Tutorial No 3
Dr. Salma Malik
MBBS
Scenario
A 58-year-old male is admitted to the emergency
department with severe upper abdominal pain.
History
• The patient reports that he has a long-standing history
of mild “stomach” pain, but today just after lunch he felt
a sharp, stabbing pain in the region just inferior to his
sternum. He described the pain as “piercing,” and noted
it spread quickly across the left upper part of his
abdomen.
History cont.
• The pain was very intense for hours, but then subsided.
He was nauseous all afternoon (symptoms started after
lunch) and vomited once. He described the vomitus as
appearing like “coffee grounds.” He now reports vague
pain over his left shoulder.
Physical examination
• Hypoactive bowel sounds
• Guarding of the superior and anterolateral abdominal
wall
• Epigastric and left hypochondrial regions are tender
during deep palpation
Investigation
• Erythrocytes (count) 4.9
4.3–5.6
• Leukocytes (count) 13.2
3.54–9.06
• Hemoglobin 11
14–17
• Helicobacter pylori Positive
• Fecal occult blood (FOBT) Negative
Imaging Studies
Postero-anterior and lateral chest radiographs indicated
a pneumoperitoneum under the left dome of the
diaphragm. This was confirmed by abdominal computed
tomography (CT).
Endoscopy
Esophagogastroduodenoscopy (EGD) revealed a
discrete, well-circumscribed, 1.5 cm mucosal lesion with
a “punched-out” base. Gastric biopsy indicated the
presence of gram-negative rods consistent with H. pylori.
Discussion
1. Describe the anatomy of the stomach.
2. Breifly talk about the blood supply and venous
drainage of the stomach
3. Describe the innervation of the stomach
4. Describe the peritonium and the peritonial cavity
[Link] the anatomical basis for the symptoms and
signs associated with this case .
1. A 2-year-old boy presents with pain in his groin that has
been increasing in nature over the past few weeks. He is
found to have a degenerative malformation of the
transversalis fascia during development. Which of the
following structures on the anterior abdominal wall is likely
defective?
(A) Superficial inguinal ring
(B) Deep inguinal ring
(C) Inguinal ligament
(D) Sac of a direct inguinal hernia
• The answer is B. The deep inguinal ring lies in the
transversalis fascia, just lateral to the inferior epigastric
vessels. The superficial inguinal ring is in the
aponeurosis of the external oblique muscle. The inguinal
ligament and the anterior wall of the inguinal canal are
formed by the aponeurosis of the external oblique
muscle. The sac of a direct inguinal hernia is formed by
the peritoneum
2. A 29-year-old man comes to a local hospital with
duodenal peptic ulcer and complains of cramping epigastric
pain. Which of the following structures harbors the cell
bodies of abdominal pain fibers?
(A) Lateral horn of the spinal cord
(B) Anterior horn of the spinal cord
(C) Dorsal root ganglion
(D) Sympathetic chain ganglion
(E) Celiac ganglion
• The answer is C. Cell bodies of the abdominal pain
fibers are located in the dorsal root ganglion. The lateral
horn of the spinal cord contains cell bodies of
sympathetic preganglionic nerve fibers; the anterior
horn contains cell bodies of general somatic efferent
(GSE) fibers. The sympathetic chain ganglion contains
cell bodies of sympathetic postganglionic fibers, which
supply blood vessels, sweat glands, and hair follicles.
The celiac ganglion contains cell bodies of sympathetic
postganglionic fibers, which supply the visceral organs
such as stomach and intestine.
3. A 33-year-old man with a perforated gastric ulcer complains
of excruciating pain in his stomach. It is observed that the pain
comes from peritoneal irritation by gastric contents in the lesser
sac. Which of the following nerves contain sensory nerve fibers
that convey this sharp, stabbing pain?
(A) Vagus nerves
(B) Greater splanchnic nerves
(C) Lower intercostal nerves
(D) White rami communicantes
(E) Gray rami communicantes
• The answer is C. Pain sensation originating from
peritoneal irritation by gastric contents in the lesser sac
is carried by lower intercostals nerves. The vagus
nerves carry sensory fibers associated with reflexes in
the gastrointestinal (GI) tract. The greater splanchnic
nerves and white rami communicantes carry pain
(general visceral afferent [GVA]) fibers from the wall of
thestomach and other areas of the GI tract. The gray
rami communicantes contains no sensory fibers but
contain sympathetic postganglionic fibers.
4. A young boy is brought to the hospital after a bicycle
accident and possible pelvic fracture. While awaiting a
computed tomography (CT) scan of his pelvis, a physician
proceeds with a focal neurologic examination. In testing the
child’s reflexes, which of the following nerves would carry
afferent impulses of the cremasteric reflex?
