Deck 19: The Abdominal Wall, the Peritoneal Cavity, the Retroperitoneal Space,and the Alimentary Tract

Question 1

An 8-year-old boy was admitted to the hospital with a temperature of $101^{\circ} \mathrm{F}$ , a furred tongue, and pain in the right lower quadrant. On examination, the skin on the right lower quadrant was tender to the touch, and the abdominal muscles were contracted and rigid. A diagnosis of acute appendicitis was made.

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

A) An acutely inflamed appendix produces an inflammation of the peritoneal coat covering it.
B) Should the inflammatory process spread, for example, if the appendix should rupture, the parietal peritoneum would become involved.
C) The parietal peritoneum, the abdominal muscles, and the overlying skin are supplied by the same segmental spinal nerves.
D) The segmental nerves supplying the right lower quadrant of the abdominal wall are T7, T8, and T9.
E) The pain in the right lower quadrant and the regional contraction of the abdominal muscles is an attempt by the body to keep the inflamed appendix immobile so that the inflammatory process remains localized.

Answer 1

The segmental nerves supplying the right lower quadrant of the abdominal wall are T7, T8, and T9.

Question 2

A workman engaged in demolishing a building lost his balance and fell astride a girder on the floor below. On examination, he was found to have extensive swelling of his perineum, scrotum, and penis. He was unable to urinate normally, passing only a few drops of bloodstained urine. The lower part of the anterior abdominal wall was also swollen, but his thighs were normal.

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

A) The patient's fall ruptured the urethra in the perineum.
B) When the patient attempted to micturate, the urine extravasated beneath Colles' fascia.
C) The urine passed over the scrotum and penis under the membranous layer of superficial fascia.
D) The urine passed upward beneath the membranous layer of superficial fascia on the anterior abdominal wall.
E) The urine could not extend posteriorly because of the attachment of Colles' fascia to the tip of the coccyx.
F) The urine did not extend into the thigh because of the attachment of the membranous layer of superficial fascia to the fascia lata, just below the inguinal ligament.

Answer 2

The urine could not extend posteriorly because of the attachment of Colles' fascia to the tip of the coccyx.

Question 3

A 45-year-old woman was shopping in a liquor store when an armed robbery took place. A shootout occurred and a bullet ricocheted off the wall and entered her left side. Fortunately, the bullet did not enter the peritoneal cavity. One year later, in addition to diminished skin sensation over the left lumbar region and umbilicus, she noticed a bulging forward of the left side of her anterior abdominal wall.

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

A) The bullet cut the ninth and tenth intercostal nerves just below the costal margin on the left side.
B) The diminished skin sensation was caused by the loss of the sensory nerve supply to the ninth and tenth thoracic dermatomes.
C) Portions of the oblique, transversus, and rectus abdominis muscles on the left side were paralyzed.
D) Atrophy of the pyramidalis muscle resulted in loss of support to the abdominal viscera, which then sagged forward.

Answer 3

Atrophy of the pyramidalis muscle resulted in loss of support to the abdominal viscera, which then sagged forward.

Question 4

A 9-week-old boy was admitted to the hospital with a swelling in the right groin that extended down into the upper part of the scrotum. When he cried, the swelling enlarged. On careful palpation it was possible to reduce the size of the swelling, and this procedure was accompanied by a gurgling noise.

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

A) The swelling was situated above and medial to the pubic tubercle on the right side.
B) The child had a right indirect inguinal hernia.
C) The processus vaginalis in its upper part had failed to become obliterated before birth.
D) The hernial sac in an indirect inguinal hernia emerges from the superficial inguinal ring.
E) The superficial inguinal ring lies above and medial to the pubic tubercle.
F) The contents of the hernial sac consisted only of the greater omentum.

Question 5

A 75-year-old man with chronic bronchitis noticed that a bulge was developing in his left groin. On examination, an elongated swelling was seen above the medial end of the left inguinal ligament. When the patient coughed, the swelling enlarged but did not descend into the scrotum. The patient had weak abdominal muscles.

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

A)The inguinal swelling was a direct inguinal hernia.
B) The cause of the hernia was weak abdominal muscles.
C) The hernial sac was wide and in direct communication with the peritoneal cavity.
D) A rise in intraabdominal pressure on coughing caused the hernial swelling to expand.
E) The swelling occured lateral to the inferior epigastric artery.

Question 6

A 40-year-old woman noticed a painful swelling in her right groin after helping her husband move some heavy furniture. On examination, a small tender swelling was noted in the right groin.

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

A) The excessive exertion caused a rise in intraabdominal pressure.
B) A hernial sac formed of parietal peritoneum was forced downward.
C) The peritoneum was forced through the right femoral canal.
D) The patient had a right-sided femoral hernia.
E) The neck of a femoral hernial sac is situated below and medial to the pubic tubercle.

