Moore's Blue Boxes - Abdomen

Front 1

Clinical Significance of Fascia and Fascial Spaces of Abdominal Wall (198)

Back 1

liposuction can surgically remove unwanted subcutaneous fat via percutaneous suction

Scarpa's fascia used to close abdominal skin incisions b/c of strength

endoabdominal fascial space gives surgeon's route to approach posterior wall w/out entering peritoneal sac (reduces risk of contamination); can also place prostheses for repair of hernia

Front 2

Protuberance of the Abdomen (205)

Back 2

prominent abdomen normal in infants and young children (contain lg. amts. of air, lg. liver)

in shape adult has "scaphoid" shape when supine -- ideal visceral protection

6 causes of protrusion: Food, Fluid, Fat, Feces, Flatus, and Fetus

w/ underdeveloped ant. ab. muscles, cannot resist increased weight... pelvis tips and produces lumbar lordosis

Front 3

Protuberance of the Abdomen (205)

Back 3

prominent ab. normal in infants and young children (GI full of air, muscles still gaining strength, lg liver)

Adult: normal scaphoid when supine

Causes of protuberance: 1) Food, 2) Fluid, 3) Fat, 4) Feces, 5) Flatus, 6) Fetus

Front 4

Abdominal Hernias (205)

Back 4

most occur in inguinal, umbilical, and epigastric regions

umb: sm, common in newborns, weak umbilical ring (esp if low birth weight)

can herniate at fiber transitions (aponeuroses -- open in obesity, surgery, wounds)

epigastric - through linea alba
spigelian h. - occur along semilunar line
*>40, obesity

Front 5

Palpation of the Anterolateral Abdominal Wall (206)

Back 5

cold hands make wall tense / involuntary spasms --> *guarding*

involuntary guarding always indicates pathology

supine, arms at side, knees flexed gives maximal relaxation of ab. wall

Front 6

Superficial Abdominal Reflexes (206)

Back 6

quickly stroke horizontally, lateral to medial, towards the umbilicus

usually will see contraction of abdominal muscles / umbilicus will move towards stimulus

freq. absent w/ obesity

Front 7

Injury to Nerves of the Anterolateral Abdominal Wall (208)

Back 7

inferior thoracis spinal nerves (T7-T12) and iliohypogastric & ilioinguinal nerves (L1) innervate abdominal musculature

*multi-segmental innervation

*run oblique / horizontal

injury --> weakness, predisposition to herniation

Front 8

Abdominal Surgical Incisions (208)

Back 8

when possible, follow Langer lines
split muscles between fibers (avoid necrosis)
*RA can be transected
retract toward neurovascular supply

Front 9

Longitudinal Incisions (208)

Back 9

centrally in abdomen

ex. median, paramedian

preferred for exploratory surg -- good view and can be widened as needed; cut rapidly w/out danger

linea alba requires careful re-alignment for proper healing

Front 10

Oblique and Transverse Incisions (209)

Back 10

most commonly on one side of midline in peripheral abdomen

direction aligns with muscle fibers, bone lines, or nerve courses

McBurney - for appendectomy
Gridiron - "muscle splitting"
Subcostal - gallbladder, biliary ducts, spleen (2.5 cm inferior to margin to avoid 7/8 thoracic spinal n)
Suprapubic (Pfannenstiel) - "bikini" - for OBGYN operations

Front 11

High Risk Abdominal Incisions (209)

Back 11

include pararectus and inguinal incisions

p: along lateral border of RA -- likely to cut nerve supply / inf. epigastric artery

i: may injure ilioinguinal n directly or w/ sutures
necessary for repairing hernias, may result in pain in L1 dermatome region (inc. scrotum / labium majus)

Front 12

Incisional Hernia

Back 12

protrusion of omentum or organ through surgical incision

if muscular and aponeurotic layers don't heal properly, increase likelihood of hernia

inc. risk w/ advanced age, debility, obesity, post-op infection

Front 13

Minimally Invasive (Endoscopic) Surgery (209)

Back 13

procedure done through endoscope

requires only tiny perforations of abdominal wall

reduced risk of nerve injury, incisional hernia, or contamination

minimizes healing time

Front 14

Reversal of Venous Flow and Collateral Pathways of Superficial Abdominal Veins (212)

Back 14

w/ SVC / IVC obstruction, anastomoses provide collateral pathways

sm. cutaneous veins of umbilicus can anastomose w/ paraumbilical veins

Caval or portal obstruction / hypertension, surface veins can become distended --> caput medusae

Front 15

External Supravesical Hernia (214)

