Block 6 Anatomy Abdomen BRS Pretest W Xpl Prt 2

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Block 6 Anatomy Abdomen BRS Pretest W Xpl Prt 2 - Quiz

Questions and Answers
  • 1. 

    Which of the following gives rise to all structures of the kidney?

    • A.

      Somitic mesoderm

    • B.

      Intermediate mesoderm

    • C.

      Splanchnic lateral plate mesoderm

    • D.

      Somatic lateral plate mesoderm

    • E.

      Neural crest

    Correct Answer
    B. Intermediate mesoderm
    Explanation
    Sadler, pp 229–231.) The kidney forms in three stages. The pronephric, metanephric, and mesonephric kidneys all form from the urogenital ridge, an extension of intermediate mesoderm into the coelomic cavity. Mesoderm derived from the somites (somatic; answer a) gives rise to components of the axial skeleton and associated muscle and connective tissues. Splanchnic lateral plate mesoderm (answer c) gives rise to the smooth muscle and connective tissue tunics of the abdominal viscera. Somatic lateral plate mesoderm (answer d) contributes substantially to the skeleton, connective tissue, and muscle mass of the appendages. Neural crest (answer e) forms the sensory and sympathetic chain ganglia and other structures.

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  • 2. 

    A middle-aged woman describes flushing, severe headaches, and a feeling that her heart is “going to explode” when she gets excited. At the beginning of a physical examination her blood pressure (130/85) is not significantly above normal. However, on palpation of her upper left quadrant, the examining physician notices the onset of sympathetic signs. Her blood pressure (200/135) is abnormally high. A subsequent CT scan confirms the suspected tumor of the left adrenal gland. The patient is scheduled for surgery. The symptoms that the patient correlates with the onset of excitement were most likely due to neural stimulation of the adrenal glands. The adrenal medulla receives its innervation from which of the following?

    • A.

      Preganglionic sympathetic nerves

    • B.

      Postsynaptic sympathetic nerves

    • C.

      Preganglionic parasympathetic nerves

    • D.

      Postganglionic parasympathetic nerves

    • E.

      Somatic nerves

    Correct Answer
    A. Preganglionic sympathetic nerves
    Explanation
    Moore and Dalley, pp 63–64, 320.) The adrenal medulla is innervated from thoracic levels of the spinal cord mediated by preganglionic sympathetic nerve fibers traveling in the lesser and least splanchnic nerves, with some contribution from the greater splanchnic and lumbar splanchnic nerves [thus not (answer b)]. Because both the adrenal medulla and postganglionic sympathetic neurons are adrenergic and derived from neural crest tissue, the homology of the chromaffin cells and postganglionic sympathetic neurons is apparent. There appears to be no parasympathetic innervation (answers c and d) to the adrenal medulla or cortex. There is no somatic (answer e) innervation by the adrenal medulla, by definition a visceral organ.

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  • 3. 

    A 42-year-oldman presents with an enlarged left adrenal gland on CT scan. He is scheduled for adrenalectomy. The left adrenal gland is located, and the venous drainage is ligated to prevent life-threatening quantities of adrenalin from entering the bloodstream on manipulation of the gland. Normally, the left adrenal venous drainage is into which of the following?

    • A.

      Inferior vena cava

    • B.

      Left azygos vein

    • C.

      Left inferior phrenic vein

    • D.

      Left renal vein

    • E.

      Superior mesenteric vein

    Correct Answer
    D. Left renal vein
    Explanation
    Moore and Dalley, pp 316–318.) The venous drainage from each adrenal gland tends to be through a single vein. The left adrenal gland usually drains into the left renal vein superior [thus not (answers a and b)] to the point where the gonadal vein enters the left renal vein. The left adrenal vein usually anastomoses with the hemiazygos vein and may provide an important route of collateral venous return. Left inferior phrenic vein (answer c) and superior mesenteric vein (answer e) has no connections with adrenal veins. The right adrenal gland usually drains directly into the inferior vena cava.

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  • 4. 

    Which of the following statements concerning a direct inguinal hernia is correct?

    • A.