Question 7

A 55-year-old man was admitted to the hospital with a large hard, fixed, intraabdominal mass. On examination of the abdomen, the mass was situated on the transpyloric plane. The inguinal lymph nodes were normal.

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

A) Radiologic examination of the stomach showed nothing abnormal.
B) The right testicle was enlarged and was much harder than normal.
C) A diagnosis of malignant disease of the right testis was made.
D) The malignant tumor had metastasized to the lumbar lymph nodes lying on the transpyloric plane on the posterior abdominal wall, which is the normal lymphatic drainage of the testis.
E) In malignant disease of the testis the superficial inguinal lymph nodes only become involved if the tumor spreads to involve the scrotal skin.
F) The normal testis is tethered to the skin of the scrotum.

Question 8

A 25 -year-old man involved in purchasing drugs was knifed in the abdomen in the left upper quadrant. On examination in the emergency department, it was difficult to determine whether the knife had penetrated the peritoneal cavity. It was decided to do a midline peritoneal lavage below the umbilicus to see if there was any free blood in the peritoneal cavity.

-The following layers of tissue were penetrated by the trocar and cannula to enter the peritoneal cavity except which?

A) Skin
B) Fatty and membranous layers of superficial fascia
C) Rectus sheath and rectus abdominis muscle
D) Deep fascia
E) Fascia transversalis
F) Extraperitoneal tissue and parietal peritoneum

Question 9

A 45-year-old man was admitted to the emergency department complaining of severe pain in the right lower quadrant of the anterior abdominal wall. He had repeatedly vomited, and his temperature and pulse rate were elevated. His history indicated that he had acute appendicitis and that the pain had suddenly increased. On examination, the muscles of the lower part of the anterior abdominal wall in the right lower quadrant showed rigidity. The diagnosis of peritonitis after perforation of the appendix was made.

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

A) The perforation of the appendix had resulted in the spread of the infection from the appendix to involve the parietal peritoneum.
B) The parietal peritoneum in the right iliac region, the muscles of the anterior abdominal wall, and the overlying skin are all supplied by the segmental nerves T12 and L1.
C) Irritation of the parietal peritoneum reflexly increases the tone of the abdominal muscles, causing rigidity.
D) The greater omentum tends to become stuck down to the appendix and restricts the spread of infection.
E) The pain was intensified after perforation of the appendix because of stimulation of the autonomic pain endings in the parietal peritoneum.

Question 10

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?

A) Hemorrhage from a duodenal ulcer often reveals itself by the passage of black stools on defecation.
B) The pyloric sphincter prevents most of the blood from the duodenal lumen from passing up into the stomach.
C) The gastroduodenal artery lies behind the first part of the duodenum and was probably eroded by the ulcer.
D) The gastroduodenal artery is a small branch of the hepatic artery.
E) The duodenal ulcer was most likely to be situated on the posterior wall of the first part of the duodenum.

Question 11

A 47-year-old woman was operated on for the treatment of a chronic gastric ulcer that had not responded to medical treatment. At operation for partial gastrectomy, it was found that the posterior wall of the stomach was stuck down to the posterior abdominal wall. The surgeon had to proceed with great care to avoid damaging important structures lying on the posterior abdominal wall.

-The following structures located on the posterior abdominal wall were possibly involved in the disease process except which?

A) The right kidney
B) The pancreas
C) The left suprarenal gland
D) The left kidney
E) The lesser sac of peritoneum
F) The splenic artery

Question 12

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?

A) The normal flow of portal blood through the liver is impaired by cirrhosis of the liver.
B) The portal-systemic anastomoses become enlarged in this condition.
C) At the lower end of the esophagus, a branch from the right gastric vein anastomoses with an esophageal tributary of the azygos vein.
D) Rupture of a varicosed esophageal vein could produce a severe hemorrhage so that the patient would vomit up blood.
E) With portal hypertension the paraumbilical veins linking the superficial veins of the skin (systemic veins) to the portal vein become congested and visible.

Question 13

A 48-year-old woman with a history of repeated vomiting was admitted to the hospital with a diagnosis of large bowel obstruction. To decompress the stomach a nasogastric tube was passed.

-When passing a nasogastric tube some important anatomic facts should be considered except which?

A) The well-lubricated tube is inserted through the wider nostril.
B) The tube is directed backward along the nasal floor and not upward because it may become caught on the nasal choanae.
C) The distance between the nostril and the cardiac orifice of the stomach is about $23 \mathrm{in} .(57.5 \mathrm{~cm}$ ).
D) The distance between the cardiac orifice and the pylorus is 4.8 to $5.6 \mathrm{in}$ . (12 to $14 \mathrm{~cm}$ ).
E) Esophageal narrowing may offer resistance to the tube behind the cricoid cartilage, 7.2 in. $(18 \mathrm{~cm})$ from the nostril.
F) The left bronchus and the arch of the aorta cross in front of the esophagus and may impede the descent of the tube, $11.2 \mathrm{in}$ . $(28 \mathrm{~cm})$ from the nostril.
G) Where the esophagus enters the stomach there is a slight resistance to the descent of the tube.