Back 15

leaves peritoneal cavity through supravesical fossa

medial to direct inguinal hernia

danger of damage to iliohypogastric n. during surgical repair

Front 16

Postnatal Patency of the Umbilical Vein (214)

Back 16

will become occluded and degenerate to round ligament of the liver

during infancy; patent, can be used for umbilical vain catheterization

(catheterization in infants w/ erythroblastosis fetalis or hemolytic dx of the newborn)

Front 17

Maldescent of Testis (220)

Back 17

undescended: 3% full-term, 30% premature infants

95% occur unilaterally

cryptorchidism - testes not descended, not retractable

greatly increased risk for malignancy, freq. not detected until progression (not palpable)

Front 18

Cancer of the Uterus and Labium Majus (220)

Back 18

lymphogenous metastasis commonly along lymphatic pathways paralleling routes of venous drainage

uterus - most drainage deep

some follows round ligament to inguinal canal

∴ can spread from uterus to labium majus to superficial inguinal lymph nodes

Front 19

Inguinal Hernias (223)

Back 19

protrusion of parietal peritoneum and viscera

most are reducible -- returned to cavity by manipulation

80-90% hernias in inguinal region
direct (1/3) vs. indirect (2/3)

superficial inguinal ring palpable on exam -- if dilated, may admit finger. will feel impulse on cough w/ hernia

deep inguinal ring felt as depression sup. to ing. lig., 2-4 cm superolateral to pubic tubercle -- mass here indicates indirect

Front 20

Cremasteric Reflex (225)

Back 20

light stroking of skin in medial thigh causes contraction of cremaster muscle, retraction of testes

*highly active in children

have child sit cross-legged, squatting -- can then palpate descended testes in scrotum

Front 21

Cysts and Hernias of the Canal of Nuck (225)

Back 21

inguinal hernias 20x more common in ♂ > ♀

♀: if processes vaginalis persists, forms a small peritoneal pouch known as canal of Nuck; may extend to labium majus

cysts cause bulge in anterior part of labium majus, potential for indirect ing. hernia

Front 22

Hydrocele (225)

Back 22

presence of excess fluid in a persistent processus vaginalis

assoc. w/ indirect ing. hernia

detection requires transillumination -- shine bright light to side of scrotum -- transmission of red light indicates excess serous fluid in scrotum

injury / inflammation may produce hydrocele in adults

Front 23

Hematocele (226)

Back 23

collection of blood in the tunica vaginalis

from rupture of branches of testicular artery by trauma

blood does not transilluminate (∴ can distinguish between hematocele and hydrocele)

Front 24

Torsion of the Spermatic Cord (226)

Back 24

twisting

surgical emergency to avoid necrosis

torsion obstructs venous drainage, causes edema and hemorrhage

most common during adolescence, twisting freq. just above superior pole

fix both testes to scrotal septum to prevent recurrence

Front 25

Anesthetizing the Scrotum (227)

Back 25

anterior third supplied by L1 through ilioinguinal n.

posterior 2/3 supplied by S3 through perineal and posterior femoral cutaneous n.

must inject more superiorly to anesthetize anterior surface than is necessary to cover posterior surface

Front 26

Spermatocele and Epididymal Cyst (228)

Back 26

spermatocele - retention cyst (fluid collection) in epididymis, usually near head

contains milky fluid, generally asymptomatic

epididymal cyst -- collection of fluid anywhere in epididymis

Front 27

Vestigial Remnants of Embryonic Genital Ducts (228)

Back 27

may see rudimentary structures on superior edge of testes and epididymis

remnants of genital ducts in embryo, rarely observed w/out pathology

appendix of the testis -- cranial end of paramesonephric duct (becomes half of uterus)

appendices of the epididymis - cranial end of mesonephric duct (in male forms ductus deferens)

Front 28

Varicocele (228)

Back 28

dilated/tortuous pampiniform plexus

visible standing or straining (disappears supine)

results from defective valves

99% of the time on the left side - right angle bend between l testicular vein and l renal vein

if r side, does not reduce -- consider retroperitoneal neoplasm

Front 29

Cancer of the Testis and Scrotum (229)

Back 29

testicular lymph drainage: retroperitoneal lumbar lymph nodes (inferior to renal veins) then to mediastinal and supraclavicular nodes

scrotal lymph drainage - to superficial inguinal lymph nodes (in subcutaneous tissue inferior to inguinal ligament, near great saphenous vein)

Front 30

Patency and Blockage of the Uterine Tubes (232)