      It protrudes through the inguinal (Hesselbach’s) triangle

    • B.

      It is the most common type of abdominal hernia in newborn boys

    • C.

      It traverses the entire length of the inguinal canal

    • D.

      It contains all three fascial layers of the spermatic cord

    • E.

      It exits the inguinal canal via the superficial inguinal ring

    Correct Answer
    A. It protrudes through the inguinal (Hesselbach’s) triangle
    Explanation
    Moore and Dalley, pp 213, 223–225.) A direct inguinal hernia protrudes through a space bounded superolaterally by the inferior epigastric vessels, medially by the rectus abdominus muscle, and superior to the inguinal ligament (Hesselbach’s triangle). The other statements (answers b, c, d, e) are true of an indirect inguinal hernia. A direct hernia traverses only the most medial part of the inguinal canal and is not covered by the most internal layers of spermatic cord fascia.

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  • 5. 

    While moving furniture, an 18-year-old teenager experiences excruciating pain in his right groin. A few hours later he also develops pain in the umbilical region with accompanying nausea. At this point he seeks medical attention. Examination reveals a bulge midway between the midline and the anterior superior iliac spine, but superior to the inguinal ligament. On coughing or straining, the bulge increases and the inguinal pain intensifies. The bulge courses medially and inferiorly into the upper portion of the scrotum and cannot be reduced with the finger pressure of the examiner. It is decided that a medical emergency exists, and the patient is scheduled for immediate surgery. Nausea and diffuse pain referred to the umbilical region in this patient most probably are due to which of the following?

    • A.

      Compression of the genitofemoral nerve

    • B.

      Compression of the ilioinguinal nerve

    • C.

      Dilation of the inguinal canal

    • D.

      Ischemic necrosis of a loop of small bowel

    • E.

      Ischemic necrosis of the cremaster muscle

    Correct Answer
    D. Ischemic necrosis of a loop of small bowel
    Explanation
    (Moore and Dalley, pp 321–324.) The diffuse central abdominal pain in the patient presented is probably referred pain from the loop of small bowel incarcerated within the herniated peritoneal sac that then undergoes ischemic necrosis. Compression of the bowel results in compromise of the blood supply and subsequent ischemic necrosis [thus not (answer e)]. The visceral afferent fibers from the distal small bowel travel along the blood vessels to reach the superior mesenteric plexus and lesser splanchnic nerves, which they follow to the T10–T11 levels of the spinal cord. The pain, therefore, is referred to (appears as if originating from) the T10–T11 dermatomes, which supply the umbilical region. Because the gut develops as a midline structure, visceral pain tends to be centrally located regardless of the adult location of any particular region of the gut. As a result of dilation (answer c) of the inguinal canal by the hernial sac, however, the patient also experiences localized somatic pain mediated by the iliohypogastric, ilioinguinal (answer b), and genitofemoral nerves (answer a), but this was not what
    the question asked.

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  • 6. 

    A 77-year-old woman complains to her doctor about left sided chest pain, difficulty swallowing and the sensation that food is stuck in her esophagus. Antacids don’t seem to help much. The symptoms seems to get worse if she lies down shortly after meal and she often has some small reflux of acidic stomach contents. A barium swallow study is performed and one of the late images taken is illustrated below. Based on the history and radiological image which of the following is the most likely diagnosis?

    • A.

      Sliding hiatal hernia

    • B.

      Para esophageal hiatal hernia

    • C.

      Congenital Bochdalek hernia

    • D.

      Pylorospasm

    • E.

      Congenital hypertrophic pyloric stenosis

    Correct Answer
    A. Sliding hiatal hernia
    Explanation
    (Moore and Dalley, pp 250, 252.) This patient has a sliding hiatal hernia. Sliding hiatal hernias are more common than paraesophageal hiatal hernias (answer b). Sliding hiatal hernias are generally acquired in middle age and lead to chest pain, difficulty swallowing food and acid reflux. A congenital Bochdalek hernia (answer c) is unlikely since they usually allow a portion of the small intestine to enter the left pleural cavity and are a medical emergency in newborns. Neither pylorospasm (answer d) nor congenital hypertrophic pyloric stenosis (answer e) is likely since barium is reaching the small intestine.

