Umich Written Quiz Duodenum, Pancreas, Liver, and Gallbladder

The structure that traverses the space between the aorta and first part of the
superior mesenteric artery and is vulnerable to the nutcracker-like
compression by these two vessels is the:
Duodenum
Jejunum
Pancreas
Splenic vein
Transverse colon

The correct answer is:

Duodenum

The superior mesenteric artery crosses over the third part of the
duodenum, and the aorta is posterior to the third part of the duodenum. If
something causes these vessels to become enlarged, they can crush the
duodenum, and the passage of food 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.

A patient with jaundice was diagnosed with cancer of the head of the
pancreas. Which structure was compressed by the tumor?
Common bile duct
Common hepatic duct
Cystic duct
Left hepatic duct
Right hepatic duct

The correct answer is:

Common bile duct

Tumors in the head of the pancreas often obstruct the common bile duct,
blocking the normal bile recycling circuit. This blockade prevents excretion of
bilirubin, a yellow-colored pigment that is a 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.

A surgeon needs to construct a bypass between the veins of the portal and
caval systems to circumvent insufficient drainage through the natural
portacaval anastomoses. Which plan is likely to be successful?
Coronary vein to right gastroepiploic vein
Inferior mesenteric vein to splenic vein
Left colic vein to middle colic vein
Splenic vein to left renal vein
Superior mesenteric vein to splenic vein

The correct answer is:

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 the portal hypertension. The
coronary vein, right gastroepiploic 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.

A patient was diagnosed with pancreatitis due to a reflux of bile into the
pancreatic duct caused by a gallstone. The stone is likely to be lodged at the:
Common bile duct
Common hepatic duct
Cystic duct
Hepatopancreatic ampulla

The correct answer is:

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 ampulla in the wall of the
duodenum, the bile and pancreatic enzymes are emptied into the second
portion of the duodenum, 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.

An ulcer near the pyloroduodenal junction perforated and eroded a large

artery immediately posterior to the duodenum. The ligation of the eroded
vessel at its origin would LEAST affect the arterial supply to the:
First part of the duodenum
Second part of the duodenum
Greater curvature of the stomach
Head of the pancreas
Tail of the pancreas

The correct answer is:

Tail of the pancreas

The gastroduodenal artery is the artery that has ruptured. This artery
gives off the anterior and posterior superior pancreatoduodenal arteries, which
supply the first and second parts of the duodenum, as well as the head of the
pancreas. The gastroduodenal artery also gives off the right gastroomental
artery, which supplies the right half of the greater curvature of the stomach. In
contrast, 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.

A radiological examination of a patient revealed a large tumor in the quadrate

lobe of the liver. During the surgical removal of the tumor, one of the vessels
that needs to be clamped to effectively control bleeding is the:
Left hepatic artery
Right hepatic artery

The correct answer is:

Left hepatic artery

The left and right hepatic arteries help support the parenchyma and
stroma of the liver. The left hepatic artery supplies the left & quadrate lobes of
liver, and part of the caudate lobe. The right 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.

A 58-year-old patient was diagnosed with a severe case of portal hypertension

due to alcoholic cirrhosis of the liver. It was determined that a bypass between
the vessels of the portal and caval systems was necessary. The plan most
likely to be successful is:
Coronary vein to right gastro-omental vein
Left colic vein to sigmoidal vein

Inferior mesenteric vein to splenic vein

Splenic vein to left renal vein
Superior rectal vein to inferior rectal vein

The correct answer is:

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 the portal hypertension. The
coronary vein, right gastro-omental vein, left colic vein, sigmoidal vein, inferior
mesenteric vein, and splenic vein are all part of the portal system. Any
bypasses among these veins will not relieve the portal hypertension. The
superior and inferior rectal veins already form a portal-caval anastomosis;
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.

Upon endoscopic examination of a 65-year-old man who had a history of a

chronic duodenal ulcer, it was found that the ulcer had been eroding the
posterior wall of the first part of the duodenum. If erosion perforates the wall,
the gastric expellant of high acidity would endanger the structures in its
vicinity. Which is least likely to be endangered?
Common bile duct
Gastroduodenal artery
Main pancreatic duct
Portal vein

The correct answer is:

Main pancreatic duct

The pancreas is inferior to the superior portion of the duodenum, and the
main pancreatic duct is found deep within the pancreas. It is not likely that this
structure would be damaged by the duodenal ulcer. The portal vein,
gastroduodenal artery, and the common bile duct all pass immediately deep to
the first part of the duodenum. (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.