Back 30

fallopian tubes offer an external opening into peritoneal cavity, rarely leads to infection

mucous plug -- effectively blocks external opening of uterus

for fertilization to occur, pathway must open

test patency clinically w/ air / radiopaque dye injected into uterine cavity -- should flow through uterine tubes to peritoneal cavity
*hysterosalpingography

Front 31

Peritoneum and Surgical Procedures (232)

Back 31

well innervated -- invasive, open incisions come w/ a lot of pain (more so than laparoscopy)

serosa allows for watertight end-to-end anastomoses of intraperitoneal organs

high incidence of complications -- peritonitis and adhesions; remain outside of peritoneal cavity whenever possible

Front 32

***

Peritonitis and Ascites (233)

Back 32

peritonitis - infection / inflammation of the peritoneum resulting from surgical contamination or traumatic wound (gas, fecal matter, bacteria enter)

rapid absorption from cavity (inc. bac. toxins) -- generalized infection dangerous / lethal

often sever ab. pain, tenderness, nausea, vomiting, fever, constipation

ascitic fluid -- excess fluid in cavity
from internal bleeding, portal hypertension, cancer metastasis, starvation

*from pain, people lie with knees flexed, breath shallowly, rapidly

Front 33

Peritoneal Adhesions and Adhesiotomy (233)

Back 33

damage to peritoneum bring inflammation / walls sticky w/ fibrin

fibrin replaced w/ fibrous tissue upon healing, forms abnormal attachments between adjacent viscera

adhesions -- "scar tissue"

may form after surgery

volvulus -- obstruction where gut becomes twisted around an adhesion

Front 34

Abdominal Paracentesis (233)

Back 34

treatment of generalized peritonitis -- removal of ascitic fluid and administration of large doses of antibiotics

surgical puncture for aspiration or drainage of fluid allows for analysis

use local anesthetic, needle and cannula inserted through ab. wall perhaps through linea alba
insert superior to empty bladder, avoid inferior epigastric artery

Front 35

Intraperitoneal Injection and Peritoneal Dialysis (233)

Back 35

peritoneum is a semipermeable membrane, rapid absorption b/c of relation to many capillary beds

I.P. injection -- ex. using barbiturates

in renal failure, can use dilute sterile solution to draw waste products out of blood.

changes in mesothelial cells and underlying CT cause progressive decline in effectiveness (∴ use as a temporary measure)

Front 36

Functions of the Greater Omentum (238)

Back 36

prevents visceral peritoneum from adhering to parietal peritoneum

mobile, large, fat laden; moves w/ peristaltic movements of viscera

will form adhesions w/ inflamed organs (ex. appendix -- will wall it off and "protect" other organs from it)

cushions; insulates

Front 37

Abscess Formation (238)

Back 37

circumscribed collection of purulent exudate = abscess

ex. from perforation of duodenal ulcer, rupture of gallbladder, or perforation of appendix

Front 38

Spread of Pathological Fluids (238)

Back 38

peritoneal recesses collect pathological fluids (ex. pus)

recesses determine extent and direction of spread of fluids

Front 39

***

Flow of Ascitic Fluid and Pus (238)

Back 39

fluid flows along paracolic gutters (esp. when standing)

absorption is slow in pelvis cavity -- can sit patient w/ peritonitis at 45` angle, fluid will drain to pelvis via gutters

gutters also provide pathways for spread of sloughed tumor cells

Front 40

***

Fluid in Omental Bursa (239)

Back 40

Perforation of posterior wall of stomach can fill omental bursa w/ fluid

also, inflamed or injured pancreas -- pancreatic fluid into bursa ... forms pancreatic pseudo-cyst

Front 41

Intestine in the Omental Bursa (239)

Back 41

uncommon

loop of intestine passes through omental foramen into bursa, can become strangulated
-cannot incise, rather, must decompress intestine and manually remove

Front 42

Severance of the Cystic Artery (241)

Back 42

must ligate/clamp then cut cystic artery during cholecystectomy (removal of gall bladder)

if severed, can control flow w/ compression on hepatic artery in hepatoduodenal ligament

Front 43

***

Esophageal Varices (247)

Back 43

submucosal veins form a portosystemic anastomosis -- veins drain to both portal and systemic venous systems

portal hypertension causes a reversal of flow, causes enlargement --> esop. varicies

rupture can causes severe, life-threatening hemorrhage

*common in alcoholics w/ cirrhosis

Front 44

Pyrosis (248)

Back 44

heartburn

most common type of esophageal discomfort / substernal pain

result of regurgitation of food / gastric fluid into lower esophagus

GERD - gastroesophageal reflux disorder

may be assoc. w/ hiatal hernia

Front 45

Displacement of the Stomach (250)

