Block 2 – Clinical Correlates
Clinical Correlate Explanation
Ascites Effusion of peritoneal cavity with ascitic fluid
Peritonitis Inflammation of peritoneal cavity
Scar tissue that connects parietal and visceral
Right lateral paracolic gutter
Drains fluid above intestine from the liver to
Lowest point of peritoneal cavity when patient
is lying down (fluid can collect here)
Lesions of the stomach wall that break and
cause contents of stomach to spill into omental
bursa (lesser sac) and cause peritonitis and
severe hemorrhaging due to erosion of splenic
artery by gastric fluid.
Acute inflammation of appendicitis caused
when stuff gets stuck in it. Will present with
high rebound tenderness
Vagotomy Surgical section of the vagus n.
Inflamed/injured pancreas resulting in
pancreatic fluid in the omental bursa
Severe pain from visceral afferents are
perceived as pain from somatic afferents at the
same level since they have cell bodies in the
same dorsal root ganglion. Pain or discomfort
is perceived as an “ache” and can be difficult
to localize until it becomes severe.
Accessory pancreatic duct
May exist superiorly to the main pancreatic
duct and enter duodenum at the minor
duodenal papilla if the remnant of the duct
from the dorsal pancreatic bud was not
obliterated. Found in 56% of population
Commonly injured spleen
“Ruptured spleen” – caused by thin capsule
and overlying peritoneum bursting and
disrupting parenchyma or pulp of spleen.
“Intraperitoneal hemorrhage” – profuse
bleeding of spleen that can be caused by
*Most likely to be injured by ribs 9-11.
Common in females over 40, obese, and fertile.
High in cholesterol content.
Pain from attack involves gallstone lodged in
bile duct. Pain can be referred to epigastric
region, infrascapular region on right side in the
back, and on top of shoulder (C3, 4) due to
nerve supply by phrenic and periphery nn.
Arises from blockage in drainage of blood
from sinusoids in liver to inferior vena cava,
forcing blood to take alternate routes to heart.
Common in alcoholics because of liver
Varicose veins around umbilical. Liver cells
are dying and there are lots of connective tissue
there. Portal v. takes other routes to try and get
to the vena cava (traveling via anastomose
between paraumbilical v. of portal system and
cutaneous vv. of abdominal wall (superficial
epigastric vv.) of the systemic system.
Will have blood in feces due to anastomose of
superior rectal v. of portal system and
middle/inferior rectal vv. of systemic system.
Esophageal anastomose for portal system
If patient vomits, bleeding will occur and will
kill them because it will be hard to stop the
Congenital diaphragmatic hernia
Caused by failure of pleuroperitoneal folds to
fuse and close the pericardioperitoneal canals.
More common on the left side because the liver
is not in the way.
Caused by abnormal separation between the
respiratory and esophageal diverticula. Most
common form is when posterior end of foregut
fuses with the trachea, causing air to enter the
stomach. Commonly associated with atresia of
the esophagus (blind-ended pouch of
Caused when ventral pancreas splits, enclosing
part of the duodenum and obstructing it.
Gut doesn’t retract back into the body after
forming in the umbilical cord
Malrotation of the gut
Duodenum could end up in front of the
transverse colon, inhibiting peristalsis.
Remnant of vitelline duct persists connecting a
portion of ileum that sticks out (diverticulum)
and is connected to anterior abdominal wall.
Cyst of ileum
A cyst could form where a part of gut was
closed off on either side of the vitelline duct.
Continuation of gut into umbilical cord
The gut is still continuous with umbilical cord
and could cause feces to spew into it.
Failure of the kidney to ascend and could be
misdiagnosed as a tumor of the pelvis which
may interfere with pregnancy.
During ascent, kidneys get too close to each
other and the lower poles fuse anteriorly to the
aorta, usually around the inferior mesenteric
artery. Can cause problems if there is an
aneurysm behind it.
Height of kidneys
Right kidney is usually lower than the left one
due to the liver.