Question 14

The following statements concerning an indirect inguinal hernia are correct except which?

A) It is the most common form of abdominal hernia.
B) The neck of the hernial sac lies medial to the inferior epigastric artery.
C) The sac is the remains of the processus vaginalis.
D) The hernial sac can extend into the scrotum.
E) At the superficial inguinal ring, the hernial sac lies above and medial to the pubic tubercle.

Question 15

A mother took her 20-day-old baby boy to a pediatrician because he had started to vomit after his feeds. The baby was breast-fed. For the first 15 days after birth, the baby had taken his feeds very well and had slept contentedly in his crib following the normal after-feed burp. However, in the previous 5 days, the baby had begun to vomit toward the end of each feed, shooting the milk out of his mouth for a distance of 1 to $2 \mathrm{ft}$ . After carefully questioning the mother and after a physical examination of the boy, the pediatrician made the diagnosis of congenital hypertrophic pyloric stenosis.

-He was able to ascertain the following additional signs and symptoms except which?

A) Once the milk had been vomited, the child immediately would feed again, only to repeat the same performance.
B) On gentle palpation of the anterior abdominal wall, a small firm swelling was felt just below and medial to the tip of the left eighth costal cartilage.
C) On observing the anterior abdominal wall, an occasional wave of gastric peristalsis was seen traveling across the epigastrium from left to right.
D) The stools were small in quantity and infrequent.
E) The child showed signs of dehydration as evidenced by a depressed anterior fontanelle of the skull.

Question 16

A 6-year-old girl was examined by a pediatrician because she had a history of recurrent pain in the region of the umbilicus. The pain was dull and aching in nature and lasted for about 1 week. It had recurred on four occasions in the previous 2 years. Then 2 days before the examination, the child had severe rectal bleeding and had fainted.

-On examination of the child, the pediatrician found the following signs and symptoms consistent with the diagnosis of Meckel's diverticulum except which?

A) Tenderness of the anterior abdominal wall in the right iliac region
B) Anemia
C) Stools streaked with dark red blood
D) Pyrexia of $102^{\circ} \mathrm{F}$

Question 17

A 30-year-old man involved in a barroom brawl was seen in the emergency department. He was found to have a bloodstained tear on the seat of his trousers and lacerations of the anal margin. During the fight he was knocked down and fell in the sitting position on the leg of an upturned bar stool. While under observation he developed the signs and symptoms of peritonitis.

-The signs and symptoms displayed by this patient could be explained by the following anatomic statements except which?

A) The patient had impaled his rectum on the leg of the upturned bar stool.
B) At operation, a laceration of the anterior wall of the middle of the rectum was found.
C) The leg of the bar stool had entered the rectovesical pouch.
D) The rectal contents had contaminated the peritoneal cavity and were responsible for the development of peritonitis.
E) The anterior surface of the middle third of the rectum has no peritoneal covering.

Question 18

A 46-year-old man had been treating himself for hemorrhoids for the past 3 years. He had noticed that his feces were often slightly blood stained. For the past 12 months, he had noticed that when he had his bowels open, he always felt that more was to come. Sometimes he went to the toilet several times a day but was only able to pass flatus and blood-stained mucus. Recently, pain had developed down the outside of his right leg. Digital examination of the rectum revealed a large, hard-based ulcer on the posterior wall of the rectum with extensive induration of the pararectal tissues. A diagnosis of advanced carcinoma of the rectum was made.

-The following statements about this patient are probably correct except which?

A) Some of the bleeding was from the carcinomatous ulcer of the rectum as well as from the hemorrhoids.
B) The lymphatic drainage of the rectum takes place first into the pararectal lymph nodes.
C) Carcinoma of the rectum never metastasizes to the liver.
D) Examination of the right leg revealed some weakness of the muscles supplied by the sciatic nerve.
E) The carcinoma had extended posteriorly to involve the sacral plexus.
F) The patient indicated that the leg pain was felt in skin areas supplied by branches of the sciatic nerve.

Question 19

A 72-year-old woman was suspected of having a tumor of the sigmoid colon. The physician decided to confirm the diagnosis by performing a sigmoidoscopy.

-The following anatomic statements are correct concerning the procedure of sigmoidoscopy except which?