Back 45

may move anteriorly w/ pancreatic pseudo-cysts or abscesses in omental bursa

visible in lateral radiographs and CT

after pancreatitis, posterior wall of stomach may adhere to posterior wall of omental bursa (where it covers pancreas)

Front 46

Hiatal Hernia (250)

Back 46

protrusion of part of the stomach into mediastinum through esophageal hiatus (in diaphragm)

occur most often in middle age; w/ weakening of diaphragm, widening of hiatus

paraespophageal h.h. - less common, cardia remains in normal position; pouch of peritoneum extends thorugh -- usually no regurgitation

sliding h.h.- esophagus, cardia, and fundus slide superiorly, esp. when supine or bending over
*regurg. possible

Front 47

Congenital Diaphragmatic Hernia (252)

Back 47

CDH

part of stomach and intestine herniate through defect (foramen of Bochdalek) in diaphragm

1/2200 newbords

consequent pulmonary hypoplasia (limited space for L lung to develop) -- mortality 76%

Front 48

***

Pylorospasm (256)

Back 48

spasmodic contraction of the pylorus

failure of smooth muscle fibers to relax normally

food does not pass easily from stomach to duodenum, stomach overfills --> vomiting

usually occurs in infants (2 -12 w)

Front 49

***

Congenital Hypertrophic Pyloric Stenosis (252)

Back 49

marked thickening of the smooth muscle in the pylorus

1/150 ♂; 1/750 ♀ infants

narrows pyloric canal, restricts flow --> 2` dilation of proximal stomach

strong genetic link -- high incidence in infants of monozygotic twins

Front 50

Carcinoma of the Stomach (256)

Back 50

may palpate mass in body or pyloric part of stomach

gastroscopy -- can inspect mucosa of air-inflated stomach; observe lesions, take biopsies

stomach has extensive lymph drainage -- difficult surgical problem (most difficult are aortic and celiac nodes and those at head of pancreas)

*cancer freq. in pyloric region (req. removal of pyloric and gastro-omental nodes)

Front 51

Gastrectomy (256)

Back 51

total removal is uncommon

partial g. may be used to remove carcinoma

good collateral circulation (+)

usually requires removal of all involved regional lymph nodes

Front 52

***

Gastric Ulcers, Helicobacter pylori, and Vagotomy (256)

Back 52

an ulcer is an open sore

'peptic ulcer' - pyloric canal / duodenum

9/10 assoc. w/ H. pylori
inc. risk w/ chronic anxiety (↑ gastric secretions 15x; overwhelms bicarb)

hemorrhage if penetration of gastric arteries

Vagus n. controls acid secretion; can cut n. to reduce production (most commonly selective for stomach; not "truncal")
"selective proximal vag." - targets just region w/ parietal cells; spares all others

Front 53

***

Visceral Referred Pain (257)

Back 53

organic pain - ranges dull to severe, freq. poorly localized... radiates to dermatome levels where visceral afferents connect

ex. gastric ulcer to epigastric region (reaches T7/T8 via greater splanchnic)

pain from parietal peritoneum -- somatic; usually severe, localized, felt as rebound tenderness (most sensitive to stretching)... peritoneum is supplied by somatic sensory fibers via thoracic nerves

Front 54

***

Duodenal Ulcers (264)

Back 54

or peptic ulcers

inflammatory erosions of duodenal mucosa

65% in posterior wall of superior d., w/in 3cm of pylorus

if it perforates wall and allows leak --> peritonitis

liver, gallbladder, or pancreas may adhere to inflamed duodenum

bleeding is common; severe hemorrhage if gastroduodenal artery affected

Front 55

Developmental Changes in the Mesoduodenum (264)

Back 55

early fetal, entire duodenum has mesentery

most of mesentery fuses w/ posterior abdominal wall b/c of pressure from transverse colon

*since this is a 2` attachment, can be surgically separated w/out risk to neurovascular supply

Front 56

Paraduodenal Hernias (264)

Back 56

2 or 3 inconstant folds / fossae (recesses) at duodenojejunal jxn
{superior duodenal fossa, paraduodenal fossa, inferior duodenal fossa}

loop of intestine may enter and strangulate

surgical repair must take care not to injure branches of inferior mesenteric artery / vein or ascending branches of the left colic artery

Front 57

Brief Review of the Embryological Rotation of the Midgut (268)

