U Michigan Written Quiz: Stomach and Spleen

While performing emergency surgery to control hemorrhage brought on by

arterial erosion caused by a duodenal ulcer, surgeons ligated the badly
damaged gastroduodenal artery near its origin, which affected all of its
branches as well. Assuming "average anatomy", in which of the following
arteries would blood now flow in retrograde fashion (backwards) from
collateral sources?
Left hepatic
Right gastroepiploic
Short gastric
Left gastric
Omental branches

The correct answer is:

right gastroepiploic
If the gastroduodenal artery and its branches were ligated, blood would
flow in a retrograde direction from the left gastroepiploic artery, which is a
branch of the splenic artery, to the right gastroepiploic artery, a ligated branch
of the gastroduodenal artery. This flow from the left to right gastroepiploic
artery would allow blood to reach the entire greater curvature of the stomach.
Remember--there are many anastomoses around the stomach that will allow
this organ to receive blood even if one branch is ligated.
The left hepatic artery is a branch of the proper hepatic artery; it supplies
blood to the left and quadrate lobes of the liver, as well as part of the caudate
lobe. The short gastric arteries are branches of the splenic artery which
supply the fundus of the stomach. The left gastric artery is a branch of the
celiac trunk which supplies the left portion of the lesser curvature. Omental
branches are branches of the left and right gastroomental arteries which
supply the greater omentum.

During an emergency splenectomy, the surgeon accidentally tore the

gastrosplenic ligament and its contents. The artery (ies) likely to be damaged
in this event is (are) the:

Left gastric
Splenic
Short gastric
Middle colic
Caudal pancreatic

The correct answer is:

Short gastric
The short gastric arteries branch from the splenic artery near the hilum
of the spleen. They travel in the gastrosplenic ligament to supply the fundus of
the stomach. So, these arteries might be damaged if the gastrosplenic
ligament was disrupted. The left gastric artery is a branch of the celiac trunk
which supplies the left half of the lesser curvature. The splenic artery travels
deep to the stomach to reach the hilum of the spleen. Although its branches
travel in the gastrosplenic ligament, the splenic artery passes within the
splenorenal ligament to reach the splenic hilum, and it would not be damaged
by an incision in gastrosplenic ligament. The middle colic artery is a branch of
the superior mesenteric artery which supplies the transverse colon. The
caudal pancreatic artery is a branch of the splenic artery which supplies the
tail of the pancreas. It, along with most of the pancreas, is retroperitoneal.
The fundus of the stomach receives its arterial supply from the:
Common hepatic
Inferior phrenic
Left gastroepiploic
Right gastric
Splenic
The correct answer is:

Splenic

As it enters the hilum of the spleen, the splenic artery gives off short
gastric arteries which supply blood to the fundus of the stomach. These short
gastric arteries travel in the gastrosplenic ligament to reach the fundus. The
common hepatic artery does not directly supply the stomach--it gives off the
gastroduodenal artery, which supplies the right portion of the greater
curvature of the stomach with the right gastro-omental artery. The inferior
phrenic artery is a branch of the aorta which supplies blood to the diaphragm.
The left gastro-omental artery is a branch of the splenic artery which supplies
the left half of the greater curvature. The right gastric artery is a branch of the
proper hepatic artery which supplies the right half of the lesser curvature. See
Netter Plate 290 to get a good picture of these arteries and their areas of
distribution.

Which of the following is NOT in contact with the spleen?

Colon
Diaphragm
Duodenum
Pancreas
Stomach

The correct answer is:

Duodenum
The duodenum is not in contact with the spleen. The inferior portion of
the spleen contacts the left colic flexure. The superior portion of the spleen
contacts the diaphragm--the spleen is convexly curved to fit the concavity of
the diaphragm. The tail of the pancreas inserts into the hilum of the spleen.
The stomach contacts the anteriomedial portion of the spleen. You should
really know what organs contact the spleen and where these organs contact
the spleen!

In order to approach the area posterior to the stomach, a surgeon decided to

go through the lesser omentum. Before incising the mesentery she was
careful to find and preserve a nerve lying in the upper portion of the
hepatogastric ligament, i.e., the
Celiac branch of the anterior vagal trunk
Celiac branch of the posterior vagal trunk
Greater splanchnic branch to the right suprarenal gland
Hepatic branch of the anterior vagal trunk
Hepatic branch of the posterior vagal trunk

The correct answer is:

Hepatic branch of the anterior vagal trunk
The hepatic branch of the anterior vagal trunk travels in the upper portion
of the hepatogastric ligament. The posterior vagal trunk supplies a celiac
branch deep to the hepatogastric ligament. The greater thoracic splanchnic
branches to the suprarenal glands come off the greater thoracic splanchnic
nerves as they pass through the diaphragm. Then, the greater thoracic
splanchnic nerves continue on to synapse in the celiac ganglia.