Bifid ureter 2 ureters coming out of one kidney.
Ureteric calculi (kidney stones)
Can get lodged in one of the three ureteric
constrictions. Cause sharp, stabbing pain which
travels inferioanteriorly from loin (back) to
groin and is referred to spinal cord segments
T12 – L2 due to the marked distention of the
muscular wall of the ureter.
Referred visceral pain of Diaphragm Referred to dermatomes C3,4,5 (phrenic n)
Referred pain of heart C8-T5
Referred pain of stomach Dermatomes T6-T9
Allows for expansion of the bladder and access
to bladder and prostate without entering the
Rectal polyps Usually form at curves of rectum.
External hemorrhoids can be seen on the
outside. Result from varicosities in the veins of
the rectum and anal canal (see above
Lateral fornix of uterus
Can feel uterine artery at this location to
determine blood flow.
Enlargement of the prostate
Common during the aging process. Can
interfere with the micturation (urination) due to
constriction of the urethra.
Ectopic tubal pregnancy
Occurs in about 1/250 pregnancies. Most
common in women who have had damage to
their uterine tubes.
Importance of Rectal exams
Essential since you can feel the prostate and
seminal vesicles of males and the cervix of
Maintenance of perineal body
After parturition and operative procedures, it’s
important to properly rebuild the perineal body
to maintain its proper anatomical and
physiological functions of support to the pelvic
diaphragm and to aid in muscular contraction.
Bleeding of superficial perineal pouch
May occur during parturition when the
vascular vestibular bulbs tear from sustained
pressure (due to location on either side of
vagina) by the fetus or secondary to other
Extent and attachment of Colle’s fascia
Is of clinical importance in males because this
can help determine the spread of urine which
may leak from a rupture of the penile urethra.
Could go into the superficial perineal pouch
following trauma to the perineum that ruptures
the portion of the urethra lying below the UG
diaphragm. Urine can fill the superficial
perineal space and pass ventrally to the
scrotum, penis, and spermatic cords, as well as
ascend to the lower abdomen where it would
lie deep to Scarpa’s fascia.
Fistulae and Painful abscesses of anal glands
Caused by obstruction and infection of the
glands found within anal sinuses.
Incontinence of feces
Can result due to damage to external anal
sphincter, puborectalis m., and internal anal
sphincter either surgically or in childbirth.
Enlarged or painful medial superficial
Since lymphatic vessels from upper anal canal
drain into preaortic nodes (the internal and
common iliac nodes), if nodes in this region
are painful or enlarged, a prompt rectal
examination should occur.
Abscesses in ischiorectal and pararectal
Can be drained via an incision into the
ischiorectal fossa. Usually traverse the fossa
posteriorly to connect.
Pudendal nerve block
Inject an anesthetic near the pudendal nerve
before it enters the pudendal canal. To find the
correct location of the canal, palpate the ishial
tuberosity and place the injection medial to the
bone. Will anesthetize dermatomes S2-S2 and
the lower portion of the vagina.
Infection of abdominal wall
Abdominal wall below the arcuate line is more
susceptible to infection because muscle is
covered by just one layer rather than 2.
Protuberance of the abdomen
Normal in young infants and children because
their GI tracts contain a fair amount of air and
livers are quite large. For adult, the most
common causes are fat, feces, fetus, flatus,
fluid, and food. (6 F’s)
Most common in the inguinal, umbilical
(common in newborns because ant. Abdominal
wall is weak in the umbilical ring, acquired
hernias here are common in fat people and
women), and epigastric regions (through the
Indirect inguinal hernia
Most common, due to failure of the stalk of
processus vaginalis to obliterate. Can be
congenital, or acquired (weakness is present
but made worse by heavy lifting, etc). Hernia
always presents LATERAL to inferior
epigastric artery, and passes through deep and
superficial inguinal ring. Usually enters the
scrotal sac, leaving a bulge in the abdominal
Direct inguinal hernia
Doesn’t pass through deep inguinal ring,
presents MEDIAL to inferior epigastric artery
and protrudes through Hesselbach’s triangle.
