Duodenum, Pancreas, Liver, and Gallbladder Practice Quiz

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Duodenum
--------------
This question is asking you to identify the organ that is secondarily
retroperitoneal. This means that it started out peritonealized but
became pressed against the posterior body wall and stuck there
during development. Except for the first few centimeters of the
superior segment and the duodenojejunal junction, the duodenum
Which organ becomes retroperitoneal during rotation of the gut
is a secondarily retroperitoneal organ - it used to have a mesen-
tube?
tery, but that was lost during gut rotation. Although the kidney
is a retroperitoneal organ, it is not secondarily retroperitoneal
- it started developing in the retroperitoneum and stayed there.
The spleen, stomach, and transverse colon are all peritonealized.
What segments of the colon are peritonealized? The cecum,
transverse colon, and the sigmoid colon are peritoneal, but the
ascending and descending colon are retroperitoneal.
Gastroduodenal artery
---------------
The gastroduodenal artery lies behind the superior part of the
duodenum. It has three branches: the posterior superior pancre-
A 40 year-old male with a long history of duodenal ulcer prob- aticoduodenal artery, the anterior superior pancreaticoduodenal
lems was brought in for emergency surgery to control severe artery, and the right gastroomental artery. The other vessels are
hemorrhage into the peritoneal cavity. The surgeons found that not near the superior duodenum. The coronary vein is made of
erosion by the ulcer of a vessel passing behind the first part of the right and left gastric veins and located in the lesser curvature
the duodenum was the source of the hemorrhage. Which of the of the stomach. The inferior pancreatoduodenal arcade is found
following vessels passes behind the first part of the duodenum in the inferior part of the head of the pancreas. It supplies the
and would need to be clamped off to control the bleeding? pancreas and duodenum. It is near the horizontal (3rd) part of the
duodenum, not the superior part. The proper hepatic artery is a
branch of the common hepatic artery which delivers oxygenated
blood to the liver. Finally, the splenic vein comes from the spleen--it
joins the superior mesenteric vein to form the portal vein.
Inferior vena cava
------------------
The epiploic foramen, also called the omental foramen, is the
passageway between the greater and lesser peritoneal sacs. The
inferior vena cava lies immediately posterior to this foramen, so
During a cholecystectomy (removal of the gall bladder), the sur- this is the vessel that was probably cut. The aorta lies next the
gical resident accidentally jabbed a sharp instrument into the inferior vena cava, but it is a little more to the left and a little deep-
area immediately posterior to the epiploic foramen (its posterior er--it does not lie immediately posterior to the epiploic foramen.
boundary). He was horrified to see the surgical field immediately The hepatic portal vein is anterior to the epiploic foramen. The
fill with blood, the source which he knew was the: right renal artery is a branch off of the aorta. Like the aorta, it is
too deep to be a vessel immediately behind the foramen. Finally
the superior mesentric vein is anterior to the foramen. Remember,
this is one of the two vessels that makes the hepatic portal vein,
so if the hepatic portal vein is anterior to the foramen, the SMV
should be too. (See Netter's 256 for some relevant pictures)
Gallbladder fossa and inferior vena cava
------------
This question is asking you to identify the structures that make
the line that separates the true/functional lobes of the liver. The
concept of functional lobes contrasts with traditional anatom-
ical terminology, which separated the liver into the left, right,
The division between the true right and left lobes (internal lobes)
quadrate and caudate lobes. These traditional lobes were based
of the liver may be visualized on the outside of the liver as a plane
on anatomical appearance, while the functional lobes are based
passing through the:
on the distribution of the portal vein, hepatic arteries, and hepatic
bile ducts. The functional lobes of the liver are separated into a
right and left lobe by the gallbladder fossa and the inferior vena
cava. So, the old "right lobe" corresponds to the functional right
lobe, while the caudate, quadrate, and left lobes under anatomical
terminology are lumped together as one big left lobe.
Esophagus, stomach, duodenum, colon, etc.
NOT gallbladder

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 Duodenum, Pancreas, Liver, and Gallbladder Practice Quiz
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----------------
The orally ingested contrast medium would coat all the structures
of the gut tube, including the esophagus, stomach, duodenum,
Orally ingested contrast medium opacifies what? and colon. The medium should go anywhere that ingested food
might go in the GI tract. The gallbladder, however, is not a part
of the passageway for food - it concentrates and secretes stored
bile. So, the gall bladder would not be filled with contrast.