During emergency surgery, it was found that a chronic gastric ulcer had
perforated the posterior wall of the stomach and eroded a large artery running
immediately posterior to the stomach. The artery is the:
Gastroduodenal
Common hepatic
Left gastroepiploic
Splenic
Superior mesenteric

The correct answer is:

Splenic
Netter Plate 288 will help you to understand this answer. The splenic
artery is a branch of the celiac trunk. It passes deep to the stomach and
sends branches to the pancreas before reaching the spleen. If the posterior
wall of the stomach eroded, gastric juices could damage the splenic artery.
The gastroduodenal artery lies behind the first portion of the duodenum. An
ulcer in this portion of the duodenum might jeopardize the gastroduodenal
artery. The common hepatic artery is a branch of the celiac trunk which runs
superior to the lesser curvature of the stomach. The left gastroepiploic artery
runs on the left side of the greater curvature of the stomach. Finally, the
superior mesenteric artery arises from the aorta at the L1 level, posterior to
the pancreas. It crosses over the third portion of the duodenum.

Which ligament is a derivative of the dorsal mesogastrium?

Coronary
Falciform
Hepatoduodenal
Hepatogastric
Gastrocolic

The correct answer is:

Gastrocolic
Structures involving the spleen and posterior part of the developing
stomach (which becomes the greater curvature) are derived from the dorsal
mesogastrium. This includes the gastrocolic ligament (including the omental
apron), gastrophrenic ligament, gastrosplenic ligament, and the splenorenal
ligament. The liver develops in the ventral mesogastrium. This means that any
structures involving the liver and its attachment to the lesser curvature of the
stomach or the body wall will be derivatives of the ventral mesogastrium. This
includes the coronary ligament, the falciform ligament, the left and right
triangular ligaments, the hepatogastric ligament, and the hepatoduodenal
ligament.

Which of the following structures does not lie at least partially in the
retroperitoneum?
adrenal gland
duodenum
kidney
pancreas
spleen

The correct answer is:

spleen
The spleen is the only organ listed which is covered entirely by visceral
peritoneum. About the other organs... The kidney and suprarenal glands are
retroperitoneal organs. This is different than the secondarily retroperitoneal
organs that started out in a mesentery and then got pushed against the
posterior wall. The kidneys and the suprarenal glands began developing in the
retroperitoneum and stayed there. The duodenum and pancreas are partially
peritonealized and partially retroperitoneal. The first two centimeters of the
superior duodenum is peritonealized, but the rest of the duodenum, until the
duodenojejunal junction, is retroperitoneal. For the most part, the pancreas is
secondarily retroperitoneal, although the tail of the pancreas is peritonealized,
lying within the splenorenal ligament.

The spleen:
Develops in the dorsal mesogastrium
Develops in the ventral mesogastrium
Develops in both the dorsal and ventral mesogastria
Is always retroperitoneal
Becomes retroperitoneal during its development

The correct answer is:

develops in the dorsal mesogastrum
The spleen and pancreas develop behind the stomach in the dorsal
mesogastrium; the liver develops in the ventral mesogastrium. The spleen is
not a retroperitoneal organ--it is covered by visceral peritoneum on all its
surfaces.

Which is a derivative of the dorsal mesogastrium?

Falciform ligament
Hepatoduodenal ligament
Hepatogastric ligament
Greater omentum
Lesser omentum

The correct answer is:

greater omentum
During the development of the gut, there are two mesogastria attaching
to the developing stomach: the dorsal mesogastrium and the ventral
mesogastrium. Different organs begin to develop in each mesogastrium--the
spleen and pancreas develop in the dorsal mesogastrium and the liver
develops in the ventral mesogastrium. So, the structures involving the spleen
and the posterior part of the developing stomach (which becomes the greater
curvature) are derived from the dorsal mesogastrium. These include: the
greater omentum (gastrophrenic ligament, gastrosplenic ligament, gastrocolic
ligament) and splenorenal ligament. The structures involved with the liver and
its attachment to the stomach wall form the ventral mesogastrium. These
include the lesser omentum (hepatogastric ligament, hepatoduodenal
ligament) and the ligaments of the liver (falciform ligament, coronary
ligaments, right and left triangular ligaments). Of the answer choices, only the
greater omentum is part of the dorsal mesogastrium.
In order to do a vagotomy (section of vagal nerve trunks) to reduce the
secretion of acid by cells of the stomach mucosa in patients with peptic ulcers,
one needs to cut the gastric branches and retain vagal innervation to other

