Abdomen Forum 2011

Surface Anatomy Guy: Document where the following organs/structures can be palpated: Liver Spleen Gallbladder Draw in: Linea alba Linea semilunaris McBurney’s point ASIS Deep Inguinal ring Opening in transversalis fascia Superficial Inguinal ring Opening in external oblique 1 2 Linea Alba 3 Liver= can be palpated at its inferior margin below right costal margin, when patient is inhaling deeply (can feel edge of the liver “slipping” over fingers) Spleen= Press down just below the left costal margin with your right hand while asking the patient to take a deep breath. It may help to use your left hand to lift the lower rib cage and flank (actually not palpable on most individuals) Gallbladder= normally not palpable; can be if enlarged (from a medical issue) by pressing under the right, middle costal margin, under the rib cage Spermatic cord goes through entire inguinal canal (males) Round ligament of uterus (in females) ASIS 4 Deep inguinal ring Superficial I.R.

Surface Anatomy Guy: Draw in the 4 lines to create the “9-region pattern” Name the 9 regions. What organs are found in each? 1 Right Hypochondrium 2 Left Hypochondrium Epigastric 3 Right Flank Left Flank R.H. = liver Epigastic = liver, gallbladder, stomach, transverse colon L.H. = stomach, spleen, some descending colon R.F.. = ascending colon Umbilical = small intestine, some transverse colon L.F. = small intestine, descending colo R.G. = some ascending colon Pubic = small intestine, cecum, appendix, sigmoid colon, rectum, anal canal L.G. = descending colom, small intestine Umbilical 4 Right Groin Pubic Left Groin

Patient A – 42 year-old male presenting after trying to move his dishwasher Compare and Contrast! Patient B – newborn male Direct inguinal hernia (more in common in older men with weaker abdominal muscles) invade Hesselbach’s triangle, and can go through the superficial ring and pick up transversalis fascia Indirect Hernia (congenital; goes through both inguinal rings)

Identify! 1 What's my lymphatic drainage? 2 5 3 4 6 Liver (mostly drained by celiac pre-aortic lymph node; some lymph will pass to inferior phrenic nodes then go to thorax, and round/falciform ligament drains to anterior abdominal wall) Spleen Left kidney Abdominal aorta Inferior vena cava Ascending colon

6 Identify! 1 3 2 5 7 4 8 9 Gallbladder Abdominal Aorta Inferior Vena Cava Gallstones (referred pain to left shoulder) Left kidney Liver Spleen Diaphragm (median arcuate ligament) Hepatic portal vein 5 7

Identify! 6 4 5 1 3 2 8 7 Abdominal aorta Right kidney Left kidney Duodenum (2nd part) IVC Liver Psoas major muscle Transverse colon 7 2 3

Identify! 4 2 1 3 5 6 7 8 Left common iliac artery Right common iliac Inferior vena cava Ascending colon (cecum?) Psoas major m. (hip flexion; attaches to lesser trochanter) External oblique m. Internal oblique m. Rectus abdominis m. 5

SUPER BONUS! Identify! Superior Mesenteric Artery

6 5 4 2 1 3 Identify; What’s wrong? 48-year-old male with abdominal pain. CT scans reveal: PANCREOTITIS 6 5 4 Liver Spleen Left kidney Pancreas Stomach Heart (right atrium) 2 1 3

44-year-old male with pain in lower right quadrant. CT scan reveals: History? What’s wrong? 44-year-old male with pain in lower right quadrant. CT scan reveals: Appendicitis appendocolith (-lith= stone) with inflammation

CT scan of a 50-year-old male reveals: 1 Spleen Right kidney Peritoneal sac Ascites 3 2

Barium swallow in a 43-year-old female with abdominal pain: Duodenal Diverticulum (ridges on 3) 2 Pylorus of stomach Superior part of duodenum Descending duodenum Duodenal Diverticulum (not the pancreas) jejunum 4 3 1 5

Barium swallow in a 39-year-old female with dysphagia: Hint: What congenital anomaly is responsible? Dysphagia lusoria chronic constriction aberrant right subclavian is going behind the esophagus and pinching it improper origin

MRI of a 9-month-old male with dysphagia and an abdominal mass reveals the following: ? Splenomegaly (by tumor?) Gaucher’s Disease

Barium enema in a 38-year-old female with a abdomino-pelvic mass reveals the following: Large colonic diverticulosis in the sigmoid colon filled with poop and blood *

Barium enema in a 1-year-old male with difficulty defecating reveals: * * Stenosis of rectum, sigmoid colon Hirschsprung’s Disease lacking nervous innervation, no peristalsis

Barium enema and CT scan of a 23-year-old male with a lumbar mass reveals the following: Lumbar Hernea (through the lumbar triangle) iliac crest, lat dorsi, external oblique muscles

Radiograph from a 73-year-old female with abdominal pain and elevated WBCs: Hint: Pneumoperitoneum (gas in the peritoneum) usually from the disruption of a hollow viscus (in this case, an organ in the GI tract) can result from a peptic ulcer, bowel obstruction, appendicitis, diverticulitis

CT scan from a 30-year-old female with complaints of vomiting and weight loss: Enlarged spleen; spleen infected and pushing on stomach, leading to vomiting and weight loss 1 3 4 Superior mesenteric syndrome? Stomach Right kidney Portal vein Superior mesenteric artery 2

24-year-old female presents with the chief compliant of suprapubic pain. A pelvic radiograph reveals: Stone/mass found in an ectopic kidney Stone in the bladder (the inferior-most structure

GO! 3 5 1 2 4 6 Celiac trunk Splenic artery Left gastric artery Common hepatic artery Hepatic artery proper Gastroduodenal artery Anterior superior pancreaticoduodenal artery 6 7

GO! 1 3 4 2 Superior mesenteric artery Ileocolic artery Right colic artery Ileal arteries RED ARROW= Marginal arter (links the left and middle arteries)

GO! 4 3 1 2 Superior Mesenteric Vein Inferior Mesenteric Vein Splenic Vein Main Portal Vein 4 3 1 2

GO! 1 2 3 Super BONUS! 4 Common hepatic duct Cystic duct Common bile duct Main pancreatic duct SUPER BONUS = lumbar vertebrae (pars interarticularis) Super BONUS! 4

Referred Pain Guy: A 30-year-old male presents with pain in the region indicated. What organ is indicated? What spinal cord levels are involved? Cell bodies in what location are responsible for relay of pain from this organ? A 16-year-old female presents with a fever and pain in the region indicated. Which organ is implicated? What spinal cord level is involved? Is this somatic or visceral pain? A 36-year-old female presents with pain in the region indicated. 1 2 3 YELLOW: 1) Stomach 2) T5-T9 (greater splanchnic) 3) dorsal root ganglia @ T5-T9 RED: 1) Appendix/Small intestine 2) T9-T11 (lesser splanchnic) 3) Visceral pain interpreted as somatic pain (when shifts to right quadrant= SOMATIC) somatic because it is irritation parietal peritoneum GREEN: Liver, GALLBLADDER, duodenum 4