Back 57

primordial gut: foregut, midgut, hindgut

for 4 weeks, midgut and Sup. Mesent. Art. physiologically herniated into proximal part of umbilical cord, attached to yolk sac by y. stalk

rotates 270` around axis of SMA on return to abdomen

malrotation results in congenital anomalies such as volvulus (twisting) of the intestine

Front 58

Navigating the Small Intestine (268)

Back 58

when portions delivered through surgical wound, proximal (orad) and distal (aborad) ends of loop of bowel are not apparent

place hands on mesentery, and follow to its root, untwisting as necessary...
once straightened to match direction of root:

cranial end = orad
caudal end = aborad

Front 59

Ischemia of the Intestine (268)

Back 59

occlusion of vasa recta by emboli causes ischemia

if severe, results in necrosis

ileus -- paralytic obstruction; comes w/ severe colicky pain, distention, vomiting, fever, dehydration

Front 60

Ileal Diverticulum (of Meckel) (270)

Back 60

congenital anomaly in 1-2% population

remnant of proximal embryonic yolk stalk (diverticulum) appears as a finger-like pouch

always at site of yolk stalk attachement on antimesenteric border; 30-60 cm from iliocecal jxn (infants), 50 cm (adults)

74% of the time free;
26% - attached to umbilicus

pain / inflammation may mimic appendicitis; if gastric tissue present, can ulcerate

Front 61

Position of the Appendix (275)

Back 61

retrocecal appendix -- extends superiorly toward the right colic flexure, usually free

may lie beneath peritoneal covering of cecum; fused to cecum or post. ab. wall

may project inferiorly toward or across pelvic brim

McBurney point -- base of appendix lies deep to a point 1/3 of the way along oblique line joining R ASIS to umbilicus

Front 62

***

Appendicitis (275)

Back 62

acute inflammation -- common cause of severe ab. pain

usually maximal tenderness at McBurney point

in young people, caused by hyperplasia of lymphatic follicles in appendix, occludes lumen

in older people, obstruction from fecalith -- concretion of fecal matter

pain starts as vague (referred to T10); severe parietal peritoneum irritation, extending R thigh worsens pain

may also come from thrombosis in appendicular artery --> ischemia, gangrene, perforation

rupture --> peritonitis

Front 63

Appendectomy (275)

Back 63

surgical removal of the appendix

performed via transverse or gridiron incision centered at McBurney point RLQ

i.d. iliohypogastric n to preserve
appendix at convergence of the three teniae coli
stump usually cauterized and invaginated into cecum; close incision in layers

Front 64

Laparoscopy (275)

Back 64

when Dx unclear, may examine abdomen w/ laparoscope

useful to differentiate acute appendicitis from other causes of abdominal pain such as inflammatory pelvic dx

may use to remove gallbladder and appendix; fix abdominal obstruction

Front 65

Mobile Ascending Colon (277)

Back 65

when inferior part of ascending colon has mesentery, cecum and proximal part of colon are abnormally mobile

present 11% pop., may cause volvulus and poss. obstruction

Cecopexy -- procedure to anchor tenia coli of cecum and proximal ascending colon to abdominal wall

Front 66

Colitis, Colectomy, Ileostomy, and Colostomy (279)

Back 66

chronic inflammation char. by severe inflammation and ulceration of colon and rectum

colectomy - terminal ileum, colon, rectum, and anal canal are removed

ileostomy - establish opening between ileum and skin in anterolateral abdominal wall

colostomy - create artificial cutaneous opening into colon

Sigmoidostomy - establishes artificial anus by creating cutaneous opening into sigmoid colon

Front 67

***

Colonoscopy (279)

Back 67

procedure to observe and photograph interior of colon

req. elongated endoscope (usually fiberoptic colonoscope) inserted into colon via anus and rectum

can do minor procedures such as biopsies or polyp removal

most tumors in rectum; 12% at rectosigmoid jxn

Front 68

***

Diverticulosis (280)

Back 68

disorder where multiple false diverticula (external evaginations of mucosa of colon) develop

primarily affects middle-aged / elderly

60% of the time in sigmoid colon

Colonic diverticula -- not true d., b/c they're formed from protrusions of mucous through weak points in muscle, rather than including whole wall

most common on mesenteric side of 2 non-mesenteric teniae coli (site where nutrient arteries perforate muscle to reach submucosa)

rupture --> diverticulitis

*diet high in fiber greatly reduces risk

Front 69

Rupture of the Spleen (284)

Back 69

well protected by ribs 9-12

*still most frequently injured organ in abdomen

severe blows on left side may break ribs, 2` puncture of spleen; blunt trauma causes sudden marked increase in intra-abdominal pressure

if ruptured, there is profuse bleeding (intraperitoneal hemorrahge) and shock

*recall parenchyma of spleen is like an open local circulatory system

Front 70

Splenectomy and Splenomegaly (285)