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  • 7. 

    A 24-year old man was a passenger in an automobile broadsided by another vehicle. Although he was wearing a seat belt he felt “terrible,” and had left sided abdominal, flank, and shoulder pain. During the ambulance ride into the emergency room his blood pressure kept dropping, he appeared pale, had a rapid heartbeat, with otherwise normal lung and heart sounds. Intravenous saline was started en route. Which of the following abdominal organs is most likely damaged?

    • A.

      Stomach

    • B.

      Duodenum

    • C.

      Pancreas

    • D.

      Left kidney

    • E.

      Spleen

    Correct Answer
    E. Spleen
    Explanation
    (Moore and Dalley, pp 284–285.) The spleen is one of the most frequently injured organs in the abdomen. This is especially so if the spleen was enlarged as a consequence of infectious mononucleosis making it more susceptible to rupture. Because it has an extensive blood supply, shock and death from bleeding into the peritoneal cavity can occur if a ruptured spleen is left untreated. The symptoms described above are consistent with blood loss most likely associated with a ruptured spleen.
    None of the other abdominal organs, stomach (answer a), duodenum (answer b), pancreas (answer c), and kidney (answer d) are likely to cause the sudden drop in blood pressure.

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  • 8. 

    Volvulus is most likely to occur within segments of the GI tract that are intraperitoneal, not retroperitoneal. Which segments of the GI tract are susceptible to volvulus, and to where does the referred pain of volvulus tend to occur for that segment?

    • A.

      Duodenum; epigastric region

    • B.

      Jejunum; epigastric region

    • C.

      Ascending colon; umbilical region

    • D.

      Descending colon; umbilical region

    • E.

      Sigmoid colon; suprapubic region

    Correct Answer
    E. Sigmoid colon; suprapubic region
    Explanation
    (Moore and Dalley, pp 277, 257–258.) Volvulus (twisting of the GI tract on itself) which limits movement of material within the lumen and may compromise blood flow occurs most frequently with the jejunum and ileum and the sigmoid colon. These are intraperitoneal segments of the GI tract. The jejunum and ileum are both midgut derivatives and thus refer pain to the periumbilical region [thus not (answer b)]. The sigmoid colon is the most mobile portion of the large bowel and is derived from the hindgut and tends to refer pain to the suprapubic region (especially on the left side) [thus not answers c and d)]. The duodenum (answer a) is retroperitoneal and generally does not undergo volvulus.

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  • 9. 

    You have a patient who has renal failure as a result of Alport’s syndrome. While he is currently on dialysis, he is hoping to receive a transplanted kidney. He asks you if they are going to remove one of his bad kidneys and put the new transplanted kidney back in the same place. You tell him which of the following?

    • A.

      The right kidney is always removed since it is more inferior and easier to remove and the new kidney will go in its place

    • B.

      The left kidney will be removed because it is easier to move the descending colon out of the way and the newly transplanted kidney will go in its place

    • C.

      He will keep both of his kidneys, and the newly transplanted kidney will be placed on the left posterior wall just inferior to his left kidney since there is more room because the left kidney is higher

    • D.

      The newly transplanted kidney will be placed in the iliac fossa in the greater pelvis, attached to branched iliac vessels and the ureter connected directly to the bladder

    Correct Answer
    D. The newly transplanted kidney will be placed in the iliac fossa in the greater pelvis, attached to branched iliac vessels and the ureter connected directly to the bladder
    Explanation
    Moore and Dalley, pp 311–312.) The newly transplanted kidney will be placed in the iliac fossa in the greater pelvis, attached to branched iliac vessels and the ureter connected directly to the bladder. Generally unless the kidneys are infected the host kidneys are left in place [thus not (answers a and b)]. The newly transplanted kidney is placed in the greater pelvis and connected to the iliac vessels [thus not (answer c)]. Often the internal iliac artery is connected to the renal arteries. Normally, anastomotic connections across the midline from the opposite internal iliac artery keep pelvic organs with enough blood to maintain proper function. The transplanted renal vein is often connected to, the external iliac vein, since it is typically larger and thus easier to establish anastomoses.