Pancreas, greater omentum, stomach
NOT duodenum
------------
The duodenum receives blood from the gastroduodenal artery, a
branch of the common hepatic artery. It also receives blood from
the inferior pancreatoduodenal artery, which is a branch of the
superior mesenteric artery. So, the duodenum is receiving blood
from the common hepatic artery and the superior mesenteric
To stop hemorrhaging from a ruptured spleen, it was necessary
artery, but it is not receiving any blood from the splenic artery.
to temporarily ligate the splenic artery near the celiac trunk. The
The splenic artery supplies blood to the body of the pancreas
blood supply to which structures will be affected?
with the dorsal and superior pancreatic arteries; it supplies blood
to the tail of the pancreas with the caudal pancreatic artery. The
splenic artery supplies the fundus of the stomach with short
gastric arteries and the left portion of the greater curvature with
the left gastroomental artery. The left gastroomental artery also
supplies blood to the greater omentum through omental branches.
All of these structures would be affected if the splenic artery was
ligated.
Head of the pancreas
-----------
Tumors in the head of the pancreas often obstruct the common
A 50-year-old female patient with severe jaundice was diagnosed bile duct, blocking the normal bile recycling circuit. This blockade
with pancreatic cancer. You suspect that the tumor is located in prevents excretion of bilirubin, a yellow-colored pigment that is a
which portion of the pancreas? red blood cell breakdown product. The accumulation of bilirubin
in various tissues, including the skin, causes jaundice. Tumors in
other areas of the pancreas are not as likely to block the common
bile duct and cause jaundice.
Duodenum
------------
The superior mesenteric artery crosses over the third part of
A patient was admitted with symptoms of bowel obstruction. Fur-
the duodenum, and the aorta is posterior to the third part of
ther examination revealed that the obstruction was caused by the
the duodenum. If something causes these vessels to become
nutcracker-like compression of the bowel between the superior
enlarged, they can crush the duodenum, and food will not be able
mesenteric artery and the aorta. The compressed bowel is most
to pass through the duodenum. This is often called the "nutcracker
likely the:
effect," and it is only seen in the third part of the duodenum. Take
a look at Netter Plate 292 for an illustration of the third part of the
duodenum lying between these important vessels.
Superior portion of the duodenum
------------
The superior part of the duodenum is the one segment of the
duodenum that has no circular folds. When food enters the duo-
denum from the pyloric sphincter, it enters the ampulla, which is
A medical student was asked to identify a small specimen taken a smooth area of the duodenum containing a high percentage
for pathological examination from a surgically removed duode- of mucosal cells. These cells secrete mucus to neutralize the
num. The student noted that the specimen revealed a thin wall acidic contents of the stomach. If the stomach contents is not
and no circular folds. The specimen is from which segment? sufficiently neutralized, the thin wall of the ampulla may develop an
ulcer. If the ulcer burns through the entire wall, it might jeopardize
the gastroduodenal artery, lying behind the first segment of the
duodenum. The descending, horizontal, and ascending portions
of the duodenum all have circular folds. For an illustration of the
different linings of the duodenum, see Netter Plate 262.
Common hepatic duct, liver, and cystic duct
-----------
The triangle of Calot is formed by the cystic duct laterally, the
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liver superiorly, and the common hepatic duct medially. It is an
important landmark in this region, because the cystic artery can
You are observing a laparoscopic cholecystectomy. The surgeon
be found in the triangle of Calot. During a cholecystectomy, the
states that he is next going to expose the cystic artery in order
cystic artery needs to be ligated. Although the cystic artery usually
to staple across it. He asks you where he should look for it. You
branches from the right hepatic artery, there is some variation.
reply, "In the triangle of Calot." What structures form this triangle
However, if you locate the triangle of Calot, you can find the cystic
and are the keys to finding the artery?
artery in that triangle, trace it back to its origin, and then ligate it
there.
Common bile duct, gastroduodenal artery, portal vein
NOT main pancreatic duct
-----------
Upon endoscopic examination of a 65-year-old man who had a The pancreas is inferior to the superior portion of the duodenum,
history of a chronic duodenal ulcer, it was found that the ulcer had and the main pancreatic duct is found deep within the pancreas. It
been eroding the posterior wall of the first part of the duodenum. is not likely that this structure would be damaged by the duodenal
If erosion perforates the wall, the gastric expellant of high acidity ulcer. The portal vein, gastroduodenal artery, and the common bile
would endanger the structures in its vicinity. Which structures are duct all pass immediately deep to the first part of the duodenum.
endangered? (The portal vein and common bile duct are associated with the
proper hepatic artery, forming the portal triad.) These structures
would all be at risk from the ulcer. See Netter Plate 279 for a
picture illustrating this relationship.