(A) Subcostal nerve
(B) Lateral femoral cutaneous nerve
(C) Genitofemoral nerve
(D) Iliohypogastric nerve
(E) Femoral nerve
• The answer is C. Stimulation of the cremaster muscle
draws the testis up from the scrotum toward the
superficial inguinal ring. The efferent limb of the reflex
arc is the genital branch of the genitofemoral nerve,
whereas the afferent limb is the femoral branch of the
genitofemoral nerve. The other nerves are not involved
in the cremasteric reflex.
5. A radiograph of a 32-year-old woman reveals a perforation
in the posterior wall of the stomach in which the gastric
contents have spilled into the lesser sac. The general
surgeon has opened the lienogastric (gastrosplenic) ligament
to reach the lesser sac and notes erosion
of the ulcer into an artery. Which of the following vessels is
most likely involved?
(A) Splenic artery
(B) Gastroduodenal artery
(C) Left gastric artery
(D) Right gastric artery
• The answer is E. The left gastroepiploic artery runs
through the lienogastric ligament, and hence, it is the
artery most likely injured. The splenic artery is found in
the lienorenal ligament. The right and left gastric
arteries run within the lesser omentum. The
gastroduodenal artery descends between the
duodenum and the head of the pancreas.
6. A 26-year-old patient is admitted to a local hospital
with a retroperitoneal infection. Which of the following
arteries is most likely to be infected?
(A) Left gastric artery
(B) Proper hepatic artery
(C) Middle colic artery
(D) Sigmoid arteries
(E) Dorsal pancreatic artery
• The answer is E. The pancreas is a retroperitoneal
organ, except for a small portion of its tail. The dorsal
pancreatic artery would be the infected artery because it
arises from the splenic artery and runs retroperitoneally
along the superior border of the pancreas behind the
peritoneum. The other arteries run within layers of the
peritoneum. The left gastric arteries run within the lesser
omentum; the proper hepatic artery runs within the free
margin of the lesser omentum; the middle colic artery
runs within the transverse mesocolon; the sigmoid
arteries run within the sigmoid mesocolon.
7. An elderly man with prostatic hypertrophy returns to his
urologist with another case of epididymitis. An acute infection
involving the dartos muscle layer of the scrotum most likely
leads to an enlargement of which of the following lymph nodes?
(A) Preaortic nodes
(B) Lumbar nodes
(C) External iliac nodes
(D) Superficial inguinal nodes
(E) Common iliac nodes
• The answer is D. The superficial inguinal lymph nodes
receive lymph from the scrotum, penis, buttocks, and
lower part of the anal canal, and their efferent vessels
enter primarily to the external iliac nodes and ultimately
to the lumbar (aortic) nodes. The deep inguinal nodes
receive lymph from the testis and upper parts of the
vagina and anal canal, and their efferent vessels enter
the external iliac nodes.
8. Because of an inflammatory bowel disease (Crohn
disease) and a small bowel obstruction leading to bowel
ischemia, an elderly woman requires bypass of her ileum
and jejunum and is scheduled for a gastrocolostomy. The
surgeon will ligate all arteries that send branches to the
stomach. Which of the following arteries may be spared?
(A) Splenic artery
(B) Gastroduodenal artery
(C) Inferior pancreaticoduodenal artery
(D) Left gastroepiploic artery
(E) Proper hepatic artery
• The answer is C. The inferior pancreaticoduodenal
artery does not supply the stomach. All of the other
arteries supply the stomach. Gastrocolostomy is used to
establish a communication between the stomach and
colon, bypassing the small intestine when the patient
has Crohn disease (inflammation disease) and small
bowel obstruction.
9. A 38-year-old woman with peptic ulcer disease of the
stomach experiences severe abdominal pain. Which of
the following nervous structures is most likely involved?
(A) Greater splanchnic nerve
(B) Ventral roots of the spinal nerve
(C) Lower intercostal nerve
(D) Vagus nerve
(E) Gray ramus communicans
• The answer is A. The greater splanchnic nerve carries
pain fibers from the upper GI tract. Neither the ventral
roots of the spinal nerves nor the gray rami
communicantes contain sensory nerve fibers. The vagus
nerve contains sensory fibers associated with reflexes,
but it does not contain pain fibers. The lower intercostal
nerves carry general somatic afferent (GSA) pain fibers
from the diaphragm, abdominal wall, and peritoneum
but not GVA pain fibers from the GI tract.
10. A 3-year-old boy is diagnosed as having a persistent
processus vaginalis in its middle portion. Which of the
following conditions is most likely to be associated with this
developmental anomaly?
(A) Direct inguinal hernia
(B) Gubernaculum testis
(C) Hematocele
(D) Hydrocele
(E) Cryptorchidism
• The answer is D. If a middle portion of the processus
vaginalis persists, it forms a congenital hydrocele. If the
entire processus vaginalis persists, it develops a
congenital indirect inguinal hernia. Gubernaculum testis
is the fetal ligament that connects the bottom of the
fetal testis to the developing scrotum. Hematocele is an
effusion of blood into the cavity of the tunica vaginalis.
Cryptorchidism is failure of the testis to descend from
the abdomen to the scrotum.