This is the second in a series of comprehensive clinical anatomy and imaging questions for the abdomen.  Good luck!

Reviewed by Nick Lowe and Katrina Bogus

Abdominal Anatomy Part Two

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Question 1
On radiography, you identify the patient has a bleed at the most proximate point of the midgut. Which surface anatomy point references this location?
A
Subcostal plane
B
Supracristal plane
C
Transpyloric plane
D
Transtubercular plane
Question 1 Explanation: 
The most proximate point of the midgut is the termination major duodenal papilla. Thus the GI bleed is most likely located at the third, horizontal, duodenal portion. This is classically located at the level of L3, found anteriorlty with the subcostal line.
Question 2
Pfannenstiel approach risks which of the following structures?
A
Integrity of transversus abdominis
B
Iliohypogastric nerve
C
Ilioinguinal nerve
D
The nerve piercing psoas major posteroanteriorly
Question 3
Which of the following is not a major structural constituent of the posterior abdominal wall?
A
Quadratus lumborum
B
Quadratus femoris
C
Psoas major
D
Lumbar vertebral bodies
Question 4
Which of the following organs are LESS likely to result in back-ache in the acute-phase of haemorrhage?
A
Left suprarenal gland
B
Oesophagus
C
Abdominal aorta
D
Stomach
Question 4 Explanation: 
This question's answer rests on the knowledge of which organs are RETROPERITONEAl - thus "plastered" to the posterior abdominal wall. Knowledge of such renders it relatively trivial to estimate whether they are likely to immediately cause localised backache on bleeding. As such, the only structure listed above that is NOT retroperitoneal is the stomach - which is intraperitoneal.
Question 5
A patient presents to ED short of breath, with cold peripheries and a decreased LOC. On general inspection it is immediately noted the patient has Cullen's sign of bilateral flank bruising.  The physician feels supero-laterally to the umbilicus to where a pulsatile wave notably moves the hands laterally.  Which of the following best describes this physical examination?
A
Overdose of dabigatran
B
A left renal arterial aneurysm
C
A ruptured aortic aneurysm
D
Acute pancreatitis
Question 6
What is the vertebral level of the arterial branch supplying the region that includes the distal oesophagus, stomach and spleen?
A
T12
B
L1
C
L2
D
L3
Question 6 Explanation: 
This region is the foregut, which is supplied by the coeliac trunk. The latter branches from the abdominal aorta at T12.
Question 7
A patient is undergoing lymphatic clearance of the foregut, second to a finding of pancreatic adenocarcinoma.  Where is the prominent anastomosis that will keep the foregut structures from undergoing infarct in theatre?
A
About the third portion of the duodenum
B
About the splenic hilum
C
About the gastroomental arcade of the gastric greater curvature
D
About the head of the pancreas
Question 7 Explanation: 
This is referring to the anastomosis between branches of the coeliac trunk and superior mesenteric artery - termed the superior and inferior pancreaticoduodenal branches respectively - which are continuous with one another about the head of the pancreas.
Question 8
A patient with emergent presentation to ED is brought into surgery.  They reported periumbilical pain that rapidly transferred to the right lower quadrant of the anterior abdominal wall. When the surgeon uses a Gridiron approach, she ligates a portion of mesentery to prevent haemorrhage as the structure is ablated.  From where does the ligated artery ORIGINATE?
A
Marginal artery
B
Ileal branches of the superior mesenteric artery
C
Superior rectal artery
D
Ileocolic artery
Question 8 Explanation: 
This describes the classic referral pattern of appendicitis, from midgut referral to peritoneal localisation as inflammation progresses. The patient has an appendectomy with ligature of the mesoappendix, which contains the appendicular branch of the ileocolic artery.
Question 9
Of aortic anatomy ...
A
The oesophageal hiatus is the conduit for the aorta
B
The supracristal plane represents the origin of the renal arteries
C
The superior mesenteric artery is the first obstacle of an ascending horseshoe shaped kidney
D
The subcostal plane is the approximate site of IMA origin
Question 10
A patient requiring end-of-line paracentesis to relieve ascites presents to the ED.   With the patient supine, where is the ultrasound probe most likely to detect fluid accumulation?
A
Subphrenic recess
B
Morison's pouch
C
Left lateral paracolic gutter
D
Right medial paracolic gutter
Question 11
The following pathology report is presented
Patient with history of hepatic cirrhosis has malignancy infiltrating from the bare area of the liver toward the inferior hemidiaphragm ipsilaterally
Which of the following structures mark the area of the malignancy?
A
The collective coronary ligaments
B
The round ligament
C
The porta hepatis
D
The left and right triangular ligaments
Question 12
Which of the following is not a constituent of the foramen of Winslow?
A
Hepatoduodenal ligament
B
Inferior vena cava
C
The caudate lobe
D
The quadrate lobe
Question 13
The hindgut does not include ...
A
The rectum
B
The sigmoid colon
C
The descending colon
D
The ascending colon
Question 13 Explanation: 
The hindgut commences 2/3 along the transverse colon. Thus the ascending colon is proximal to this marker and cannot be a member of it.
Question 14
Nociceptive referral to the T9 dermatome is most likely indicative of sensory output from ...
A
The right kidney
B
The transverse colon
C
The sigmoid colon
D
The lower oesophageal sphincter
Question 15
Which of the following is not true of the marginal artery?
A
Is the rationale for watershed infarcts of the midgut-hindgut junction
B
Courses between the layers of the mesentery for a time
C
Owes some of its blood supply to a major branch from the abdominal aorta at the level of T12
D
Supplies the large bowel
Question 15 Explanation: 
The marginal artery is the anastomosis between branches of the midgut and hindgut, which originate from branches at the levels of L1 and L3 respectively. T12 is the origin level of the coeliac axis, which is the supply of the foregut only.
Question 16
A patient presents with sharp epigastrium pain.  After examination and investigation, a hiatus hernia is diagnosed.  The patient had, had emergent gastroscopy which showed ischaemic change of the superior-most stomach.  What is the blood supply occluded in this instance?
A
Branches of the splenic artery
B
The right gastric
C
The left gastric
D
The gastroomental arcade
Question 16 Explanation: 
The gastric fundus has herniated through the oesophageal hiatus at T10 (classically) in this instance. It is, variably, supplied by short gastric branches from the splenic artery as it courses from the coeliac axis to the splenic hilum.
Question 17
Vagal postganglionics to the small bowel are not involved in ...
A
Mass movement regulation
B
Maintaining tonus of the bowel
C
Defecation reflex
D
Stimulation of the submucosal enteric nervous plexus
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