abdominal organs. Where would a surgeon look for these branches in relation
to the stomach?
along the gastroepiploic vessels
along the greater curvature
along the lesser curvature
in the base of the omental apron
in the gastrocolic ligament
The correct answer is:
along the lesser curvature
The vagal branches to the stomach are found on the lesser curvature.
The anterior vagal branches are derived from the left vagal nerve and the
posterior vagal branches are derived from the right vagal nerve. This makes
sense, since during the rotation of the gut, the left side of the stomach rotated
to become the ventral aspect of the stomach. Vagotomies are done to reduce
the acid secretion of the stomach, since the vagus sends one of the signals
that stimulates the parietal cells of the stomach to release HCl.
RIGHT
While performing a splenectomy (removal of the spleen) following an
automobile accident, the surgeons were especially attentive to locate and
preserve the tail of the pancreas which is closely associated with the spleen.
This they found in the:
gastrocolic ligament
gastrosplenic ligament
phrenicocolic ligament
splenorenal ligament
transverse mesocolon

The correct answer is:

splenorenal ligament

The splenorenal ligament is the peritoneal structure that connects the

spleen to the posterior abdominal wall over the left kidney. It also contains the
tail of the pancreas. The gastrocolic ligament connects the greater curvature
of the stomach with the transverse colon. The gastrosplenic ligament
connects the greater curvature of the stomach with the hilum of the spleen.
The phrenicolic ligament connects the splenic flexure of the colon to the
diaphragm. Finally, the transverse mesocolon connects the transverse colon
to the posterior abdominal wall.
During a full workup on a 2-month-old infant with a history of intermittent
gastrointestinal pain and vomiting, physicians discovered that the cause was
lack of emptying of the stomach. They immediately suspected that the cause
was a spasmodic contraction of which of the following parts of the stomach?
cardiac notch
fundus
lesser curvature
pylorus
rugae

The correct answer is:

pylorus
Pyloric stenosis is a congenital disorder in which the pylorus is thickened
causing obstruction of the gastric outlet to the duodenum. This problem is
more commonly seen in males. Symptoms like projectile vomiting appear
several weeks after birth.

A patient was diagnosed with bleeding ulcer of the lesser curvature of the
stomach. Which artery is most likely involved?
Gastroduodenal
Left gastric
Left gastro-omental (epiploic)

Right gastro-omental (epiploic)

Short gastrics

The correct answer is:

left gastric
The left gastric artery is the artery that supplies the lesser curvature of
the stomach (along with the right gastric artery.) These two arteries would be
most likely to cause bleeding at the lesser curvature of the stomach. The left
gastric is one of the three arteries that comes off of the celiac trunk. The left
and right gastro-omental arteries are the two arteries that supply the greater
curvature of the stomach. The gastroduodenal artery is a branch off the
common hepatic artery that supplies the duodenum, head of the pancreas,
and the greater curvature of the stomach. The short gastric arteries are 4 or 5
small arteries from the splenic artery that supply the fundus of the stomach.
A 60-year-old male executive who had a history of a chronic duodenal ulcer
was admitted to the ER exhibiting signs of a severe internal hemorrhage. He
was quickly diagnosed with perforation of the posterior wall of the first part of
the duodenum and erosion of an artery behind it by the gastric expellent. The
artery is most likely the:
Common hepatic
Gastroduodenal
Left gastric
Proper hepatic
Superior mesenteric

The correct answer is:

