Deck 20: The Viscera Associated With the Alimentary Tract: The Liver, the Pancreas, and the Spleen

Question 1

A 55-year-old woman with a history of flatulent dyspepsia suddenly experienced an excruciating colicky pain across the upper part of the abdomen. On examination in the emergency department, she was found to have some rigidity and tenderness in the right upper quadrant. A diagnosis of biliary colic was made.

-The following statements would explain this patient's symptoms except which?

A) The pain of gallstone colic is caused by spasm of the smooth muscle in the wall of the gallbladder and distension of the bile ducts by the stones.
B) The pain fibers from the gallbladder and bile ducts ascend through the superior mesenteric plexus and the greater splanchnic nerves to enter the thoracic segments of the spinal cord.
C) Referred pain is felt in the right upper quadrant or the epigastrium.
D) T7 through T9 dermatomes are involved.
E) The violent contractions of the gallbladder wall are attempts to expel the gallstones.

Answer 1

The pain fibers from the gallbladder and bile ducts ascend through the superior mesenteric plexus and the greater splanchnic nerves to enter the thoracic segments of the spinal cord.

Question 2

On examination of the abdomen of a 31-year-old woman, a large swelling was found to extend downward and medially below the left costal margin. On percussion, a continuous band of dullness was noted to extend upward from the left of the umbilicus to the left axillary region. On palpation, a notch was felt along the anterior border of the swelling. A diagnosis of splenic enlargement was made.

-The signs displayed by this patient can be explained by the following statements except which?

A) The spleen has a notched anterior border caused by incomplete fusion of its parts during development.
B) Because of the presence of the left colic flexure and the phrenicocolic ligament, the spleen is unable to expand vertically downward.
C) A pathologically enlarged spleen extends downward and forward, toward the umbilicus.
D) The spleen is situated in the upper left quadrant of the abdomen beneath the diaphragm.
E) The long axis of the spleen lies along the twelfth rib.

Answer 2

The long axis of the spleen lies along the twelfth rib.

Question 3

A 19-year-old football player was accidently kicked on the left side of his chest. On returning to the locker room he said he felt faint and collapsed to the floor. On examination in the emergency department, he was found to be in hypovolemic shock. He had tenderness and guarding in the left upper quadrant of his abdomen. He also had extreme local tenderness over his left tenth rib in the midaxillary line. A diagnosis of a ruptured spleen and the possibility of a fractured tenth rib was made. Explain the tenderness and guarding in the abdomen in this patient.

Answer 3

Initially in this patient, the spleen underwent a subcapsular hemorrhage, and later, in the locker room, the capsule gave way, allowing the blood to
escape into the peritoneal cavity. The presence of blood in the peritoneal cavity irritated the parietal peritoneum, causing tenderness in the left upper
quadrant and reflex guarding of the muscles in the same area.

Question 4

A 40 year-old obese woman complaining of indigestion was admitted to the hospital for investigation. She had a past history of gallstones and transient attacks of jaundice. Large gallstones have been known to erode through the posterior wall of the gallbladder and enter the intestinal tract.

-Which part of the intestinal tract is likely to initially contain the stone?

A) The sigmoid colon
B) The descending colon
C) The transverse colon
D) The ascending colon
E) The jejunum

Question 5

A 50-year-old woman with a history of flatulent dyspepsia suddenly experienced an excruciating colicky pain across the upper part of the abdomen. On examination after the attack, some rigidity and tenderness was noted in the right hypochondrium. Two days later the patient became jaundiced, and it was noticed that the degree of jaundice varied from day to day. The diagnosis of biliary colic was made. Why should a person passing a gallstone experience pain? Why is the pain experienced in the area described above? Why does the jaundice vary in intensity?

Question 6

A 65-year-old woman was admitted to the hospital with progressive jaundice of three months' duration and weight loss. She had not experienced any colicky pain. On examination, a soft swelling could be felt in the abdomen in the region of the tip of the right ninth costal cartilage. A diagnosis of cancer of the head of the pancreas was made. What anatomic structure is responsible for the swelling?

Question 7

A patient with thrombocytopenic purpura was advised to have a splenectomy to stop the episodes of bleeding from the gums and gastrointestinal tract. The operation was successful. Eighteen months later the clinical features returned. Can you explain in anatomic terms the recurrence of the bleeding after the condition had apparently been cured by splenectomy?

Question 8

Following a splenectomy, it was noticed that pancreatic juice was exuding through the patient's abdominal wound. Is the pancreas likely to be damaged during splenectomy? Which part of the pancreas?

Question 9

The anatomic arrangement of the terminal part of the bile duct and the main pancreatic duct is subject to considerable variation. Which variations are likely to be associated with a pancreatitis should a gallstone become impacted at the lower end of the bile duct?
quadrant and reflex guarding of the muscles in the same area.