You are observing a laparoscopic cholecystectomy. The surgeon states that

he is next going to expose the cystic artery in order to staple across it. He
asks you where he should look for it. You reply, "In the triangle of Calot." What
stuctures form this triangle and are the keys to finding the artery?
Common hepatic duct, liver and cystic duct
Cystic duct, right hepatic artery and right hepatic duct
Gall bladder, liver and common bile duct
Left hepatic duct, liver and cystic duct
Right branch of portal vein, liver and common bile duct

The correct answer is:

Common hepatic duct, liver and cystic duct

The triangle of Calot is formed by the cystic duct laterally, the liver
superiorly, and the common hepatic duct medially. It is an important landmark
in this region, because the cystic artery can be found in the triangle of Calot.
During a cholecystectomy, the cystic artery needs to be ligated. Although the
cystic artery usually branches from the right hepatic artery, there is some
variation. However, if you locate the triangle of Calot, you can find the cystic
artery in that triangle, trace it back to its origin, and then ligate it there.

A medical student was asked to identify a small specimen taken for

pathological examination from a surgically removed duodenum. The student

noted that the specimen revealed a thin wall and no circular folds. The
specimen is from which segment?
Superior
Descending
Horizontal
Ascending

The correct answer is:

Superior

The superior part of the duodenum is the one segment of the duodenum
that has no circular folds. When food enters the duodenum from the pyloric
sphincter, it enters the ampulla, which is a smooth area of the duodenum
containing a high percentage of mucosal cells. These cells secrete mucus to
neutralize the acidic contents of the stomach. If the stomach contents is not
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.

A patient was admitted with symptoms of bowel obstruction. Further

examination revealed that the obstruction was caused by the nutcracker-like
compression of the bowel between the superior mesenteric artery and the
aorta. The compressed bowel is most likely the:
Duodenum
Jejunum
Ileum

Ascending colon
Transverse colon

The correct answer is:

Duodenum

The superior mesenteric artery crosses over the third part of the
duodenum, and the aorta is posterior to the third part of the duodenum. If
something causes these vessels to become enlarged, they can crush the
duodenum, and food will not be able to pass through the duodenum. 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.

The division between the true right and left lobes (internal lobes) of the liver
may be visualized on the outside of the liver as a plane passing through the:
gallbladder fossa and round ligament of liver
falciform ligament and ligamentum venosum
gallbladder fossa and inferior vena cava
falciform ligament and right hepatic vein
gallbladder fossa and right triangular ligament

The correct answer is:

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 anatomical terminology, which separated the
liver into the left, right, quadrate and caudate lobes. These traditional lobes
were based on anatomical appearance, while the functional lobes are based
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.
During a cholecystectomy (removal of the gall bladder), the surgical
resident accidentally jabbed a sharp instrument into the area
immediately posterior to the epiploic foramen (its posterior boundary).
He was horrified to see the surgical field immediately fill with blood, the
source which he knew was the:
aorta
inferior vena cava
portal vein
right renal artery
superior mesenteric vein

The correct answer is:

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 this is the vessel that was
probably cut. The aorta lies next the inferior vena cava, but it is a little more to
the left and a little deeper--it does not lie immediately posterior to the epiploic
foramen. The hepatic portal vein is anterior to the epiploic foramen. 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)

RIGHT
A patient was admitted with symptoms of an upper bowel obstruction. Upon
CT examination, it was found that the third (transverse) portion of the
duodenum was compressed by a large vessel causing the obstruction. The

vessel involved is most likely to be the:

inferior mesenteric artery
superior mesenteric artery
inferior mesenteric vein
portal vein
splenic vein

The correct answer is:

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 the duodenum. If
something causes these vessels to become enlarged, they can crush the
duodenum, and food won't be able to pass through the duodenum. 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. You should know
what structures are involved in the "nutcracker effect" and how they are
causing an upper bowel obstruction!