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  • 10. 

    Allen is a 30-year-old bachelor who frequents “singles” bars. He is cautious and always uses a condom in his sexual encounters. Recently, he has felt “off,” experiencing a sore throat, malaise, and a slight fever. When you see him in your office, he has a few swollen lymph nodes and has a large palpable structure in the left upper abdomen indicated by the asterisk in the accompanying radiograph. He had a positive monospot test and an elevated sedimentary rate. The structure you palpated was which of the following?

    • A.

      Hepatomegaly

    • B.

      Splenomegaly

    • C.

      The stomach

    • D.

      A tumor of the liver

    • E.

      Liver cirrhosis

    Correct Answer
    B. Splenomegaly
    Explanation
    (Moore and Dalley, p 285.) The patient in the scenario has infectious mononucleosis, a virus-induced illness, leading to swollen lymph nodes and spleen. The splenomegaly is evidenced by the very rounded contours of the organ. Infectious mononucleosis can exhibit liver involvement; however, the organ indicated is not the liver (not answers a, d, and e) but the spleen in the upper left hypochondrium. The bright organ between it and the vertebra is the left kidney. The liver is on the opposite side of the abdominal cavity. The stomach (answer c) is not seen.

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  • 11. 

    A patient complained of severe abdominal pain on several occasions, but no cause could be identified. She was recently diagnosed with vasculitis of small and medium muscular blood vessels (polyarteritis nodosa) so you ordered an abdominal arteriogram to determine whether there were abdominal vascular changes that would explain her abdominal pain. On her arteriogram there is a tortuous vessel indicated by the arrow. What is this vessel?

    • A.

      Left gastric artery

    • B.

      Superior mesenteric artery

    • C.

      Splenic artery

    • D.

      Right gastric artery

    • E.

      Right gastro-omental artery

    Correct Answer
    C. Splenic artery
    Explanation
    (Moore and Dalley, p 284.) The splenic artery originates from the celiac trunk and courses tortuously along the posterior aspect of the pancreas. The left gastric artery (answer a) is a separate branch of the celiac trunk and courses along the lesser curvature of the stomach where it anastomoses with the right gastric artery (answer d), a branch of hepatic artery. The right gastro-omental (gastroepiploic) artery (answer e) is a branch of the gastroduodenal artery and courses along the greater curvature of the stomach. The superior mesenteric artery (answer b) is more inferior seen running to the right side of the patient.

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  • 12. 

    Which of the following is structure 20 in the axial CT of the abdomen with intravenous contrast below?

    • A.

      Celiac trunk (artery)

    • B.

      Common hepatic artery

    • C.

      Left crus of diaphragm

    • D.

      Splenic artery

    • E.

      Superior mesenteric artery

    Correct Answer
    B. Common hepatic artery
    Explanation
    (Moore and Dalley, p 284.) Structure 20 is the common hepatic artery. The celiac [18; (answer a)] artery (trunk) gives off the splenic [19; (answer d)] artery (to the patient’s left) and the common hepatic [20; (answer b)] artery (to the patient’s right). Other labeled structures are as follows: 17, right adrenal gland; 21, portal vein; and 22, left adrenal gland. The crus of diaphragm (answer c) is seen covering each side of the abdominal aorta. The superior mesenteric artery (answer e) is not seen in this image and would be further inferior with the abdomen.

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  • 13. 

    Pathology within some abdominal organs can occasionally cause referred pain in the shoulder and neck regions, C3–C5, because the diaphragm receives its motor and afferent innervation from this level as a result of its cranial embryonic development. Which of the following abdominal organs sometimes causes unilateral shoulder/neck pain?

    • A.

      Liver; left side

    • B.

      Gallbladder; right side

    • C.

      Pancreas; right side

    • D.

      Spleen; right side

    • E.

