Anat MEQs for the Abdomen and Pelvis (taken from past year

promotional exams)
2004 Pros
a)Describe the boundaries and contents of the ischiorectal fossa.
The boundaries of the ischiorectal fossa (in the perineum) are as follows: it is a
wedge-shaped area lying on both sides of the anus; its lateral wall is formed by the
part of the obdurator internus below the pelvic diaphragm and at the lower border
the gluteus maximus, while its medial wall and roof is formed by the pelvic
diaphragm (levator ani), and its base is formed by skin and subcutaneous
tissue. Its contents are as follows: ischiorectal fat pads (continuous posteriorly) and
the pudendal/Alcock’s canal, which contains the pudendal nerves and vessels, which
runs on the lateral side of the fossa and gives off inferior rectal branches in the fossa
to supply the external sphincter of the anus and the anorectal canal
b) Outline the origin, course and distribution of the pudendal nerve
The pudendal nerve is a somatic nerve originating from the sacral plexus (formed by
the anterior rami of the sacral spinal nerves) in the pelvis (S2, S3, S4). Its course is as
follows: from the sacral plexus, it exits the pelvis through the greater sciatic foramen
(below the piriformis), then curves around the ischial spine and sacrospinous
ligament to enter the perineum (anorectal triangle) via the lesser sciatic foramen,
and runs in the pudendal canal. Its distribution is as follows: it gives off the inferior
rectal nerve in the ischiorectal fossa, which supplies the external anal sphincter and
provides cutaneous innervation to the anorectal triangle (also the mucous
membrane of the lower ½ of anal canal); it gives off a perineal branch, which
supplies the perineal muscles (eg. muscles in the urogenital triangle, such as
the bulbospongiosus, ischiocavernosus) (deep branch) and the cutaneous
innervation of the perineum (eg. posterior labial/scrotal branches- superficial
branch))- running in the deep perineal pouch, it pierces the perineal membrane, and
exits anteriorly into the superficial perineal pouch as the dorsal cutaneous nerve of
the clitoris/penis, where it gives sensory innervation to the glans.

