries of the portal vein would become enlarged, and blood would try to find alternate routes. The four major alternate routes are sites where the portal vein tributaries anastomose with systemic veins: superior rectal/inferior rectal (hemorrhoids), esophageal/esophageal (esophageal varices), colic/retroperitoneal lumbar veins, paraumbilical/epigastric (caput medusae). Dilated systemic veins are called varices and the common types are listed in the parentheses above. Since the spleen is like a “bag of blood”, backup in the splenic vein will cause it to enlarge as well.

 

Case 3. Gastric juices would collect in the omental bursa (lesser sac). Borders of this area are:

Superior: liver and diaphragm
Inferior: transverse mesocolon, transverse colon, greater omentum
Posterior: pancreas
Anterior: stomach and lesser omentum
Left: spleen
Right: epiploic foramen

The juices would erode the pancreas. Since the vagus nerves control secretion of the stomach acid (provide parasympathetic innervation to parietal cells), cutting the vagi would reduce secretion. The descending colon would not be affected because the vagus nerves do not provide its parasympathetic innervation – the pelvic splanchnics do (hindgut organ).

 

Case 4. The celiac trunk arises from the anterior surface of the abdominal aorta just distal to the aortic hiatus of the diaphragm. It has 3 major branches:

Left gastric which travels on the lesser curvature of the stomach and supplies it.

Splenic which travels across the superior surface of the pancreas to reach the spleen (it supplies both the spleen and pancreas). Near its termination, the splenic also gives off the left gastroepiploic artery and the short gastric arteries, both of which supply the greater curvature of the stomach.

Common hepatic which supplies the liver, stomach, duodenum and gallbladder via its branches. The common hepatic artery gives off the gastroduodenal artery (supplies 1st part of duodenum) and right gastric artery (supplies lesser curvature of stomach), at which point it becomes known as the proper hepatic artery. The proper hepatic artery divides into the right and left hepatic arteries that supply the right and left lobes of the liver, respectively. The cystic artery, a branch of the right hepatic artery, supplies the gallbladder. The right gastroepiploic artery (supplies the greater curvature of the stomach) is a branch of the gastroduodenal artery.


Case 5. Lymphatic vessels in the abdominal cavity accompany the veins. Lymph from the viscera drains first to peripheral nodes that are located near the visceral organs. These are named by the organ itself, i.e. gastric, hepatic, colic, etc. Depending on the location of the organ, lymph then passes into either the preaortic nodes (located near the origins of the major vessels) or the lumbar nodes (found along the lateral aspect of the abdominal aorta). In general, intraperitoneal organs drain to the preaortic nodes, while retroperitoneal organs drain to the lumbar nodes. Exceptions to this rule would be organs that are secondarily retroperitoneal (were intraperitoneal first, then became retroperitoneal) such as the duodenum, pancreas, and ascending and descending colon…these drain to the preaortic nodes. Lymphatic vessels from the preaortic nodes converge to form several intestinal trunks, while those from the lumbar nodes form two lumbar trunks. Lymph from the trunks drains to the cisterna chyli (a lymphatic sac) and then the thoracic duct. The thoracic duct empties its contents into the venous system near the junction of the left subclavian and internal jugular veins. Therefore, lymphatic drainage of the liver would be: hepatic nodes, preaortic nodes, intestinal trunk, cisterna chyli, thoracic duct. Lymphatic drainage of the kidney would be: renal nodes, lumbar nodes, lumbar trunk, cisterna chyli, thoracic duct.


Case 6. The junction of the transpyloric plane and semilunar line is found at the tip of the 9th costal cartilage – or more simply, the junction of the transpyloric plane and costal margin. This site is a landmark for the gallbladder. During surgery you most likely cut the proper hepatic artery (right and left branches are also possible if you are superior enough). The sympathetic fibers are branches of the greater splanchnic nerve (liver is foregut, greater splanchnic innervates foregut), they are postganglionic, and they synapsed in the celiac ganglia. Pain fibers from the gallbladder would travel backwards in the greater splanchnic and therefore enter the spinal cord between the T5-T9 regions. Pain is referred to the right side of the trunk over the 5th-9th ribs. It is also possible for pain to be referred to the shoulder (C5) through the phrenic nerve (C3-5) if the inflammation causes irritation of the diaphragm.


Practice questions:

1. B
2. C
3. D
4. C
5. A

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