      Appendix; left side

    Correct Answer
    B. Gallbladder; right side
    Explanation
    . (Moore and Dalley pp 257–258, 330.) Enlargement of the gallbladder is a common complication of gallstone development. If the gallbladder enlarges enough and becomes inflamed then it can contact the inferior surface of the diaphragm, leading to right-sided shoulder/neck pain. The liver, if inflamed, would also produce right-sided shoulder/neck pain [thus not (answer a)]. The pancreas (answer c) is mainly a midline organ that is retroperitoneal, thus even when infected and inflamed it is unlikely to contact the center of the diaphragm (that portion which carries afferent information back to cervical levels of the spinal cord). An enlarged spleen could cause left sided shoulder/neck pain [thus not (answer d)]. Normally the appendix (answer e) is too inferior to contact the diaphragm and would cause pain on the left not right side.

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  • 14. 

    Sensation of fullness in the rectum involves stretch receptors, which of the following provides innervation for those receptors?

    • A.

      Lumbar sympathetic chain

    • B.

      Pelvic splanchnic nerves (nervi erigentes)

    • C.

      Pudendal nerve

    • D.

      Sacral sympathetic chain

    • E.

      Vagus nerve

    Correct Answer
    B. Pelvic splanchnic nerves (nervi erigentes)
    Explanation
    (Moore and Dalley, p 276.) Sensation produced by distention of the rectum travels along the pelvic splanchnic nerves to sacral levels S2–S4. Fecal continence is affected by nerves from the S2–S4 segments of the spinal cord. The principal effector, the puborectalis portion of the levator ani muscle, is innervated by somatic twigs from the sacral plexus. The external anal sphincter is controlled by the pudendal nerve (answer c), which also carries pain sensation associated with external hemorrhoids. The lumbar (answer a) and sacral (answer d) sympathetic chain would provide motor innervation to the rectum. The vagus (answer e) nerve does not innervate the rectum.

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  • 15. 

    A 50-year-old man comes in for a physical so he can attend a boy scout camp with one of his sons. You suggest a colonoscopy after he returns from camp. He agrees, but wants you to describe the procedure and potential risks and complications. You explain that the goal of a colonoscopy is to look at the entire length of the large intestine from the anus to the small intestine (ileocecal junction), observing polyps or diverticuli with a flexible fiber optic colonoscope inserted through the anus. There is a small risk of perforating the bowel especially when the colon takes a sudden turn or twists on itself at regions where it is intraperitoneal rather than attached to the posterior abdominal wall (retroperitoneal). Which of the following regions of the colon generally poses the greatest risk for perforation because the bowel takes either a sudden change in direction or is suspended by a mesentery?

    • A.

      Rectum, sigmoid colon and descending colon

    • B.

      Sigmoid colon, descending colon and splenic flexure

    • C.

      Sigmoid colon, splenic flexure and descending colon

    • D.

      Sigmoid colon, splenic flexure and hepatic flexure

    • E.

      Descending colon, transverse colon and ascending colon

    Correct Answer
    D. Sigmoid colon, splenic flexure and hepatic flexure
    Explanation
    (Moore and Dalley, pp 277– 280.) The colon normally has two regions where it is retroperitoneal: the ascending and descending colon. There are also two normal points of flexure: the hepatic (right) and splenic (left) flexures. Therefore, the sigmoid colon, splenic flexure, and hepatic flexure are the regions where the gastroenterologist has the greatest difficulty passing the fiberoptic scope, and thus have the greatest risk of bowel perforation. This is perhaps most easily visualized by looking at Fig. 2.44 on p 278 of Moore & Dalley. Other answers (answers a, b, c, and e) are not correct.

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  • 16. 

    Which of the following is the principal supply to the body and tail of the pancreas?

    • A.

      Common hepatic artery

    • B.

      Inferior phrenic artery

    • C.

      Left gastric artery

    • D.

      Splenic artery

    • E.

