Case 1
A 48-year-old male with a history of alcoholism is brought into the ER with severe epigastric pain and hematemesis. Upon physical examination you find him to be jaundiced and tachycardic with low blood pressure. Other physical findings include spider nevi (hemangiomas) on the cheeks, neck, upper extremities, and torso; ascites; splenomegaly; and tortuous dilated veins radiating from the umbilicus (caput medusae ). The patient also tells you that he often has bloody stools, which prompts you to perform a rectal examination during which you find internal hemorrhoids. After completing your work-up, you correctly make a diagnosis of alcoholic cirrhosis of the liver.
1. Discuss the etiology of the following symptoms considering the anatomy of the portal venous system: hematemesis, caput medusae, internal hemorrhoids.
2. What is the cause of ascites and splenomegaly?
3. Suggest possible treatments for lowering the blood pressure in the portal system.
Case 2
A 42-year-old business executive was admitted to the hospital after visiting the emergency room complaining of severe epigastric pain and pain over her right shoulder. She had a history of gastric ulcer which had been treated previously with medication, but on questioning, she admitted that she had been so busy recently that she had forgotten to refill her prescription and had not taken her medication in some time. As a result of the history and physical findings, the physician suspected that she was suffering from a perforated gastric ulcer. Gastroscopy was performed which confirmed the diagnosis. When the surgeon examined the patient's stomach during the surgery, she found a small perforation on the posterior aspect of the body of the stomach near the lesser curvature. The perforation was repaired and, in addition, a vagotomy was performed. During the vagotomy, the surgeon found it necessary to cut the left gastric artery and ligate it.
1. What structures are at risk for damage by gastric juices if a perforation like the one described above occurs?
2. Why did the patient experience pain over her shoulder as well as in her abdomen?
3. What is a vagotomy and why was it performed?
4. Since the left gastric artery had to be ligated during the surgery, how will the stomach obtain an adequate blood supply?
5. Variations in the arteries of the celiac trunk are quite common, and thus are of particular interest to surgeons working in this area. Suppose the common hepatic artery originated from the left gastric artery in this case (an uncommon, but possible, variation) and the surgeon had to ligate the left gastric artery proximal to the bifurcation. How would this affect blood flow to the stomach? to other organs?
Case 3
A fifty-four year old woman presents to your clinic with complaints of cramping, "colicky" abdominal pain, nausea and vomiting, severe constipation (obstipation), dizziness, and a fever for the past two days. Previous surgical history includes an appendectomy. On physical exam you note that her blood pressure is 75/40, heart rate 130, and her temperature is 102. Her abdomen is distended, and auscultation reveals intermittent high-pitched bowel sounds. On light palpation, peritoneal irritation is demonstrated by the presence of involuntary guarding and rebound tenderness. You order a CBC (complete blood count) which demonstrates a white blood cell count of 14,000. You also order an abdominal X-ray which reveals a small bowel obstruction with dilated small bowel loops (greater than 3 cm in diameter), multiple air-fluid levels within the small bowel and a lack of gas in the distal colon and rectum. The diagnosis of a small bowel obstruction is made, and the patient is sent to surgery for evaluation .
1. The patient had his small bowel resected and anastomosed, what should the surgeon take care?
2. How to distinguish the jejunum and ileum in the operation?
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