OSPE

GASTRONUTRITIONAL BLOCK
 ‫اللهم ال سهل اال ما جعلته سهل وأنت جتعل احلزن اذا شئت سهل‬

Important Points
1. Read the questions carefully.
2. Make sure your write the FULL name of the structures with the
correct spelling.
Example: IVC ✕ Inferior Vena Cava ✓
Thoracic aorta ✕ Descending thoracic aorta ✓
3. There is NO guarantee whether or not the exam will go out of this
file.
Good luck!
 Case 1

Write the relations of the esophagus.

I. Cervical part:
Anteriorly:
1) Trachea
2) Recurrent laryngeal nerves (vagus nerve)

Posteriorly:
1) Vertebral column

Laterally:
1) Lobes of thyroid gland
 Case 1
Write the relations of the esophagus.

II. Thoracic part:

Anteriorly:
1) Trachea
2) Left recurrent laryngeal nerve
3) Left principal bronchus
4) Pericardium
5) Left atrium

Posteriorly:
1) Bodies of the thoracic vertebrae
2) Thoracic duct
3) Azygos vein
4) Right posterior intercostal arteries
5) Descending thoracic aorta (at the lower end)
 Case 1
Write the relations of the esophagus.

II. Thoracic part:

Laterally - Right:
1) Mediastinal pleura
2) Terminal part of the azygos vein.

Laterally - Left:
1) Mediastinal pleura.
2) Left subclavian artery.
3) Aortic arch.
4) Thoracic duct.

III. Abdominal Part

Anteriorly:
1) Left lobe of liver

Posteriorly:
1) Left crus of diaphragm
 Case 2
Write 3 structures passing anteriorly and 3 structures
passing posteriorly to the stomach.

Anteriorly:
1) Anterior abdominal wall.
2) Left pleura & lung.
3) Diaphragm.
4) Left lobe of the liver.
5) Left costal margin.

Posteriorly:
1) Lesser sac
2) Splenic artery
3) Pancreas
4) Transverse mesocolon.
5) Transverse colon.
6) Left crus of diaphragm.
7) Left suprarenal gland.
8) Part of left kidney
9) Spleen
 Case 3
A 55-year- old woman develops a hiatal hernia in which the fundus of the stomach protrudes through the
esophageal hiatus of the diaphragm into the thorax.

I. What is the level of the esophageal opening of the diaphragm?

Thoracic 10.

II. What structure is at great risk of injury during surgical repair in

this case?
Vagus nerve.
More accurate to say: anterior gastric (left vagus) and posterior
gastric (right vagus)

III. Enumerate 2 other structure that pass through the esophageal

opening of the diaphragm?
1) Branches of left gastric vessels.
2) lymph vessels.
 Case 4
A heavy smoker 50-year old man has an upper abdominal pain and heartburn that on and off for several months.
2 weeks ago he vomited dark blood. Gastroscopy examination revealed peptic ulcer.

I. Identify C
A. Cardiac orifice. A
B. Pylorus.
C. Fundus.

II. List 4 arteries supplying the stomach.

1) Left gastric.
2) Right gastric.
3) Left gastroepiploic.
4) Right gastroepiploic.
B
5) Short gastric
 This slide was added by Dr. Jameela

I. Enumerate the structures posterior to the head of

pancreas.
Bile duct and portal vein Level Surface Anatomy
5th Intercostal Stomach fundus
II. What are the arteries supplying the transverse colon & Space
their origin.
Tip of 9th costal Gallbladder Fundus comes in contact with anterior
Superior mesenteric artery (from midgut) and inferior mesenteric cartilage abdominal wall
artery (from hind gut)
T10 (7th Costal Cartilage) - Cardiac orifice
III. What are the sites of the esophageal constrictions?
T12 Pancreas (tail)
1. The first (pharyngo-esophageal) is at the junction with the
pharynx. L1 Transpyloric plane –
2. The second (aortobronchial) is at the crossing with the aortic Stomach pylorus -
Pancreas (head, neck, body)
arch and the left main bronchus. Duodenum 1st part (superior)
3. The third (diaphragmatic) is at the junction with the stomach.
L1  L3 Duodenum 2nd part (descending)
IV. Describe the relations of the spleen.
Anteriorly: Stomach, tail of pancreas, left colic flexure & left kidney L3 Subcostal plane - Duodenum 3rd part (horizontal)
Posteriorly: Diaphragm, that separates it from the left pleura (left L3  L2 Duodenum 4th part (ascending)
costo-diaphragmatic recess), left lung & 9, 10 & 11 ribs.
Inferiorly: left colic flexure
Medially: left kidney
 Case 5
A 57-year-old male brought to the ER where he diagnosed with perforated duodenal ulcer in the posterior wall of the
first part of the duodenum.

I. Which artery lies behind the ulcer in his case?

Gastroduodenal artery 6

II. Enumerate 3 different organs supplied by this artery.

1) Stomach (pylorus)
2) Duodenum
3) Head of pancreas

III. Identify:
1. Accessory pancreatic duct
2. Minor duodenal papilla
3. Major duodenal papilla
4. Hepatopancreatic ampulla
5. Main pancreatic duct
6. Bile duct
 Case 6
A 48-year-old man has lost 10 kilos over the last 3 months and presented with upper abdominal pain that
radiates to the back between the scapulae. During examination the doctor noticed jaundice. CT scan reveals
tumor of the head of the pancreas.