      Superior mesenteric artery

    Correct Answer
    D. Splenic artery
    Explanation
    (Moore and Dalley, pp 284–287.) The body and tail of the pancreas receive most of their blood supply from the splenic artery via the great pancreatic, dorsal pancreatic, and caudal pancreatic arteries. The head of the pancreas is supplied by the superior pancreaticoduodenal artery that arises from the gastroduodenal branch of the common hepatic artery. In addition, the pancreatic head is supplied by the inferior pancreaticoduodenal arteries that arise from the superior mesenteric artery. The chief supply to the left side of the gastric (answer c) fundus is from the splenic artery via the short gastric branches. The splenic artery also gives rise to the left gastro-omental artery that runs along the greater curvature to anastomose with the right gastro-omental branch that arises indirectly from the common hepatic artery. None of the other arteries, common hepatic (answer a), the inferior phrenic (answer b), and superior mesenteric (answer e) are close to the pancreas.

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  • 17. 

    A 42-year-old slightly overweight woman comes into your office complaining of recent blood in her stool. She has no fever and feels well otherwise. She generally has 1 or 2 bowel movements daily with no change in frequency or consistency. You ask if she has any painful hemorrhoids and she says she has none and no pain upon defecation. Prior to examining your patient what should be on your list of potential causes of blood in the stool?

    • A.

      Diverticular disease and colorectal cancer

    • B.

      Diverticular disease and internal hemorrhoids

    • C.

      Diverticular disease, external hemorrhoids, and colorectal cancer

    • D.

      External hemorrhoids and fissures, and diverticular disease

    • E.

      Diverticular disease, internal hemorrhoids, and colorectal cancer

    Correct Answer
    E. Diverticular disease, internal hemorrhoids, and colorectal cancer
    Explanation
    (Moore and Dalley, pp 280, 306, 450–451.) Potential causes of blood in the stool (hematochezia) include diverticular disease, internal hemorrhoids, and colorectal cancer [thus not (answers a and b)]. Diverticular disease mainly affects middle age and older adults. It is an outpocketing of the lining of the colon, occurring most frequently in the sigmoid colon. Diverticular disease may be caused by lack of fiber in the diet. If the diverticula get large, they may rupture blood vessels and bleed. Internal hemorrhoids are dilated (varicose) veins that develop above the pectinate line within the internal rectal venous plexus. They can develop as a consequence of hepatic cirrhosis, which could cause portal hypertension as blood resistance within the liver increases. Venous blood within the portal system backflows down the superior rectal veins and into the inferior rectal veins, that are part of the systemic venous system that does not have to pass through the liver. Most colorectal cancers initially develop as polyps, which continue to grow and differentiate and in later stages develop increased vascularity and bleed. External hemorrhoids and fissures may result in blood in the stool, but are generally painful [thus not (answers c and d)].

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  • 18. 

    During the physical exam of a 52-year-old man you note internal hemorrhoids. He complains of blood in his stool. Which of the following arteries could be the source of his rectal bleeding?

    • A.

      Superior rectal artery off the inferior mesenteric artery

    • B.

      Middle rectal artery off the internal iliac artery

    • C.

      Inferior rectal artery off the internal pudendal artery

    • D.

      Both b and c

    • E.

      A, b, and c

    Correct Answer
    E. A, b, and c
    Explanation
    (Moore and Dalley, pp 306, 445, 450–451.) A, b, and c. The rectum receives blood from three different arteries, which come from three different major branches: superior rectal artery off the inferior mesenteric artery; middle rectal artery off the internal iliac artery, and inferior rectal artery off the internal pudendal artery (Moore & Dalley, p 445). Thus none of the other answers are complete (answers a, b, c, and d). There are also three sets of veins: superior rectal veins, which drain into the hepatic portal system; middle rectal veins, which drain into the internal iliac veins (part of the systemic venous system); and inferior rectal veins, which drain into internal pudendal veins (also part of the systemic venous system). Because the internal rectal venous plexus is a potential site of portal-systemic anastomoses, internal hemorrhoids may be an indication of liver pathology.

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  • 19. 

    409. Several major anatomic structures pass through hiatal openings in the diaphragm. Which of the following lettered openings normally transmits the left vagus nerve?

    • A.

      A

    • B.

      B

    • C.

      C

    • D.

      D

    • E.

