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.

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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 post-
hepatic 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.

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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 #1

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Image #3

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Image #5

Image #6

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Image #7

James Lamberg

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