Back 70

difficult to repair ruptured spleen; will often remove spleen to prevent patient from bleeding to death

sub-total (partial) splenectomy is sometimes possible and will be followed by rapid regeneration

most splenic fxns can be assumed by liver / bone marrow

*removal of spleen comes with much greater risk for certain bacterial infections

may enlarge >10x w/ dz (ex. granulocyte leukemia)

not usually palpable; if so, below L costal margin at end of inspiration (3x norm)

Front 71

Accessory Spleen(s) (285)

Back 71

may form one or more accessory spleens near splenic hilum; embedded partly or wholly in tail of pancreas, in gastrosplenic ligament, in mesentery, or near ovaries / testis

common (10% pop), small - <1 cm (0.2-10cm norm), resemble lymph node

*if not removed in splenecotomy, symptoms indicating removal won't resolve (ex. splenic anemia)

Front 72

Splenic Needle Biopsy and SPlenoportography (286)

Back 72

costodiaphragmatic recess of pleural cavity (potential space) descends to level of 10th rib in MAL

*must take care when injecting radiopaque material into spleen (splenoportography - visualize portal vein) or doing biopsy to avoid material entering pleural cavity --> pleuritis

Front 73

***

Blockage of the Hepatopancreatic Ampulla and Pancreatitis (287)

Back 73

main pancreatic duct joins bile duct --> hepatopancreatic ampulla

this empties into duodenum... gallstone passing along may lodge at constricted distal end, will block both biliary and pancreatic duct systems

bile may back up into pancreatic duct --> pancreatitis

pancreatic duct sphincter usually blocks reflux of bile -- is weak, may spasm, allow backflow

accessory pancreatic duct may compensate for obstruction of main duct

Front 74

Accessory Pancreatic Tissue (287)

Back 74

not uncommonly develops in stomach, duodenum, ileum, or in an ileal diverticulum (stom / duod. most common)

may contain pancreatic islet cells --> prod. glucagon and insulin

Front 75

Pancreatectomies (288)

Back 75

removal of most of pancreas in cases of chronic pancreatitis

cannot remove entire head b/c of anatomy of blood supply, bile duct, and duodenum

retain a rim of pancreas at medial border of duodenum to preserve duodenal blood supply

Front 76

Rupture of the Pancreas (288)

Back 76

centrally located, so well protected

duodenum is normally sterile

has considerable fxn reserve -- thus not commonly a 1` cause of clinical problems (except diabetes)

rupture from sudden, severe, forceful compression of the abdomen (ex. MVA)

vertebral column acts as an anvil, pancreas can easily crumble; this freq. tears duct system, leaks pancreatic juices --> severe pain

Front 77

Pancreatic Cancer (288)

Back 77

cancer of p. head accounts for most cases of extrahepatic biliary obstruction
*compresses and obstructs bile duct and/or hepatopancreatic ampulla

--> retention of bile pigments, enlargement of gallbladder, jaundice

90% people w/ pancreatic cancer -- have ductular adenocarcinoma

presents w/ severe back pain

cancer of neck / back of p. may cause portal / caval obstruction

typical for early metastasis to liver via portal vein ... surgical resection of cancerous pancreas nearly futile
median survival, regardless of therapy : 2-3 mo.

Front 78

Subphrenic Abscesses (292)

Back 78

more common on R side b/c of frequency of ruptured appendices and perforated duodenal ulcers

pus from one subphrenic recess may travel to the other through hepatorenal recess

dranied w/ an incision inferior to rib 12

Front 79

Hepatic Lobectomies and Segmentectomy (293)

Back 79

R / L hepatic arteries and ducts / R /L portal veins do not communicate

removal of separate lobes of individual segments that sustained severe injury now possible

segments vary considerable in size and shape through variations in hepatic and portal vessel branching

each segmentectomy req. imaging and/or catheterization for precision

Front 80

Rupture of Liver (294)

Back 80

easily injured b/c of its size, fixed position, and friability (crumbles easily)

caused by rib fracture and can result in considerable hemorrhage and RUQ pain

surgical discretion to remove liver or simply remove contaminating material

Front 81

Aberrant Hepatic Arteries (297)

Back 81

most common source of aberrant right hepatic = SMA

most common source of aberrant left hepatic = left gastric artery

Front 82

Variations in the Relationships of the Hepatic Arteries (297)