      E

    Correct Answer
    C. C
    Explanation
    (Moore and Dalley, pp 326–329.) The diaphragm possesses three principal hiatuses shown in the diagram accompanying the question: the hiatus for the inferior vena cava (answer a), the esophageal hiatus (answer c), and the aortic hiatus (answer e). Potential diaphragmatic developmental defects include the foramen of Morgagni (answer b), just lateral to the xiphoid attachment of the diaphragm, and the pleuroperitoneal canal of Bochdalek (answer d), which is the most common site for congenital hernias. The inferior vena cava and frequently small branches of the right phrenic nerve pass through a hiatus (A) slightly to the right of the midline at the T8 level. The left phrenic nerve usually passes through the central tendon of the diaphragm on the left side to innervate the left hemidiaphragm from below. The esophageal hiatus (C) just to the left of the midline at the T10 level transmits the esophagus, the left and right vagus nerves, and the esophageal branches of the left gastric artery and vein. An acquired hiatal hernia usually is the consequence of a short esophagus or of a weakened esophageal hiatus. The two diaphragmatic crura are joined superiorly by the median arcuate ligament to form an opening (E) at the T12 level. The aortic hiatus transmits the aorta, thoracic duct, and a continuation of the azygos vein into the abdomen. The splanchnic nerves penetrate the crura on each side of the aortic hiatus to reach the abdomen.

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  • 20. 

    During the visit of a 73-year-old man to your office for ongoing control of his hypertension (155/90) you note that he has lost about 5 lb since his last visit. He reports that he just doesn’t seem to have as much room for food or as much of an appetite. He states that he is getting tired of the food at his nursing home. You palpate his abdomen and note that there is a midline pulse, which you had initially mistaken for a heartbeat, but it is slightly delayed. You grow quite concerned about this pulsating abdominal mass and send him for an abdominal CT with intravenous contrast because you think that he has which of the following?

    • A.

      A hiatal hernia

    • B.

      Splenomegaly

    • C.

      Cirrhosis of the liver

    • D.

      An aortic aneurysm

    • E.

      A horseshoe kidney

    Correct Answer
    D. An aortic aneurysm
    Explanation
    (Moore and Dalley, p 338.) An aortic aneurysm. This patient may have an abdominal aortic aneurysm. Risk factors for the development of an abdominal aortic aneurysm include hypertension, excessive weight and smoking. Males are about five times more likely to have an aortic aneurysm than females. About 5% of men over 60 years of age have abdominal aortic aneurysms. Ninety percent of the time abdominal aortic aneurysms develop inferior to the renal arteries. About two-third of the time they extend inferiorly to include one of the common iliac arteries. (What blood vessel comes off the aorta inferior to the renal arteries and superior to the bifurcation into common iliac arteries? Answer: gonadal and inferior mesenteric arteries.) Despite the retroperitoneal location of the abdominal aorta, the high-pressure in the vessel typically makes ruptures of abdominal aortic aneurysms fatal. Blood fills the peritoneal cavity and the individual bleeds to death. If discovered prior to rupture they are typically repaired if greater than about 5.5 cm in diameter. Currently they tend to be repaired intravascularly by placing a 6-inch Dacron tube with metalmesh cylinder into the aorta via the femoral artery. Anecdotally, abdominal aortic aneurysms have been known to rupture with straining, such as during defecation. None of the other conditions, a hiatal hernia (answer a), splenomegaly (answer b), cirrhosis of the liver (answer c), nor a horseshoe kidney (answer d) would normally pulsate.

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  • 21. 

    Most direct inguinal hernias occur in older men as the conjoint tendon weakens with increased abdominal pressure, often a complication of excessive abdominal weight gain. In contrast, most indirect inguinal hernias occur in which of the following?

    • A.

      Teenage females

    • B.

      Multiparous women

    • C.

      Newborn boys

    • D.

      Teenage males

    • E.

      Skinny middle aged men

    Correct Answer
    C. Newborn boys
    Explanation
    (Moore and Dalley, pp 223–225.) Most indirect inguinal hernias are congenital [present at birth; thus not (answers d and e)]. Indirect inguinal hernias recapitulate the passage of the testis through the abdominal wall, and as such, originate lateral to the inferior epigastric vessels and reopen the process vaginalis if it had ever separated from the peritoneal cavity. Large indirect inguinal hernias need to be repaired to prevent intestinal organs from being strangulated within the inguinal canal and the process vaginalis needs to be closed to prevent abdominal peritoneal fluid from accumulating in the scrotum, causing swelling upon increased intraabdominal pressure. Only about 1 in 20 inguinal hernias occur in females [thus not (answers a and b)]; 95% are within males.