A) After inserting the instrument into the anus, the lighted end enters the ampulla of the rectum after a distance of about $1.5 \mathrm{in} .(4 \mathrm{~cm})$ .
B) Some side-to-side movement may be necessary to avoid the transverse rectal folds.
C) The rectosigmoid junction will be reached approximately $6.5 \mathrm{in}$ . $(16.25 \mathrm{~cm})$ from the anal margin.
D) To negotiate the rectosigmoid junction, the tip of the sigmoidoscope should be directed anteriorly and to the patient's left.
E) Stretching of the colonic wall may give rise to colicky pain in the upper part of the abdomen in the region of the xiphoid process.

Question 20

A 3-week-old boy was taken to a pediatrician because of repeated vomiting and reluctance to feed. On questioning, the mother said the child had started to vomit on the first day of life and has vomited at least once a day since then. Early on, the mother had been reassured and told that the baby was taking his feedings too quickly and that the vomiting eventually would cease. While initially accepting this reassurance, the mother now noticed that the child did not seem hungry at feeding time; moreover, she could see that the abdomen was becoming distended. She added that the child definitely was constipated; very occasionally, hard meconium was passed. After a thorough physical examination of the child, the pediatrician made the diagnosis of primary megacolon (Hirschsprung disease).

-The examination of the child revealed the following possible signs except which?

A) The abdomen was found to be distended.
B) A rectal examination with the gloved little finger resulted in the passage of a large amount of flatus and the abdominal distension became visibly less.
C) A low barium enema followed by an $\mathrm{X}$ -ray examination showed a normal rectum.
D) On the radiograph, above the rectum, a narrowed part of the colon led to a funnel-shaped expansion, which in turn led to a greatly dilated descending colon and transverse colon.
E) On placing a stethoscope on the abdominal wall, the physician could not hear sounds of peristalsis.

Question 21

A 53-year-old man complained that for the past 4 years he had frequently passed blood-stained stools. Recently, he had noticed that his "bowel" protruded from his anus after defecation, and this caused him considerable discomfort.

-The following symptoms and signs in this patient were consistent with a diagnosis of third-degree internal hemorrhoids except which?

A) The patient suffered from intense perianal irritation caused by the mucous secretions from the prolapsed mucous membrane.
B) Proctoscopic examination revealed three pink swellings of mucous membrane at the level of the anal valves.
C) The swellings were situated at the 1,4 , and 9 o'clock positions with the patient in the lithotomy position.
D) The swellings bulged downward when the patient was asked to strain.
E) Large, congested veins were seen in the swellings.
F) The swellings remained outside the anus after defecation.
G) Abrasion of the mucous membrane was responsible for the bleeding.

Question 22

A 42-year-old woman visited her physician because she experienced an agonizing pain in the rectum, which occurred on defecation. She had first noticed the pain a week before when she tried to defecate. The pain lasted for about an hour, then passed off, only to return with the next bowel movement. She said that she suffered from constipation and admitted that sometimes her stools were streaked with blood. After a careful examination, a diagnosis of anal fissure was made.

-The following statements concerning this case are correct except which?

A) Examination of the anal canal was difficult because any attempt to insert a gloved finger into the canal caused severe pain.
B) The anus was kept tightly closed by the spasm of the external anal sphincter.
C) Gentle eversion of the anal margin under local anesthesia revealed the lower edge of a linear tear in the posterior wall of the anal canal; a small tag of skin projected from the lower end of the tear.
D) The forward edge of a hard fecal mass may have caught one of the anal valves and torn it downward as it descended.
E) Anal fissures tend to occur on the anterior and posterior walls of the anal canal because the mucous membrane is poorly supported in this region by the superficial external sphincter muscle.
F) The mucous membrane of the lower half of the anal canal is innervated by autonomic afferent nerves and is sensitive only to stretch.

Question 23

A 4l-year-old woman was seen in the emergency department complaining of a painful swelling in the region of the anus. On examination, a hot, red, tender swelling was found on the right side of the anal margin. A diagnosis of ischiorectal abscess was made.

-The following statements concerning this case are probably correct except which?

A) An ischiorectal abscess is a common complication of anal fissure.
B) The fat in the ischiorectal fossa is prone to infection that might extend laterally through the base of the anal fissure.
C) The fat in the ischiorectal fossa has a profuse blood supply.
D) A surgical incision of the abscess should provide adequate drainage of the pus.
E) The surgeon should avoid the inferior rectal nerve and vessels that cross the ischiorectal fossa from the lateral to the medial side.

Question 24

The differential diagnosis between a perforated duodenal ulcer and a perforated appendix may prove difficult. Can you explain this in anatomic terms?

Question 25

The pain of acute appendicitis is commonly first felt in the umbilical region and later in the right iliac region. Can you explain this in anatomic terms?

Question 26

Following a terrorist bomb attack, a young child was seen in the emergency department with a gaping hole in the anterior abdominal wall, and coils of gut were exposed on the surface. How would you determine by inspection whether the gut was small or large intestine?