Back 82

most people: R hepatic art crosses anterior to portal vein; posterior to common hepatic duct

sometimes: artery crosses posteror to portal vein; can run anterior to common hepatic duct, or come from SMA and not cross duct at all

Front 83

Unusual Formation of the Portal Vein (298)

Back 83

portal vein forms posterior to neck of pancreas by the union of the superior mesenteric and splenic veins; ascends anterior to the IVC

in 1/3 of individuals, IMV joins superior mesenteric / splenic veins --> thus all 2 veins form a portal vein

60% - IMV enters splenic vein
40% - IMV enters SMV

Front 84

Hepatomegaly (298)

Back 84

rise in central venous pressure --> liver engorges with blood

fibrous capsule is enlarged and can produce pain near the lower ribs

may be readily palpated below the right costal margin and may reach pelvic brim in right lower quadrant

engorgement can be caused by sustained diaphragmatic activity --> “runner’s stitch”

also caused by tumors and is a common site of metastatic carcinoma

Front 85

***

Cirrhosis of the Liver

Back 85

progressive destruction of hepatocytes and replacement with fat and fibrous tissue

alcoholic cirrhosis --> most common cause of portal hypertension (fibrous tissue surrounds blood vessels and biliary ducts within liver)

treatment = portosystemic or portocaval shunt (to relieve pressure)

Front 86

Liver Biopsy

Back 86

needle commonly directed through right 10th intercostal space in midaxillary line

patient holds breath in full expiration to reduce costodiaphragmatic recess and prevent contaminating the pleural cavity

Front 87

Infundibulum of the Gallbladder

Back 87

dilation (or pouch) at the junction of the neck and cystic duct

a common collection site of gallstones

peptic duodenal ulcer may create a false passage between the gallbladder and superior part of the duodenum that will pass gallstones into it

Front 88

Mobile Gallbladder

Back 88

short mesentery (4%) make the organ susceptible to vascular torsion and infarction

Front 89

Variation in Cystic and Hepatic Ducts

Back 89

cystic duct can run alongside common hepatic duct and adhere to it

cystic duct may be very short or absent

location is important for surgeons when ligating cystic duct during cholecystectomy

Front 90

Accessory Hepatic Ducts

Back 90

variation of the number of hepatic ducts that join the common hepatic duct

must avoid cutting because it drains a normal segment of the liver and leak bile

Front 91

***

Gallstones

Back 91

concretion in gallbladder, cystic duct, or bile duct composed of cholesterol crystals

must be big enough to produce injury to gallbladder or obstruction of the biliary tract to cause any clinical symptoms

biliary colic – stone lodged in the cystic duct (intense, spasmodic pain)

cholecystitis – inflammation of gallbladder when stone blocks the cystic duct due to bile accumulation

pain in 9th intercostals space at semilunar line, some posterior thoracic wall and shoulder pain with irritation of the diaphragm

jaundice – yellowing of skin when bile cannot leave the gallbladder

Front 92

Gallstones in the Duodenum

Back 92

cholecystenteric fistula – ulceration of tissues surrounding gallbladder

most common in superior part of duodenum and transverse colon due to their proximity to the gallbladder --> allows passage of the stone into alimentary tract

trapped stone at the ileocecal valve = bowel obstruction (gallstone ileus)

Front 93

Cholecystectomy

Back 93

must identify any variations in the Triangle of Calot (common hepatic duct, inferior border of liver, and cystic duct) to avoid bile duct or artery injury

removal procedure is often done laparoscopically

Front 94

Portosystemic Shunts

Back 94

portacaval anastomosis / portosystemic shunt = diverting blood away from portal venous system to the systemic venous system

may be done where the portal vein and IVC run close together, posterior to the liver

after splenectomy, joining the splenic vein to the left renal vein can reduce portal pressure

Front 95

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Portal Hypertension

Back 95

caused by scarring and fibrosis from cirrhosis obstructing the portal vein in liver

large volume flowing from portal system to systemic system at their anastomoses produce varicose veins  extreme cases can result in hemorrhage (i.e. esophagus)

caput medusae = veins of abdominal wall that anastomose with paraumbilical veins (portal tributaries) become varicose and look like snakes

Front 96

Perinephric Abscesses

Back 96

loosely attached layers of renal fascia may allow pus from an abscess to spread

blood from an injured kidney can do the same

Front 97

Nephroptosis ("dropped kidney")

Back 97

abnormally mobile kidney descends more than the normal 3cm when body is erect

ureter usually is proper length with loose coiling or kinks

lack of inferior support for kidneys is a reason that transplants are placed in the iliac fossa (in addition to access to major blood vessels and the nearby bladder)

