Quiz Over Symptoms Of Gallbladder

The epiploic foramen, also called the omental foramen, is the passageway between the greater and lesser peritoneal sacs. The inferior vena cava lies immediately posterior to this foramen, so this is the vessel that was probably cut. The aorta lies next the inferior vena cava, but it is a little more to the left and a little deeper--it does not lie immediately posterior to the epiploic foramen. The hepatic portal vein is anterior to the epiploic foramen. The right renal artery is a branch off of the aorta. Like the aorta, it is too deep to be a vessel immediately behind the foramen. Finally the superior mesentric vein is anterior to the foramen. Remember, this is one of the two vessels that makes the hepatic portal vein, so if the hepatic portal vein is anterior to the foramen, the SMV should be too. (See Netter's 256 for some relevant pictures)

The inguinal triangle is the site for direct inguinal hernias. It is defined medially by the lateral border of rectus abdominus, inferiorly by the inguinal ligament, and superiorly by the inferior epigastric artery.

The epiploic (omental) foramen is a passageway between the greater peritoneal sac and the lesser peritoneal sac. It is located posterior to the hepatoduodenal ligament and the first part of the duodenum. The caudate lobe of the liver forms the posterior wall of the epiploic foramen. The aorta is retroperiteoneal, and it does not form a boundary of this foramen

The bile duct is formed by union of the common hepatic and cystic ducts, lies lateral to the proper hepatic artery and anterior to the portal vein in the right free margin of the lesser omentum, traverses the head of the pancreas, and drains bile into the second part of the duodenum at the greater papilla. The endocrine part of the pancreas secretes the hormones insulin and glucagon, which are transported through the bloodstream. The main pancreatic duct carries pancreatic juice containing enzymes secreted from the exocrine part of the pancreas.

The inferior mesenteric artery supplies blood to the end of the transverse colon and all distal structures in the GI tract. This means that the splenic flexure, descending colon, sigmoid colon, and rectum would all be deprived of blood if the inferior mesenteric artery was occluded. The cecum receives blood from the superior mesenteric artery, so it would not be affected by the obstruction

The left gastric and esophageal veins would contribute to bypassing the obstruction in portal hypertension. These veins form collateral pathways that allow blood to flow around the obstructed area and relieve the increased pressure in the portal-hepatic vascular bed. This collateral circulation helps to maintain blood flow to the liver and prevent further complications of portal hypertension.

(Moore and Dalley, p 430.) The rectum receives blood from the superior rectal (hemorrhoidal) artery and from the paired middle and inferior rectal arteries. The superior rectal artery is a direct continuation of the inferior mesenteric artery, but the middle and inferior rectal arteries are branches of the internal iliac artery and continue to supply the distal rectum despite occlusion of the inferior mesenteric artery. It should be noted that Sudeck’s point, between the last sigmoidal artery and the rectosigmoid artery, is an area of potentially weak arterial anastomoses, but that is further cranial. The superior mesenteric artery (answer a) distributes arteries to the small intestine right and middle colic arteries, that supply blood as far distal as the splenic flexure of the transverse colon. The left colic artery (answer b) anastomoses with the sigmoidal arteries. The inferior mesenteric artery supplies the superior rectal artery, so answer c is not correct. The principal branch of the external iliac artery is the femoral
artery (answer e).

(Moore and Dalley, p 304.) Obstruction of any portion of the biliary tree will produce symptoms of gallbladder obstruction. If the common hepatic duct (answer b) or bile duct (answer a) is occluded by stone or tumor, biliary stasis with accompanying jaundice occurs. In addition, blockage of the duodenal papilla (of Vater), distal to the juncture of the bile duct with the pancreatic duct (answer e), can lead to complicating pancreatitis. If only the cystic duct is obstructed, jaundice will not occur because bile
may flow freely from the liver to the duodenum. Bile duct obstruction also may arise as a result of pressure exerted on the duct by an external mass, such as a tumor in the head of the pancreas. Answser d is not anatomically correct.