Splenic vein to left renal vein
-------------
The splenic vein is a major vein of the portal system, while the
left renal vein is a major vein of the caval system. These veins
are large, so a bypass between them could be useful for relieving
A 58-year-old patient was diagnosed with a severe case of portal the portal hypertension. The coronary vein, right gastro-omental
hypertension due to alcoholic cirrhosis of the liver. It was deter- vein, left colic vein, sigmoidal vein, inferior mesenteric vein, and
mined that a bypass between the vessels of the portal and caval splenic vein are all part of the portal system. Any bypasses among
systems was necessary. The plan most likely to be successful is: these veins will not relieve the portal hypertension. The superior
and inferior rectal veins already form a portal-caval anastomo-
sis; surgery would not be needed to connect these two venous
channels. However, if too much blood tries to flow through this
anastomosis, hemorrhoids will develop. These veins are not large
enough to help relieve severe portal hypertension.
Left hepatic artery
--------------
A radiological examination of a patient revealed a large tumor in The left and right hepatic arteries help support the parenchyma
the quadrate lobe of the liver. During the surgical removal of the and stroma of the liver. The left hepatic artery supplies the left
tumor, one of the vessels that needs to be clamped to effectively & quadrate lobes of liver, and part of the caudate lobe. The right
control bleeding is the: hepatic artery supplies the right lobe and part of the caudate lobe.
So, the left hepatic artery must be clamped to perform surgery on
the quadrate lobe.
Superior mesenteric artery
-------------------
The superior mesenteric artery crosses over the third part of
the duodenum, and the aorta is posterior to the third part of
A patient was admitted with symptoms of an upper bowel obstruc-
the duodenum. If something causes these vessels to become
tion. Upon CT examination, it was found that the third (transverse)
enlarged, they can crush the duodenum, and food won't be able to
portion of the duodenum was compressed by a large vessel
pass through the duodenum. This is often called the "nutcracker
causing the obstruction. The vessel involved is most likely to be
effect," and it is only seen in the third part of the duodenum. Take
the:
a look at Netter Plate 292 for an illustration of the third part of
the duodenum lying between these important vessels. You should
know what structures are involved in the "nutcracker effect" and
how they are causing an upper bowel obstruction!
First part of the duodenum, second part of the duodenum, greater
curvature of the stomach, head of the pancreas
NOT the tail of the pancreas
An ulcer near the pyloroduodenal junction perforated and eroded
-----------------
a large artery immediately posterior to the duodenum. The ligation
The gastroduodenal artery is the artery that has ruptured. This
artery gives off the anterior and posterior superior pancreatoduo-
denal arteries, which supply the first and second parts of the duo-
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 Duodenum, Pancreas, Liver, and Gallbladder Practice Quiz
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denum, as well as the head of the pancreas. The gastroduodenal
artery also gives off the right gastroomental artery, which supplies
of the eroded vessel at its origin would affect the arterial supply the right half of the greater curvature of the stomach. In contrast,
to the: the tail of the pancreas is supplied by the caudal pancreatic artery,
which is a branch of the splenic artery. It would not be affected by
damage to the gastroduodenal artery.
Hepatopancreatic ampulla
------------
The hepatopancreatic ampulla is the very short segment of duct
which represents the joining of the common bile duct and the main
pancreatic duct. Once these two ducts form the hepatopancreatic
A patient was diagnosed with pancreatitis due to a reflux of bile
ampulla in the wall of the duodenum, the bile and pancreatic
into the pancreatic duct caused by a gallstone. The stone is likely
enzymes are emptied into the second portion of the duodenum,
to be lodged at the:
through the major duodenal papilla. If a gallstone was stuck in the
hepatopancreatic ampulla, bile could back up and flow backwards
into the main pancreatic duct. If a stone was lodged in the cystic
duct, common hepatic duct, or common bile duct, bile would never
even reach the pancreas. See Netter Plate 276 for an illustration.
Left hepatic duct
-------------
Like the left hepatic vein, the left hepatic duct drains bile from
The blockage of a main bile duct in the quadrate lobe will likely
the left lobe, quadrate lobe, and part of the caudate lobe of
cause reduced flow of bile secretion in the:
the liver. So, an obstruction in the quadrate lobe would reduce
bile secretion in the left hepatic duct. The right hepatic duct and
hepatic vein drain the right lobe and part of the caudate lobe.
It is crossed by the transverse colon. It is thick-walled and has
circular folds in its interior. It has the opening for the common bile
duct and pancreatic duct on its posteromedial wall. It is secondar-
ily retroperitoneal. It is supplied by both the gastroduodenal and
superior mesenteric arteries.