Front 98

Renal Transplantation

Back 98

kidney can be removed from donor leaving the suprarenal gland intact due to a weak septum that separates the two

renal artery and vein are joined to the external iliac artery and vein, ureter is sutured into the bladder

Front 99

Renal Cysts

Back 99

polycystic kidney disease = inherited as autosomal dominant trait, markedly enlarged kidneys that are distorted by cysts

Front 100

Pain in the Pararenal Region

Back 100

extension of hip joints may increase pain resulting from inflammation in pararenal area (close relationship of kidneys to psoas major)

Front 101

Accessory Renal Vessels

Back 101

failure of embryonic vessels to degenerate results in “polar arteries and veins”

may enter/exit at the poles of the kidney

variations in number and position occur in 25% of people

Front 102

Congenital Anomalies of the Kidneys and Ureters

Back 102

bifid renal pelvis and ureter – division of the ureteric bud
incomplete division = bifid ureter
complete division = supernumerary kidney
retrocaval ureter – leaves kidney and passes posteriorly to IVC
horseshoe kidney – fusing of kidneys during embryonic period, remains at level of L3-L5 because normal ascent could not occur, may not produce symptoms
ectopic pelvic kidney – fails to ascend and lies anterior to the sacrum
may be mistaken for a pelvic tumor
receives its blood supply from common iliacs

Front 103

Renal and Ureteric Calculi

Back 103

renal calculus = kidney stone (crystallized salts)

can pass from kidney to renal pelvis to ureter and cause ureteric calculus if it causes excessive distention of the ureter

causes severe pain (ureteric colic), often referred to lumbar or inguinal regions and T11-T12 (“loin to the groin”)

removed with nephroscope (incision and removal) or lithotripsy (shockwave that breaks up the stone into fragments to pass it with the urine)

Front 104

Hiccups

Back 104

involuntary, spasmodic contraction of diaphragm

cause sudden inhalations interrupted by closure of the glottis

result from irritation of nerve endings that control muscles of respiration and especially the phrenic nerves

Front 105

Section of a phrenic nerve

Back 105

complete paralysis and eventual atrophy of muscular part of the hemidiaphragm

recognized radiographically by the permanent elevation of hemidiaphragm (forced superiorly by abdominal viscera)

Front 106

Referred pain from diaphragm

Back 106

irritation of diaphragmatic pleura --> shoulder and skin of C3-C5

Front 107

Rupture of Diaphragm and Herniation of the Viscera

Back 107

sudden large increase in intrathoracic or intra-abdominal pressure (i.e. trauma!)

most injuries sustained on left, due to support the liver gives the right side

lumbocostal triangle = non-muscular region that will herniate more easily because it is made up of fascias of the diaphragm

Front 108

Congenital diaphragmatic hernia

Back 108

posterolateral defect of diaphragm (on left) – serious breathing difficulties because of compromised space available for development and inflation of lungs

Front 109

Psoas Abcess

Back 109

often results from TB, AIDS and their developing drug resistances

abscess in lumbar region spreads from vertebrae to psoas sheath, usually surfaces in superior part of thigh

creation of iliacosubfascial fossa from inferior part of iliac fascia can trap parts of the colon (cecum on right, sigmoid on left) and cause pain

Front 110

Posterior Abdominal Pain

Back 110

injury to any structures surrounding the iliopsoas muscle will cause pain on contraction (i.e. kidneys, ureters, cecum, appendix, sigmoid colon, pancreas, etc.)

iliopsoas test – extend thigh on affected side against resistance (positive test = pain)

adenocarcinoma of the pancreas – invades muscles and nerve of posterior abdominal wall and produces excruciating pain

Front 111

Partial Lumbar Sympathectomy

Back 111

division of the rami communicantes of several lumbar sympathetic ganglia

IVC and aorta vulnerable to injury during procedure due to their proximity to the sympathetic trunk

Front 112

AAA

Back 112

pulsations can be detected to the left of the midline and confirmation of diagnosis with imaging

rupture of the aneurysm causes severe pain in abdomen or back

treated with an endovascular catheterization procedure

compression of aorta against L4 vertebra can control bleeding of pelvis or lower limbs

Front 113

Collarteral Routes for Abdominopelvic Venous Blood

Back 113

blockage of IVC can result in other pathways of venous flow

epidural venous plexus (inside vertebral column)

communicates with lumbar veins and tributaries of azygos system
persistence of embryonic veins --> persisting left IVC (often crosses to right side at the level of the kidneys)