Question 1

A 59-year-old man was involved in a head-on automobile accident. When seen in the emergency department, he was in hypovolemic shock and showed signs of extensive bruising on the lower part of the anterior abdominal wall. He was wearing a seat belt at the time of the accident. On examination, his abdomen was distended and tense; he had hypotension and tachycardia. A diagnosis of ruptured abdominal aorta was made during an emergency laparotomy. In cases of blunt traumatic injury to the abdominal aorta, do all patients become hypotensive immediately? Explain the possible role that the kidneys may play in causing damage to the aorta in deceleration injuries.

Accepted Answer

Frequently, patients with blunt rupture to the abdominal aorta may not immediately show signs of hypovolemic shock because the aorta is situated behind the peritoneum in the retroperitoneal space and the blood may not escape immediately into the peritoneal cavity (see text Fig. 5-62).
On impact, the patient may be held stationary by the seat belt, but the kidneys may continue forward until restrained by the vascular pedicles. Avulsion of the renal artery from the side of the aorta may take place under these circumstances.

Question 2

A 74-year-old man was seen in the emergency department complaining of the sudden onset of severe lumbar back pain. Three years previously he had had a myocardial infarction. On questioning, the patient admitted that he often experienced mild back and hip pains on getting up in the morning, but never had he experienced such a severe back pain. On examination, a somewhat tender pulsatile swelling could be felt in the abdomen at the level of the umbilicus. Both femoral pulses were present. A diagnosis of abdominal aortic aneurysm was made. What is the surface marking of the abdominal aorta? Explain why the back pain had started so suddenly and its significance. When an abdominal aneurysm ruptures, does an immediate fatal outcome always occur?
Into which hollow viscera or blood vessels may an aortic aneurysm rarely rupture into?

Accepted Answer

The abdominal aorta is a midline structure that enters the abdomen at the level of the twelfth thoracic vertebra, and its entrance may be projected onto the anterior abdominal wall just above the transpyloric plane (see text Fig. 8-3). The vessel extends downward to its bifurcation into the common iliac arteries at the level of the summit of the iliac crests.
The sudden onset of severe back pain can be explained by the aneurysm suddenly expanding or rupturing and pressing on the vertebral column, which lies immediately posterior to the aorta.
Death does not always immediately follow an abdominal aneurysm rupture. This can be explained by the fact that the hemorrhage may be initially confined to the retroperitoneal space, and a tamponade effect may temporarily prevent further bleeding.
The abdominal aorta is crossed by the third part of the duodenum, and cases have been reported of an aneurysm rupturing into the duodenal lumen. The inferior vena cava lies along the right side of the aorta, and an aneurysm has been known to rupture into it, producing a massive arteriovenous fistula.

Question 3

Explain in anatomic terms why penetrating injuries to the inferior vena cava are commonly fatal. Explain how it is possible to ligate the inferior vena cava below the level of the renal veins without adverse effects.

Accepted Answer

Penetrating injuries of the upper part of the inferior vena cava are commonly fatal because (a) the site of the injury is inaccessible behind the liver, duodenum, and the mesentery of the small intestine; (b) the presence of the right costal margin makes surgical access difficult; (c) the thin walls of the vena cava are likely to tear extensively and make repair difficult; and (d) the almost certain possibility that the liver is also damaged.
The extensive anastomosis of the lumbar veins with other retroperitoneal veins ensures that the blood is able to bypass the obstruction should the inferior vena cava be ligated below the level of the renal veins (see CD Fig. 8-3).

Question 4

A 63-year-old man with a long history of a duodenal ulcer was seen in the emergency department after vomiting blood-stained fluid and exhibiting all the signs and symptoms of severe hypovolemic shock.
-The following statements concerning duodenal ulcers could apply to the patient's condition except which?

Accepted Answer

The gastroduodenal artery is a large branch of the hepatic artery.

Question 5

A 58-year-old man was in a restaurant when he suddenly started to vomit blood. He was taken unconscious to the emergency department of a local hospital. On examination, he had all the signs of severe hypovolemic shock. On palpation of the anterior abdominal wall, the right lobe of the liver was felt three fingerbreadths below the costal margin. Several enlarged superficial veins could be seen around the umbilicus. His wife said that he had vomited blood 3 months previously and had nearly died. She admitted that he was a chronic alcoholic. The diagnosis was cirrhosis of the liver secondary to chronic alcoholism.
-The symptoms and signs displayed by this patient can be explained by the following statements except which?

Accepted Answer

At the lower end of the esophagus, a branch from the left gastric vein anastomoses with an esophageal tributary of the azygos vein.

Question 6

A 56-year-old man visited his physician complaining that he experiences severe pain in both legs when taking long walks. He noticed recently that the cramp-like pain occurs after walking only a hundred yards. On questioning, he said that the pain quickly disappears on rest only to return after he walks the same distance. When the physician asked about his sex life the patient admitted that he was experiencing difficulty with erection.
-The symptoms and signs displayed by this patient can be explained by the following statements except which?

Accepted Answer

The blockage of the aorta in the region of the bifurcation had effectively blocked the entrances into both common iliac arteries.

Question 7

A 23-year-old woman, who was 8 months pregnant, told her obstetrician that she had recently noticed that her feet and ankles were swollen at the end of the day. She said that the swelling was worse if she had been standing for long periods. She also noticed that the veins around her ankles were becoming prominent.
-The symptoms and signs displayed by this patient can be explained by the following statements except which?

Accepted Answer

The sympathetic trunks are not pressed on by the pregnant uterus.

Question 8

After complete occlusion of the origin of the inferior mesenteric artery with a blood clot, the blood supply of the left portion of the colon is maintained by the following arteries except which?

Accepted Answer

The left lumbar arteries do not significantly contribute to the left portion of the colon. The middle colic artery from the superior mesenteric artery, the sigmoid arteries, and the marginal artery, as well as the hemorrhoidal arteries, will maintain the blood supply to the left portion of the colon.

Question 9

In patients with an obstruction of the superior vena cava, blood may return to the right atrium through the following anastomotic channels except which?

Accepted Answer

The lateral thoracic and the superior epigastric veins are directly or indirectly connected with the superior vena cava only.

Question 10

If the common hepatic artery is unavoidably ligated during surgery, the arterial supply to the liver is maintained by the following anastomotic connections except which?

Accepted Answer

The gastroduodenal artery does not directly anastomose with the splenic artery.

Quiz 8: The Blood Vessels of the Abdomen, Pelvis, and Perineum

Explain in anatomic terms why penetrating injuries to the inferior vena cava are commonly fatal. Explain how it is possible to ligate the inferior vena cava below the level of the renal veins without adverse effects.

After complete occlusion of the origin of the inferior mesenteric artery with a blood clot, the blood supply of the left portion of the colon is maintained by the following arteries except which?

In patients with an obstruction of the superior vena cava, blood may return to the right atrium through the following anastomotic channels except which?

If the common hepatic artery is unavoidably ligated during surgery, the arterial supply to the liver is maintained by the following anastomotic connections except which?