1.

Which organ becomes retroperitoneal during rotation of the gut

tube?
Duodenum
Kidney
Spleen
Stomach
Transverse Colon
2. 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
3. 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

4. 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
5. Orally ingested contrast medium opacifies all of the following
structures except the:
colon
duodenum
esophagus
gall bladder
stomach
6. 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
7. 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
8. 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
9. 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
10. 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
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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.
19. 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
20. The inferior mesenteric vein usually joins which vein?
Inferior vena cava
Left renal
Portal
Splenic
Superior mesenteric
21. 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
22. 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
23. 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
24. 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


1. The correct answer is: 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.

2. he 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.

3. 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)

4. 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.

5. The correct answer is: gallbladder
The orally ingested contrast medium would coat all the structures of the
gut tube, including the esophagus, stomach, duodenum, 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.


11. 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.

12. 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.

13. 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.


14. 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!

15. 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.

16. 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.


17. 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.

18. The correct answer is: It is thin walled and circular folds are
absent in its interior
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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.