I. List the arterial supply of the pancreas.

1) Superior pancreaticoduodenal artery
2) Inferior pancreaticoduodenal artery
3) Splenic artery
II. Where does the main pancreatic duct open?
Major duodenal papilla in the 2nd part of the duodenum

III. From where do the arteries supplying the pancreas originate?

1. Superior pancreaticoduodenal artery originates from
gastroduodenal branch of hepatic artery of celiac
2. Inferior pancreaticoduodenal artery from superior mesenteric
artery
IV. What is the cause of jaundice in this case?
Posthepatic: the tumor will obstruct the bile duct and block the
flow of bile from the gallbladder to the small intestine
(duodenum)
 Case 7
Write 3 differences between jejunum and ileum.

Jejunum Ileum
Length Shorter (proximal 2/5) of SI Longer (distal 3/5) of SI

Diameter Wider Narrower

Wall Thicker Thinner

(more plicae circulares) (less plicae circulares)
Appearance Dark red (more vascular) Light red (less vascular)

Vessels High & Less arcades (long Low & More arcades (short
terminal branches) terminal branches
Mesenteric Fat Small amount & away from Large amount & close to
intestinal border intestinal border
Lymphoid Tissue Few aggregations Numerous aggregations (Peyer’s
patches)
 Case 8
3
5
4 1
1
6
7
3 5 2
2

Identify:
1. Stomach Identify
2. Spleen 1. Stomach
3. Opening into lesser sac (epiploic foramen) 2. Descending colon
4. Bile duct 3. Gallbladder
5. Hepatic artery 4. Root of mesentery
6. Portal vein 5. Ascending colon
7. Liver 6. Sigmoid colon
7. Teniae coli
 Case 9
A 52 year old man has been feeling unwell, he always feels tired. The doctor noticed that he is jaundiced.
Abdominal examination showed splenomegaly, ascites, caput medusa, and increased abdominal girth.
Investigations revealed chronic liver cell failure.

I. In which abdominal regions lies the liver?

Right and left hypochondrium and epigastrium

II. Enumerate the contents of porta hepatis in order (from anterior to posterior).
From anterior to posterior
1) 2 hepatic ducts
2) 2 hepatic arteries
3) 2 branches of portal vein
4) Autonomic nerve fibers
5) Hepatic lymph nodes

III. From where does the liver receive its blood supply?
Hepatic artery (30%) and portal vein (70%)

IV. Where do the hepatic veins terminate?

In the inferior vena cava.
 Case 10
During cholecystectomy a resident damaged the cystic artery before the clamp was properly placed. The assistant
surgeon applied pressure on top of the free margin of the lesser omentum to stop the bleeding.

I. Which artery runs in the free margin of the lesser

omentum?
Hepatic artery
II. From which artery the cystic artery usually arises?
Right hepatic artery
III. What are the other structures that runs in the free margin
of the lesser omentum?
Common bile duct
Portal vein
Hepatic plexus of nerves
Lymphatics
IV. Enumerate 2 other structures that run in the lesser
omentum along the lesser curvature of the stomach.
1) Right gastric vessels
2) Left gastric vessels
 Case 11
A 52-year-old woman undergoes an open abdominal cholecystectomy. During surgery her doctor inserts his index
finger into the epiploic foramen.

Enumerate the 4 boundaries of the epiploic foramen?

1) Superior: peritoneum caudate process of caudate lobe of liver.
2) Inferior: peritoneum covering 1st part of duodenum and
hepatic artery
3) Anterior: free margin of lesser omentum, hepatic artery,
common bile duct & portal vein.
4) Posterior: Peritoneum covering the inferior vena cava.
 Case 12

I. Identify: 1
1. Transverse colon. 2
2. Left colic (splenic) flexure. 7
3. Teniae coli.
4. Sigmoid or pelvic colon.
5. Appendix.
6. Ascending colon. 6
3
7. Right colic (hepatic) flexure.
8. Epiploic Appendices . 8

II. What is the level of the beginning of the rectum?

S3 (in front of 3rd sacral vertebra).

III. Where does the rectum terminate?

One inch below & in front of tip of coccyx.
4
 Case 13
A 12 year old boy is brought to the ER with a fever, nausea, and abdominal pain. Investigation revealed leucocytosis.
The case is diagnosed as acute appendicitis.

I. Identify the position of the appendix according to the numbers : Teniae coli
1. Retrocecal
2. Subcecal Epiploic
3. Pelvic Appendices
4. Postileal
5. Preileal

II. What is the most common site?

Retrocecal Terminal
ileum
III. What artery will need to be ligated during appendectomy operation?
Appendicular artery

IV. From where does this artery arise?

Ileocolic branch of superior mesenteric artery

V. Describe the surface anatomy of the appendix.

The base of appendix is marked by McBurney’s point: A point at the junction of lateral
1/3 & medial 2/3 of a line traced from right anterior superior iliac spine to umbilicus.
 Case 14
A 46-year-old male brought to ER with hematemesis. Investigation revealed liver cirrhosis and portal hypertension.

I. How the portal vein is formed?

Union of superior mesenteric and splenic veins

II. What structure lies in front of the beginning of the portal vein?
Neck of the pancreas.

III. What structure lies behind the beginning of the portal vein? Portal vein
Inferior vena cava.

IV. What is the cause of bleeding in this case?

Esophageal varices. Splenic vein

Superior
V. List 2 other site of portosystemic anastomosis. mesenteric
1) Upper part of anal canal. vein
2) Paraumbilical region.
Full list:
3) Esophagus
4) intrahepatic
5) retroperitoneal
 Case 15

Identify the structures related to the marked impressions : 7

1. stomach and duodenum
2. esophagus 1
3. gallbladder 2
4. right colic flexure
5. right kidney and right suprarenal gland 5
6
6. lesser omentum 3
7. bare area
4
 Done by:
Jawaher Abanumy Mohammed Ghandour
Nada Aldakheel Mohammed Alyousef
Khalid Aleedan

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References:
anatomyteam436@gmail.com 1- Team 435
2- Greys Anatomy for Students
@anatomy436