2005 Pros
4a) Outline the normal development and derivatives of the midgut.
The derivatives of the midgut are as follows: the 2nd ½ of the 2nd part of the
duodenum onwards all the way to the proximal 2/3s of the transverse colon.
(jejunum, ileum, cecum and appendix, ascending colon, transverse colon).
The development of the midgut is as follows: in the 8th week of fetal development,
the midgut loop develops rapidly, until it outgrows the abdominal cavity and
herniates into the umbilical cord, due to the rapidly growing liver and kidneys
that encroach into the abdominal cavity. (Vitellinointestinal duct is
attached to the midgut loop and passes through the umbilicus; eventually it
atrophies, but a remnant may be left as Meckel’s diverticulum, usually 2
feet from the ileocecal junction) The midgut loop is suspended from the posterior
abdominal wall by the dorsal mesentery, which has in its root the precursor to the
superior mesenteric artery (formed by fusion of the vitellinointestinal arteries). The
midgut loop can be divided into a cranial and a caudal section; the cranial section
becomes highly coiled (to form the jejunum and the ileum). The midgut loop
undergoes a 90 degree rotation anticlockwise (around the axis of the SMA) and
the cranial section returns to the abdominal cavity 1st. As it returns, it pushes the
hindgut derivatives (descending colon) to the left of the peritoneal cavity and the
pressure causes their mesentery to fuse with the posterior abdominal wall
(descending colon thus lies retroperitoneal). The loop is rotated a further 180
degrees anticlockwise and the caudal part now returns; its pressure causes the
derivatives of the cranial part to fuse with the posterior wall as well (in this case, the
duodenum), and is the basis for the superior mesenteric artery being sandwiched
between the duodenum posteriorly and the mobile transverse colon anteriorly. The
vitelline duct is obliterated and severs its connection with the gut in the
10th week. Finally, the cecum descends into the right iliac region and the right
ascending colon fuses with the posterior abdominal wall, becoming retroperitoneal as
well.
4b)Describe the blood supply of the derivatives of the midgut
The midgut derivatives are supplied by branches of the superior mesenteric artery.
The jejunum and ileum are supplied by jejunal and ileal branches; the cecum is
supplied by anterior and posterior ileocolic arteries; the appendix by the appendicular
artery, a branch of the posterior ileocolic artery, and the ascending colon by right
colic branches, the transverse colon (to its proximal 2/3) by middle colic artery, and
by anastomotic supply via the marginal artery as well. The distal ½ of the 2nd part of
the duodenum onwards is supplied by the inferior pancreaticoduodenal artery.
Venous drainage is by veins that run with the arteries and drain into branches of the
portal vein; mainly the superior mesenteric branch of the portal vein, which joins with
the splenic vein behind the neck of the pancreas
c) What is the anatomical basis for pain felt in the umbilical region?
The pain felt in the umbilical region from the midgut derivatives is due to referred
pain. Visceral pain from the midgut derivatives is carried in afferent fibres that follow
the course of the sympathetic innervation of the midgut (along the periarterial
plexuses to the superior mesenteric plexus, through thoracic splanchnic nerves to
the sympathetic chain, and then via white rami into the T10 spinal nerves, passing
through the dorsal root and dorsal root ganglion into the dorsal horn of the spinal
cord at the T10 level. The brain interprets this visceral pain sensation as coming from
the umbilicus, from which pain sensations travel via somatic nerves
(thoracoabdominal nerves) and also end in the dorsal horn of the spinal cord at T10
levels.
This umbilical pain can be felt in two scenarios: a herniation and
strangulation of a part of the small intestine (eg. in an inguinal or femoral
hernia), and in appendicitis.
Foregut derivatives (pancreas, stomach, gallbladder)- refer to epigastrium
Hindgut derivatives- refer to loin and inguinal region
5a) Outline the course and distribution of the pudendal nerves. See above.
5b) Give a brief description of the formation of the pelvic diaphragm. What could
happen if it is injured?
The pelvic diaphragm is formed from the levator ani and coccygeus muscles. The
origin of the pelvic diaphragm is the pubis, the white line (thickening of fascia of the
obdurator internus) and the ischial spine. The levator ani is divided into the
pubococcygeus and the iliococcygeus muscles. Anteriorly, there is a hiatus in the
pelvic diaphragm for the passage of the urethra in the male and the urethra/vagina in
the female; this hiatus is closed by the urogenital diaphragm. The sphincter
vaginae/levator prostatae form slings of fibres that support the vagina/prostate and
the perineal body. The puborectalis passes behind the anus and forms a muscular
sling that maintains the angle of the anorectal junction and acts as a sphincter; its
fibres merge with that of the deep ring of the external anal sphincter. The fibres of
the pelvic diaphragm insert on the median line of the pelvic diaphragm- involving the
perineal body, the anococygeal body (insertion of pubococcygeus and
iliococcygeus), and the coccyx. The coccygeus muscle overlies the sacrospinous
ligament and originates from the ischial spine, inserting at the coccyx.
If the pelvic diaphragm is injured, there will be a loss of support for the pelvic organs.
When intraabdominal pressure is raised (eg. in coughing, or in defecation), the
downward pressure may cause prolapse of the pelvic organs (rectal prolapse,
prolapse of the uterus. There would also be a loss of fecal continence as the angle of
the anorectal junction is no longer maintained.
There would also be stress incontinence (eg. urination when coughing)
because of alteration in the position of the bladder neck and urethra
5c) Outline the different stages of labour
Labour is preceded by weaker, irregular contractions. (Braxton-Hicks contractions)
The 1st stage of labour is the dilation of the cervix. The baby’s head is forced
downwards by uterine contractions into the cervical canal, dilating it. This is the
longest stage of labour (8-24 hrs). Dilation of the cervix provides mechanical
stimulation that triggers oxytocin release from the pituitary, which intensifies uterine
contractions, which provide further oxytocin release (+ve feedback loop)
The 2nd stage of labour is the bursting of the fetal membranes (amnion)- amniotic
fluid is released. This is soon followed by the delivery of the baby. The cord is tied
and cut. This stage takes 1 hr
The last stage of labour is the afterbirth, or delivery of the placenta. The bleeding
subsequent to delivery of the placenta is reduced by contraction of the uterine
arteries under influence of oxytocin. This stage takes 10 min