A 40 year-old male with a long history of duodenal ulcer problems was

brought in for emergency surgery to control severe hemorrhage into the
peritoneal cavity. The surgeons found that erosion by the ulcer of a vessel
passing behind the first part of the duodenum was the source of the
hemorrhage. Which of the following vessels passes behind the first part of the
duodenum and would need to be clamped off to control the bleeding?
coronary vein
gastroduodenal artery
inferior pancreatoduodenal arcade

proper hepatic artery

splenic vein

The correct answer is:

gastroduodenal artery

The gastroduodenal artery lies behind the superior part of the

duodenum. It has three branches: the posterior superior pancreaticoduodenal
artery, the anterior superior pancreaticoduodenal artery, and the right
gastroomental artery. The other vessels are not near the superior duodenum.
The coronary vein is made of the right and left gastric veins and located in the
lesser curvature of the stomach. The inferior pancreatoduodenal arcade is
found in the inferior part of the head of the pancreas. It supplies the 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.

Which organ becomes retroperitoneal during rotation of the gut tube?

Duodenum
Kidney
Spleen
Stomach
Transverse Colon
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 is a secondarily retroperitoneal organ

- it used to have a mesentery, 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.
To stop hemorrhaging from a ruptured spleen, it was necessary to temporarily
ligate the splenic artery near the celiac trunk. The blood supply to which
structure is least likely to be affected by the ligation?
Duodenum
Greater omentum
Body of pancreas
Tail of pancreas
Stomach

The correct answer is:

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 artery, but it is not receiving any blood from the splenic
artery.
The splenic artery supplies blood to the body of the pancreas 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.

A 50-year-old female patient with severe jaundice was diagnosed with

pancreatic cancer. You suspect that the tumor is located in which portion of
the pancreas?
Head
Neck
Body
Tail
Uncinate process

The correct answer is:

Head

Tumors in the head of the pancreas often obstruct the common bile duct,
blocking the normal bile recycling circuit. This blockade prevents excretion of
bilirubin, a yellow-colored pigment that is a 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.
A Kocher manuever dissects in the avascular plane behind which organ that
becomes retroperitoneal during rotation of the gut?
Duodenum
Kidney
Spleen
Suprarenal gland
Transverse colon

The correct answer is:

Duodenum

A Kocher maneuver involves reflecting the duodenum and pancreas

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 you didn't know the exact definition of a
Kocher maneuver, you 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.

The inferior mesenteric vein usually joins which vein?

Inferior vena cava
Left renal
Portal
Splenic
Superior mesenteric

The correct answer is:

Splenic

The inferior mesenteric vein usually empties into the splenic vein. The
splenic vein and the superior mesenteric vein then unite to 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.

The blockage of a main bile duct in the quadrate lobe will likely cause reduced
flow of bile secretion in the:

Left hepatic duct

Right hepatic duct

The correct answer is:

Left hepatic duct

Like the left hepatic vein, the left hepatic duct drains bile from the left
lobe, quadrate lobe, and part of the caudate lobe of 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.
Regarding the 2nd portion of the duodenum, all are correct EXCEPT:
It is crossed by the transverse colon.
It is thin walled and circular folds are absent in its interior.
It has the opening for the common bile duct and pancreatic duct on its
posteromedial wall.
It is secondarily retroperitoneal.
It is supplied by both the gastroduodenal and superior mesenteric
arteries.

The correct answer is:

interior

It is thin walled and circular folds are absent in its

The first part of the duodenum features thin walls and no circular folds. It
is called the ampulla of the duodenum. Once the duodenum turns and
becomes the second part, the walls become thicker, and circular folds
develop. The second part of the duodenum has the hepatopancreatic ampulla
in its medial wall, which is the duct formed as the common bile duct and
pancreatic 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.

A 60-year-old patient who has had a chronic ulcer of the duodenum for many
years was admitted to the hospital with signs of a severe internal hemorrhage.
The ulcer perforated the posterior wall of the first portion of the duodenum and
eroded an artery in that position. The damaged artery was:
Cystic
Gastroduodenal
Hepatic
Left gastric

The correct answer is:

Gastroduodenal

The gastroduodenal artery is a branch of the common hepatic artery--it

passes immediately posterior to the first portion of the duodenum, and it can
be damaged if there is an ulcer in this part ot the duodenum. The cystic artery
supplies the gall bladder--it can be located in the triangle of Calot. The proper
hepatic artery 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.