AAA

Question 1

Describe the abdominal blood supply?

Answer 1

GIT arterial supply: 3 anterior branches of the abdo aorta

1) Celiac trunk -> foregut (mouth to 2nd part duodenum)
2) Superior mesenteric -> midgut (3rd part duodenum to proximal 2/3 transverse colon)
3) Inferior mesenteric -> hindgut (distal 1/3 transverse colon to anal canal)

Question 2

Describe the celiac trunk?

Answer 2

Location: from abdo aorta at T12
Supplies: foregut (mouth to 2nd part duodenum)
Branches:
• L gastric a -> lesser curvature of stomach
• Splenic a -> spleen, pancreas, also greater curvature of stomach (from L gastroepiploic a and short gastric a.s.)
• Common hepatic a -> hepatic artery proper, R gastric artery and gastroduodenal artery
• Gastroduodenal a -> superior pancreaticoduodenal artery and R gastroepiploic artery

Question 3

Describe the superior mesenteric artery (SMA)?

Answer 3

Location: from abdo aorta at L1 (below celiac trunk)
Supplies: midgut (3rd part duodenum to proximal 2/3 of transverse colon)
Branches:
• Intestinal arteries (jejunal and ileal arteries)
• Inferior pancreaticoduodenal artery
• Ileocolic artery
• R and middle colic arteries

Question 4

Describe the inferior mesenteric artery (IMA)?

Answer 4

Location: arises from abdo aorta at L3
Supplies: hindgut (distal 1/3 transverse colon to anal canal)
Branches:
• L colic a
• Sigmoid arteries 
• Superior rectal artery

Question 5

Describe the arterial supply of the diaphragm?

Answer 5

Superior and inferior phrenic arteries

Superior aspect: thoracic aorta -> superior phrenic arteries (5) -> pericardiophrenic and musculophrenic arteries

Inferior aspect: thoracic aorta -> inferior phrenic arteries

Question 6

Describe the arterial supply of the pancreas?

Answer 6

Superior and inferior pancreaticoduodenal a.s.

Coeliac a. -> superior pancreaticoduodenal a
Superior mesenteric a -> inferior pancreaticoduodenal a

Question 7

Describe the arterial supply of the bile ducts?

Answer 7

• cystic artery

- posterior superior pancreaticoduodenal a

Question 8

Describe the lymphatic drainage of the pancreas?

Answer 8

pancreaticosplenic LNs and pyloric LNs

• > coeliac LNs (included in pre-aortic LNs)
• > cisterni chyli -> thoracic duct

Question 9

Describe the lymphatic drainage of the diaphragm?

Answer 9

Phrenic or parastenal LNs

Question 10

Describe the lymph drainage of the abdomen?

Answer 10

1. Pre-aortic LNs-> intestinal trunks -> cisterna chyli -> thoracic duct
   - Coeliac LNs collect from: gastric, hepatic, pancreatosplenic LNs
   - Superior mesenteric LNs collect from SMA supply
   - Inferior mesenteric LNs collect from IMA supply
2. Para-aortic LNs -> lumbar trunks -> cisterna chyli -> thoracic duct
   - Kidneys, suprarenal glands, abdo ureters
   - Posterior abdo wall
   - Testis, ovary
   - Uterus, fallopian tubes
   - Lower limbs
3. Retro-aortic LNs -> cisterna chyli -> thoracic duct
   - Posterior abdo wall

Question 11

Describe the management of an AAA?

Answer 11

Surgical intervention:

• Evaluation: All symptomatic AAA should be considered, asymptomatic AAA not considered until >5.5cm diameter
• Open repair- aneurysmal segment replaced with Dacron prosthetic graft
• Endocascular repair- stent-graft introduced through femoral a.s.
• Concurrent B-blocker -> reduce BP and HR -> reduce risk of rupture

Ruptured AAA management:
- Clinical triad: abdo/back pain, pulsatile abdo mass, hypotension
Immediate resuscitation:
- A/B- airway management: supplemental O2/ intubation
- C- V access, aggressive fluid replacement, group and hold, arterial line
- D- urinary catheter
- Notify anaesthetics, theatre and ICU

Question 12

List some DDx for severe back pain?

Answer 12

CVS
o	MI
o	Angina
Respiratory
o	Pneumonia- pleuritis
o	PE
o	Lung ca 
o	TB
o	Pneumothorax 
Neoplasia
o	Pancreatic ca
o	Vertebral mets and path #
o	Lung ca
o	Haematological- MM 
GIT
o	GORD 
o	Oesophageal stenosis, spasm, rupture, carcinoma
o	Pancreatitis 
o	PUD
Genitourinary
o	Renal colic 
MSK 
o	Muscular injury
o	Vertebral fracture- osteoporosis, osteolytic lesion
o	Disc prolapse
Infectious- epidural abscess, osteomyelitis