2006 Pros
3a) Give a brief description of the light microscopic features of the cervix
3b) outline the contents and relations of the broad ligament
3c) Briefly describe the innervation of the bladder mentioning the probable reason
why she had difficulty in emptying (woman previously underwent removal of the
uterus and fallopian tubes along with the broad ligament)
4a) Outline the main relations of the stomach and describe its lymphatic drainage
4b) What are the main light microscopic features of the mucosa in the body of the
stomach?
4c) List 3 physiological consequences of stomach removal. What advice would you
give the patient about his food intake?

3a)Light microscopic features of the cervix: part of the uterus, so presence of

thickened muscular lining (the myometrium) and the endometrial lining (simple
columnar); tubular glands (Nabothian glands) embedded in the myometrium
empty into the cervix and provide secretions for lubrication (mucus secreting
epithelial lining thrown into deep furrows and tunnels gives the
appearance in 2D of branched tubular glands)
3b) The contents and relations of the broad ligament are as follows
Contents: suspensory ligament of the ovary, round ligament of the uterus and ovary,
the fallopian tubes, embryonic remnants of the mesonephric ducts (paraoophoron
and epoophoron), uterine and ovarian vessels, and nervous plexuses. The broad
ligament attaches the uterus laterally to the walls of the pelvis; the fallopian tube
runs in its upper free edge, inferiorly layers separate to form the pelvic floor
and the ovary is attached by the mesoovarium to its posterior surface. Anteriorly
there is the uterovesical pouch; posteriorly there is the pouch of douglas. The uterine
artery runs at its base, over the ureters, near the lateral fornices of the vagina.
3c) Innervation of the bladder:
Visceromotor: parasympathetic fibres from the pelvic splanchnic nerves and inf.
hypogastric plexus (stimulate contraction of the detrusor muscle and relaxation of
the sphincter vesicae); sympathetic fibres from the vesical plexus, formed from the
hypogastric plexuses, running in the lumbar splanchnic nerves (stimulate relaxation
of the detrusor muscle and contraction of the sphincter vesicae).
Visceroreflex: fibres follow the parasympathetic innervation (S2-S4)
Visceropain: upper ½ of the bladder, afferent fibres follow the sympathetic fibres (L1-
L2 roots); lower ½ of the bladder, below the pelvic pain line, fibres follow the
parasympathetic fibres (S2-S4 roots)
Sphincter urethrae under somatic, voluntary control from the perineal branch of the
pudendal nerve (S2-S4)
Why she cannot urinate normally- perhaps some damage to the vesical plexus, or
damage to the supporting fascia/muscles that leads to an abnormal positioning of the
bladder and urethra?