-----------------
The first part of the duodenum features thin walls and no cir-
cular folds. It is called the ampulla of the duodenum. Once the
duodenum turns and becomes the second part, the walls be-
come thicker, and circular folds develop. The second part of the
Describe the 2nd portion of the duodenum.
duodenum has the hepatopancreatic ampulla in its medial wall,
which is the duct formed as the common bile duct and pancre-
atic duct join to empty their secretions into the duodenum. The
transverse colon overlies the second part of the duodenum, and
the second part of the duodenum is a secondarily retroperitoneal
organ. Also, remember that the anterior and posterior superior
pancreaticoduodenal arteries are branches of the gastroduodenal
artery, which receives blood from the celiac trunk. The anterior
and posterior inferior pancreaticoduodenal arteries receive blood
from the superior mesenteric artery.
Duodenum
------------
A Kocher maneuver involves reflecting the duodenum and pan-
creas medially by cutting through the fusion fascia along the right
side of the descending part of the duodenum. This technique
is used to gain access behind the pancreas. However, even if
A Kocher manuever dissects in the avascular plane behind which you didn't know the exact definition of a Kocher maneuver, you
organ that becomes retroperitoneal during rotation of the gut? could still answer this question. The question is asking you to
pick which organ is secondarily retroperitoneal, and the only
secondarily retroperitoneal organ listed is the duodenum. The
kidney and suprarenal gland were retroperitoneal during the entire
developmental process, and the transverse colon and spleen
are peritonealized. So, duodenum is the only answer that makes
sense here.
Splenic vein
-------------
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 Duodenum, Pancreas, Liver, and Gallbladder Practice Quiz
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The inferior mesenteric vein usually empties into the splenic vein.
The splenic vein and the superior mesenteric vein then unite to
The inferior mesenteric vein usually joins which vein? form the portal vein. Look at Netter Plate 290 for a picture of this.
Remember--the inferior vena cava and left renal vein are caval
veins--they are not involved in draining the gut.
Splenic vein to left renal vein
-------------
The splenic vein is a major vein of the portal system, while the
A surgeon needs to construct a bypass between the veins of left renal vein is a major vein of the caval system. These veins
the portal and caval systems to circumvent insufficient drainage are large, so a bypass between them could be useful for relieving
through the natural portacaval anastomoses. Which plan is likely the portal hypertension. The coronary vein, right gastroepiploic
to be successful? vein, inferior mesenteric vein, splenic vein, left colic vein, middle
colic vein, and superior mesenteric vein are all part of the portal
system. Any bypasses among these veins will not relieve the
portal hypertension.
Common bile duct
----------------
Tumors in the head of the pancreas often obstruct the common
bile duct, blocking the normal bile recycling circuit. This blockade
A patient with jaundice was diagnosed with cancer of the head of
prevents excretion of bilirubin, a yellow-colored pigment that is a
the pancreas. Which structure was compressed by the tumor?
red blood cell breakdown product. The accumulation of bilirubin
in various tissues, including the skin, causes jaundice. A tumor in
the head of the pancreas would not block the other ducts--look at
Netter 276 to see how all the ducts are related.
Duodenum
------------
The superior mesenteric artery crosses over the third part of
the duodenum, and the aorta is posterior to the third part of
The structure that traverses the space between the aorta and first
the duodenum. If something causes these vessels to become
part of the superior mesenteric artery and is vulnerable to the
enlarged, they can crush the duodenum, and the passage of food
nutcracker-like compression by these two vessels is the:
will be obstructed. This is often called the "nutcracker effect," and it
is only seen in the third part of the duodenum. Take a look at Netter
Plate 292 for an illustration of the third part of the duodenum lying
between these important vessels.
Gastroduodenal artery
--------------
The gastroduodenal artery is a branch of the common hepatic
A 60-year-old patient who has had a chronic ulcer of the duode- artery--it passes immediately posterior to the first portion of the
num for many years was admitted to the hospital with signs of duodenum, and it can be damaged if there is an ulcer in this part
a severe internal hemorrhage. The ulcer perforated the posterior ot the duodenum. The cystic artery supplies the gall bladder--it
wall of the first portion of the duodenum and eroded an artery in can be located in the triangle of Calot. The proper hepatic artery
that position. The damaged artery was: is a branch of the common hepatic artery--it travels superior to the
first portion of the duodenum. The left gastric artery is a branch of
the celiac trunk--it supplies the left side of the lesser curvature of
the stomach.

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