The small intestine features circular folds of tissue that are covered with villi - these folds are very obvious on a radiograph with barium contrast. The colon does not have similar folds in the mucosa. Some other things that distinguish the small intestine from the large intestine are: 1) The large intestine has 3 strips of longitudinal muscle, called tenia coli, instead of a continuous longitudinal muscle layer the whole way around. 2) The tenia coli are shorter than the colon, so the colon forms bulges, called haustra. 3) The surface of the colon is covered with fatty omental appendages.
The colon and small intestine share similar circular smooth muscle layers and a serosa. Although the gland structure is different in the colon versus the small intestine, this would not be visible on a radiograph. The same goes for the longitudinal muscle layer - there are differences between the two organs, but not ones that you would see on a barium contrast radiograph.

The correct answer is Sigmoid and superior rectal arteries. These two arteries provide a weak anastomosis around the critical point of Sudek, which is important in avoiding ischemia induced necrosis of the sigmoid colon during a colonectomy procedure.

When the sphincter of the bile duct contracts, it prevents the flow of bile into the duodenum. Instead, the bile is forced into the gallbladder where it is concentrated and stored for later use. This contraction of the sphincter allows the gallbladder to fill up with bile, which can then be released when needed to aid in the digestion and absorption of fats in the small intestine.

The incorrect statement pertaining to the gall bladder is that during cholecystectomy surgeons typically ligate the left hepatic artery. Cholecystectomy is the surgical removal of the gall bladder, and ligating the left hepatic artery during this procedure would not be a standard practice. The left hepatic artery supplies blood to the left lobe of the liver, and ligating it could lead to complications such as liver ischemia.

(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.

The hepatic branch of the anterior vagal trunk travels in the upper portion of the hepatogastric ligament. The posterior vagal trunk supplies a celiac branch deep to the hepatogastric ligament. The greater thoracic splanchnic branches to the suprarenal glands come off the greater thoracic splanchnic nerves as they pass through the diaphragm. Then, the greater thoracic splanchnic nerves continue on to synapse in the celiac ganglia.

The aortic hiatus is not in the central tendon of the diaphragm--the caval opening, for the inferior vena cava, is found in the central tendon of the diaphragm. The aortic hiatus is formed by the median arcuate ligament, which unites the two crura of the diaphragm. The vertebrocostal trigone is an area of the diaphragm superior to the lateral arcuate ligament. Here, the diaphragmatic muscle is deficient and the trigone is closed primarily by the inferior and superior fascia of the diaphragm. It is a significant area for hernias. The esophageal hiatus is formed entirely by the fibers of the right crus. The psoas major muscle passes behind the medial arcuate ligament. Finally, the right phrenic nerve passes through the central tendon of the diaphragm, near the vena caval foramen. See Netter Plate 181 for a picture of all these structures and their relationships.

The obturator nerve runs along the medial border of the psoas major muscle, eventually passing through the obturator canal to innervate muscles of the medial thigh. So, it might be damaged by an injury to the medial portion of psoas major. The femoral nerve runs along the lateral border of psoas major, where psoas major contacts iliacus. The genitofemoral nerve pierces through psoas major at the level of L3 or L4. The iliohypogastric and ilioinguinal nerves run under psoas major, emerging at the lateral border of psoas major to run over quadratus lumborum. The way to distinguish between these two nerves is to remember that the iliohypogastric is superior to the ilioinguinal nerve.

The inferior epigastric vessels lay on the inner surface of the transversus abdominis and are covered by parietal peritoneum. Remember, the peritoneum lies over the inferior epigastric vessels to make the lateral umbilical fold. Camper's fascia and Scarpa's fascia are two layers of the superficial fascia - Camper's is the fatty layer and Scarpa's is the membranous layer.

The hepatorenal recess, also known as Morison pouch, is a potential space located between the liver and the right kidney. It is in the subphrenic recess, which is an area beneath the diaphragm. This recess can receive infected fluids draining from the omental bursa when a person is in a supine (lying flat on their back) position. This can occur in conditions such as peritonitis or abscess formation in the abdominal cavity.