4a) Main relations of the stomach: anteriorly the left lobe of the liver and the anterior
abdominal wall; superiorly and anteriorly the diaphragm, posteriorly the lesser sac of
the peritoneum, behind which is the pancreas, left dome of diaphragm, splenic
vessels, left kidney, left suprarenal gland, and the spleen, and transverse colon
Lymphatic drainage: Generally follows the blood supply.
Lymph from the lesser curvature (supplied by the L/R gastric arteries) generally
drains into the gastric lymph nodes. Lymph from the upper part of the greater
curvature and fundus (supplied by the L gastroepiploic @ and short gastric @s,
branches of the splenic artery, drain into splenic nodes; while lymph from the lower
part of the greater curvature (supplied by the right gastroepiploic @, a branch of the
gastroduodenal artery, drains into the pancreaticoduodenal nodes. All the lymph
eventually drains into the celiac nodes, which, together with the lymph from the
other preaortic lymph nodes, drains into the intestinal trunk which merges with the
R/L lumbar trunks to form the cisterna chyi, which ascends through the aortic hiatus
in the diaphragm and drains into the junction of the left carotid and subclavian veins.
4b) Mucosa: epithelium is simple columnar with mucus secreting cells.
stomach wall has pits lined with gastric glandular cells. In the body of the stomach,
there are oxyntic glands- which contain mucus neck cells (goblet cells), acid
secreting parietal cells (large, rounded, with extensive eosinophilic
cytoplasm and central nucleus- fried egg appearance- in the isthmus, and at
their base the chief cells that secrete pepsinogen (basophilic granular cytoplasm
and basal nuclei). There are also neuroendocrine cells (eg. ECL cells). In the
antrum, there are pyloric glands, which contain much less parietal cells, mainly
containing mucus-secreting goblet cells and gastric-secreting G cells.
4c)Dumping syndrome- chyme moves quickly into the duodenum (loss of the storage
function of the stomach)- can lead to reactive hypoglycemia due to excessive release
of insulin, and patient feels full faster. Lack of IF secretion leads to deficiency in B12
absorption and pernicious anemia, which needs injections of B12. There would also
be a deficiency in protein digestion, which could lead to diarrhea. The patient should
eat small portions frequently (thus avoiding the dumping syndrome), and food
should be chopped or minced into smaller pieces

2006 Supps
4a) What are the major relations of the bile duct? (40%)
4b) Explain the jaundice and other symptoms she may have as a result of the
obstruction to the bile duct. (30%)
4c) Give a simple description of the light microscopic features of the normal
pancreas. (30%)

4a) The major relations of the 8cm long bile duct are: for the 1st part, it runs in the
free edge of the lesser omentum, forming the anterior border of the epiploic foramen,
with the hepatic artery on its left and the hepatic portal vein behind. It then lies
behind the 1st part of the duodenum and for the 2nd part, it runs medial to the 2nd part
of the duodenum, behind the head of the pancreas. Finally, it runs in the head of the
pancreas and joins with the main pancreatic duct (of Wirsung) to empty into a
common papilla (of Vater) in the medial side of the 2nd part of the duodenum, that is
closed by a sphincter (of Oddi).
4b)Obstruction of the bile duct prevents bile from being excreted into the gut.
Because bile cannot be excreted, it accumulates in the bile caniculi, and some is
eventually reverse-transported by the hepatocyte back into the blood (via MRP3)-
causing a hyperconjugated billirubinemia. Some of the bilirubin is deposited in
tissues, leading to the icterus that presents with jaundice. Other symptoms would
include pruritis (because of the bilirubin deposits), pale stool (lack of stercobilin in the
stool) and urine the color of tea (dark colored because of the presence of conjugated
bilirubin in the urine), as well as malabsorption of fats due to defective micelle
formation and emulsification (which depends on bile salts), leading to steatorrhea,
and elevated serum alkaline phosphatase (because alkaline phosphatase is secreted
by the bile duct and accumulates in cholestatic jaundice).
4c) The pancreas is covered by a fibrous capsule that extend into the pancreas as
connective tissue; within the connective tissue run blood vessels and nerves. The
pancreas is divided into endocrine and exocrine portions. The exocrine portions
consist of secretory acini, which are composed of cells that produce zymogens
(pancreatic enzymes). The acini drain their secretions into intercalated ducts,
intralobular and interlobular ducts, before finally draining into the excretory ducts;
the lining of the ducts progresses from simple cuboidal to simple columnar. The
endocrine portion consists of islets of Langerhans (relatively light-staining)
embedded in the exocrine pancreas. Using special stains, the different types of cells
can be identified- beta cells secrete insulin and form the majority of the islet cells,
alpha cells produce glucagon, D cells produce somatostatin and other cells produce
pancreatic polypeptide.