Gastroduodenal
For a good understanding of this question, take a look at Netter Plate
290. The gastroduodenal artery is a branch of the common hepatic artery; it
descends behind the first part of the duodenum. So, if an ulcer destroyed the
posterior wall of the duodenum, gastric juices could escape and destroy the
gastroduodenal artery. The common hepatic artery is a branch of the celiac

trunk found superior to the duodenum. The left gastric artery is a branch of the
celiac trunk which supplies the left side of the lesser curvature of the stomach.
The proper hepatic artery is a branch of the common hepatic artery; it travels
superiorly from the common hepatic artery to give off the right, middle, and left
hepatic arteries. Finally, the superior mesenteric artery originates from the
aorta at the bottom of the L1 level, posterior to the pancreas. It travels over the
3rd part of the duodenum and supplies the intestines, up to the last third of the
transverse colon.
A twenty-year-old woman was broad-sided on the driver side by an SUV and
was taken to the hospital emergency room. Examination showed low blood
pressure and tenderness on the left mid-axillary line. Also, a large swelling
was felt protruding downward and medially below the left costal margin. X-rays
revealed that her 9th and 10th ribs were fractured near their angles on the left
side. The abdominal organ most likely to be injured by the fracture is:
Descending colon
Left kidney
Pancreas
Spleen
Stomach

The correct answer is:

Spleen
The spleen is usually well protected by the 9th through 12th ribs on the
left side. But, if one or more of these ribs gets fractured, the spleen is the first
organ to be ruptured. The spleen can also be damaged if there is blunt trauma
to the abdomen or a sudden increase in intraabdominal pressure. This patient
has several symptoms of a ruptured spleen--she has tenderness on the left
posterior axillary line and hypotension. (Because of its spongy parenchyma
and thin capsule, a ruptured spleen will bleed profusely and a patient may
become hypotensive.) The stomach, splenic flexure of the colon, tail of the
pancreas, left kidney, and suprarenal gland are in the same quadrant of the
abdomen, and they are also at risk for injury. But, you should remember that
the spleen is at greatest risk because of its close relationship with the 9th
through 12th ribs.

You are observing an operation to remove the left suprarenal gland. To

expose the gland the surgeon mobilizes the descending colon by cutting along
its lateral attachment to the body wall and dissecting medialward in the fusion
fascia behind it. Suddenly the operative field is filled with blood. The surgeon
realizes he has failed to cut a mesenteric attachment between the left colic
flexure and another organ. As a result of the traction, the surface of the organ
tore. Which organ was injured?
Duodenum
Kidney
Liver
Spleen
Suprarenal gland

The correct answer is:

Spleen
The spleen is a peritonealized organ that is attached to the left colic
flexure. It could tear if there was too much traction while pulling the
descending colon away from the body wall. Another clue in this scenario that
points to a ruptured spleen is the large amount of blood that fills the operative
field. The spleen is covered by a very thin capsule, and it has a soft and pulpy
parenchyma. So, when it is ruptured, the spleen bleeds profusely. The
duodenum and liver are not associated with the left colic flexure. The kidney
and suprarenal glands are retroperitoneal organs that are not associated with
any mesenteric attachment.

A patient presented with a swollen spleen, which protruded medially toward

the umbilicus in the abdomen. A vertical and downward expansion of the
spleen was resisted by the:
Tail of the pancreas
Left colic flexure
Left kidney

Left renal artery

Stomach

The correct answer is:

Left colic flexure
The left colic flexure, also called the splenic flexure, is the point where
the colon takes a sharp downward turn. This flexure is the point where the
transverse colon ends and the descending colon begins. It is located
immediately inferior to the spleen, so an enlarged spleen must move medially
to avoid this colic flexure. The stomach lies medial to the speen, and the tail of
the pancreas inserts into the hilum of the spleen. These organs would not
prevent the spleen from descending inferiorly. The kidney and left renal artery
are retroperitoneal organs; they would not obstruct movement of the spleen.
The spleen contacts all of the following organs EXCEPT:
Jejunum
Kidney
Left colic flexure
Tail of the pancreas
Stomach

The correct answer is:

jejunum
The spleen is not in contact with the jejunum. The jejunum lies medial
and inferior to the spleen. The kidney is in contact with the posteromedial
surface of the spleen. The left colic flexure is in contact with the inferomedial
surface of the spleen. The tail of the pancreas touches the hilum of the
spleen. The stomach is in contact with the anteromedial surface of the spleen.
See Netter Plate 289 for a picture of the different impressions on the spleen.
Which is not a boundary of the epiploic (omental) foramen?
Aorta

Caudate lobe of the liver

First part of the duodenum
Hepatoduodenal ligament

The correct answer is:

Aorta
The epiploic (omental) foramen is a passageway between the greater
peritoneal sac and the lesser peritoneal sac. It is located posterior to the
hepatoduodenal ligament and the first part of the duodenum. The caudate
lobe of the liver forms the posterior wall of the epiploic foramen. The aorta is
retroperiteoneal, and it does not form a boundary of this foramen.