(Moore and Dalley, p 231.) Inferior epigastric artery. The lateral umbilical folds are produced by the underlying inferior epigastric arteries as they course from the external iliac artery in the inguinal region toward the rectus sheath. A direct inguinal hernia starts medial to the lateral ambilical fold and an indirect inguinal hernia starts lateral to the same fold. The medial umbilical folds are peritoneal elevations produced by the obliterated umbilical arteries (answer d). In the midline, the median umbilical ligament is formed by the underlying urachus (answer e), a remnant of the embryonic allantois. The Falx inguinalis (answer a) represents inferomedial attachment of transversus abdominis with some fibers of internal abdominal oblique, also known as: conjoint tendon. The lateral border of the rectus sheath (answer c) forms the medial edge of the inguinal triangle.

The triangle of Calot is formed by the cystic duct laterally, the liver superiorly, and the common hepatic duct medially. It is an important landmark in this region, because the cystic artery can be found in the triangle of Calot. During a cholecystectomy, the cystic artery needs to be ligated. Although the cystic artery usually branches from the right hepatic artery, there is some variation. However, if you locate the triangle of Calot, you can find the cystic artery in that triangle, trace it back to its origin, and then ligate it there.

The correct answer is "It occurs near the junction between the jejunum and the ileum." This is least likely pertaining to an ileal diverticulum because ileal diverticula are typically found in the ileum, not near the junction between the jejunum and the ileum. The other statements are more likely pertaining to an ileal diverticulum, such as occurring on the antimesenteric border of the ileum, having a cordlike attachment to the umbilicus, potentially causing symptoms similar to appendicitis, and being present in both infants and adults.

A direct inguinal hernia passes through the weak fascia in the medial inguinal fossa. This is the area between the medial and lateral umbilical folds (made of the obliterated umbilical artery and inferior epigastric vessels, respectively). A direct inguinal hernia does not pass through the deep inguinal ring or the lateral inguinal fossa--that's what an indirect hernia does. Although it's much more common for an indirect hernia to pass through the superficial inguinal ring, direct hernias could go through this ring too. However, the question is asking you to identify which region the hernia enters on the abdominal side, so superficial inguinal ring is not the correct answer. The supravesicular fossa is between the median and medial umbilical folds--it is formed where the peritoneum reflects from the anterior abdominal wall onto the bladder. Potentially, a very rare external supravesicular hernia could form here.

The ejaculatory duct is a duct which courses through the prostate gland and contains only semen. Remember, semen is the combination of sperm from the ductus deferens, seminal fluid from the seminal vesicle, and secretions of the prostate gland. The ejaculatory duct is formed by the union of the duct of the seminal vesicle and the ampulla of the ductus deferens, and it is the site where sperm and seminal fluid mix. The prostatic urethra is also contained in the prostate gland, and it carries semen, but it also carries urine out of the bladder. The membranous urethra is the continuation of the prostatic urethra outside of the prostate gland, and it carries both semen and urine as well. The seminal vesicle is a structure on the posterior surface of the bladder that produces seminal fluid. The ductus deferens is a passageway that carries sperm from the epididymis to the ejaculatory duct.

The nerve supply to the muscles of the anterior abdominal wall travels between the internal oblique and transversus abdominis muscles.

Moore and Dalley, pp 257–258, 322–323.) Visceral afferent pain fibers from the gallbladder travel through the celiac plexus, thence along the greater splanchnic nerves to levels T5–T9 of the spinal cord. Thus, pain originating from the gallbladder will be referred to (appear as if coming from) the dermatomes served by T5–T9, which include a band from the infrascapular region to the epigastrium. If the gallbladder enlarges sufficiently, then pain could be carried by the phrenic nerve (answer c), but this would refer pain to the neck. Intercostal nerves (answer b) would course above the diaphragm and thus are not involved. The vagus (answer d) generally does not transmit pain information. Pelvic splanchinics (answers e) receive pain information from pelvic organs and thus are not involved.

The greater splanchnic nerve provides sympathetic innervation to the adrenal MEDULLA, and receives contributions from spinal levels T5-T9, and modulates the enteric nervous system of the foregut.