5a)Describe the major relations of the bladder and what happens to the bladder
during progressive distension with urine
5b) What structures are accessible for examination by a gloved finger in the rectum?
5c) Outline the light microscopic features of the prostate.

5a) The major relations of the bladder are:

In the male: Superiorly the peritoneum, anteriorly the pubis and retropubic space
(cave of Retzius); posteriorly the seminal vesicles, vas deferens, the ureters, which
open obliquely into the lateral angles of the trigone, and the rectovesical pouch
containing coils of small intestine (layers of rectovesical pouch form the fascia of
Denonvillers); inferiorly the prostate and the prostatic urethra, median lobe of the
prostate, when enlarged, forms the uvula vesicae in the floor of the bladder.
In the female: Superiorly the uterovesical pouch and the uterus; posteriorly the cervix
and anterior fornices of the vagina, behind which is the pouch of Douglas; anteriorly
is the retropubic space and symphysis pubis, and inferiorly is the female urethra.
When the bladder is distended with urine, the rugae of the bladder stretch out to
accommodate the increased volume. As the bladder fills progressively, it expands
from the pelvic region and it peels off the superior covering of peritoneum, ascending
into the abdominal cavity behind the aponeuroses of the muscles of the anterior
abdominal wall. Stretch of the detrusor muscle (visceral reflex) follows
parasympathetic fibres to the inf. hypogastric plexus and the pelvic splanchnic
nerves (S2-S4) to reach the sacral centres of the spinal cord- which send efferent
fibres, in the parasympathetic nerves, to stimulate contraction of the detrusor muscle
and relaxation of the sphincter vesicae (micturition reflex).
5b)
Rectal Examination (gloved finger placed into the rectum)
Anteriorly (Male)
• Terminal phalanx: rectovesical pouch, bladder, seminal vesicles, vas deferens
• Middle phalanx: prostate
• Proximal phalanx: perineal body, urogenital diaphragm, bulb of penis
Anteriorly (Female)
• Terminal phalanx: rectouterine pouch (pouch of Douglas), vagina and cervix
• Middle phalanx: urogenital diaphragm, vagina
• Proximal phalanx: perineal body, lower part of vagina
Posteriorly
Sacrum, coccyx, anococcygeal body
Laterally: ischiorectal fossae, ischial spines

Posteriorly in both sexes, the sacrum and coccyx, as well as the anococcygeal body,
can be felt.
In the rectum, in a male:
Anteriorly: terminal phalanx can feel the coils of small intestine in the rectovesical
pouch, bladder and seminal vesicles; middle phalanx can feel prostate; terminal
phalanx can feel the perineal body, UG diaphragm and bulb of penis
In a female:
Anteriorly, terminal phalanx can feel the coils of small intestine in the rectouterine
pouch (pouch of Douglas), cervix and the posterior fornix of the vagina, middle
phalanx can feel the UG diaphragm and vagina, terminal phalanx can feel the
vagina and the perineal body (in a normal anteverted, anteflexed uterus)
5c) The light microscopic features of the prostate: Formed by a fascial condensation
externally, then the prostatic venous plexus and finally the capsule of the prostate
itself. Within the prostate, the glands are arranged in different regions – deep,
submucosal and mucosal glands. (branched tubulo-acinar glands embedded in a
fibromuscular stroma) The glands empty via ducts into the prostatic sinus of the
prostatic urethra, which is lined by urothelium and lies in the middle of the prostate.
There may be pinkish deposits known as corpora amylacea present in the glandular
tissue.
In the past the prostate was described as consisting of a number of
ill-defined lobes. However, this terminology has been replaced by
the concept of prostate zones and the gland is now described as
consisting of four zones of unequal size:

• The transition zone surrounds the proximal prostatic urethra

and comprises about 5% of the glandular tissue.
• The central zone (20%) surrounds the ejaculatory ducts.
• The peripheral zone makes up the bulk of the gland
(approximately 70%).
• The anterior fibromuscular stroma contains no glandular tissue
and lies anteriorly