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  • 22. 

    As a general surgeon specializing in oncological cases you do a fair number of bowel resections. A 55-year-old man is referred to your office by his gasteroentrogist who recently removed two polyps from his splenic flexure of the colon during an endoscopic exam. The pathology report has confirmed that they are both cancerous and recommends surgical resection of a portion of the bowel from where the polyps were removed. Lymph nodes that receive lymph from this region are removed for sampling to stage the cancer growth. The 55-year-old patient comes to your office to learn what is involved in the surgical procedure. You describe that you are probably going to remove about a foot long section of large intestine, which includes part of the transverse and descending colon and then reattach the cut ends to each other and reconnect a major artery and collect numerous lymph nodes. Which of the following  major arteries is going to be reconnected and where are you going to collect lymph nodes from to stage the potential spread of the colon cancer?

    • A.

      Aorta; splenic and suprarenal lymph nodes

    • B.

      Splenic artery; splenic and suprarenal lymph nodes

    • C.

      Marginal artery; splenic and superior mesenteric lymph nodes

    • D.

      Marginal artery; superior and inferior mesenteric lymph nodes

    • E.

      Sigmoid artery; left colic and sigmoidal nodes

    Correct Answer
    D. Marginal artery; superior and inferior mesenteric lymph nodes
    Explanation
    (Moore and Dalley, pp 276, 279–281.) The major artery that is going to be reconnected is the marginal artery and the superior and inferior mesenteric lymph nodes will be collected. About a foot long section of the splenic flexure along with the marginal artery (of Drummond) and vein, paracolic lymph nodes and adjacent mesentery would all be surgically removed. The splenic flexure receives blood from the marginal artery. Blood from the splenic flexure portion of the marginal artery comes from both the middle colic artery, which is a branch off the superior mesenteric artery and from the left colic, which is a branch of the inferior mesenteric artery. Thus, it is essential to collect lymph nodes from the base of both the superior mesenteric and inferior mesenteric arteries. Neither the splenic artery (answers b and c) nor aorta (answer a) would be sectioned. The sigmoid artery (answer e) serves the sigmoid colon and would remain intact.

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  • 23. 

    When examining a 48-year-old woman for the first time at a free clinic you note that she is quite slender and tanned. During the physical exam you note that she has prominent veins both on her anterior abdominal wall and also about her nose. During the physical exam you can palpate a fairly large firm organ that extends well below the right costal margin during both inspiration and expiration. There is no abdominal tenderness. Which of the following is the most likely explanation for your physical findings?

    • A.

      Splenomegaly

    • B.

      Hepatomegaly

    • C.

      Appendicitis

    • D.

      Cholecystitis

    • E.

      Abdominal aortic aneurysm

    Correct Answer
    B. Hepatomegaly
    Explanation
    . (Moore and Dalley, pp 212, 298, 300.) The findings are consistent with hepatomegaly. There are two pieces of physical evidence that point towards an enlarged liver as being the likely cause of the physical findings. While the liver lies in the upper right quadrant of the abdomen it is generally fairly well covered by the costal margin. Enlargement of the liver can be caused by chronic alcohol consumption. In addition, the prominent veins on her anterior abdominal wall (called caput medusae) may be a site of portal hypertension as blood backs up within the hepatic portal system and uses alternative routes, rather than through the liver, to return to the systemic circulatory system. In addition to prominent abdominal veins, portal hypertension may also cause esophageal varices and hemorrhoids. Splenomegaly (answer a) would be palpated on the left side. While both the gall bladder and appendix are on the right side of the abdomen, both cholecystitis (answer d) and appendicitis (answer c) should result in abdominal pain, which is absent in this patient. An abdominal aortic aneurysm (answer e) would normally appear in the midline and pulsate.

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