Usually occurs in men over 40 y/o and due to
weakness in abdominal wall. Very seldomly
will enter scrotal sac.
More common in women due to pressure on
leg created by pregnancy, smaller bones but
wider hips. Hernia usually presents on
MEDIAL side next to the femoral vein in the
empty space of the femoral triangle.
Surrounded by transversalis fascia anteriorly
and fascia from iliacus posteriorly.
Fractures of Sternum
Most common site is sternal angle. Should
suspect the following:
- Possibility of traumatic diaphragmatic
laceration and herniation of abdominal
contents into thoracic cavity.
- Trauma to heart or surrounding
Needle pierces the thin layer of cortical bone
on sternum and enters vascular cancellous
tissue. Useful in obtaining specimens in
suspected blood diseases or disorders.
When sternum is depressed, anterior wall
appears “sunken,” may only be a cosmetic
problem but could compromise respiration.
Place needle or tube in the midportion
intercostal space to avoid neurovascular
Nerve block anesthesia of ribs
Deliver anesthesia close to inferior border of
May occur if there is obstruction to aorta
causing blood to be shunted through various
pathways of collateral flow, including
intercostals aa. The increased expansion of
these arteries cause them to erode the overlying
Rib pain Along with subsequent radiographs, may be
the first sign of cancer in the breast or prostate
gland since ribs are frequent sites of metastasis
Due to several bilateral multiple fractures of
the ribs resulting in paradoxical respiration
- pleural lacerations and pneumothorax
with or without medistinal shift
- subcutaneous emphysema
- hemothorax secondary to lung
laceration or tear of intercostals vessel.
- Lower rib fractures could be associated
with diaphragmatic tears and
- Right rib fractures associated with liver
- Left rib fractures associated with spleen
Chest Tubes Insert above a rib and make your way up.
Internal thoracic or mammary nodes
Frequently associated with carcinoma of breast
when tumor is in the medial half of breast or
when the axillary nerves are blocked with
metastatic tumor and lymph flow is directed
Air in the pleural cavity. Most common cause
is spontaneous rupture of a part of the lung.
Relieved by placement of tube for drainage.
Condition where tear only in parietal pleura so
air can only go in, causing pressure build-up
that subsequently collapses the lung and cause
central mediastinal structures to get pushed
against opposite lung.
Referred pain of lungs
The site of referred pain secondary to
inflammation or irritation of pleura is often
associated with which part of the pleura is
involved. If costal pleura is irritated, pain is
usually present in the chest wall over the area
Post ductal coarctation
Congenital aortic narrowing distal to the
subclavian artery. Results in rib notching as
blood attempts to reach aorta via reversed
blood flow through anastomoses between the
intercostals branches of the internal thoracic a.
and the aorta. ** Internal thoracic a. can also
be used during coronary artery bypass surgery.
Superior Vena Cava syndrome Results from obstruction of the superior vena
cava resulting in fluid accumulation and edema
in head, neck, and upper limbs presenting as
redness around neck and face.
Tearing of ligamentum arteriosa
Can cause severe bleeding of aorta during
Aortic arch injury
Due to severe upper chest trauma. Can cause
mediastinal widening due to hemorrhage or to
pseudoaneurysm that is developing in the wall
of the aorta itself.
Aspiration into the lungs
Most likely occurs in the right primary
bronchus because it is more vertical and its
lumen is wider.
Thoracic aorta aneurysms
Thoracic aorta is prone to these. When aortic
arch develops an aneurysm, the left recurrent
laryngeal n. can be compressed resulting in
hoarseness of the patient’s voice.
Inflammation of the pericardial sac. Can cause
fluid accumulation in pericardial cavity which
can impede motion of the heart.
Tamponade Accumulation of fluid in pericardial cavity.
Procedure to remove fluid from cavity.
Involves placing needle into sac. Can obtain
samples for potential infectious agents.
Putting a little Doppler imaging device down
the esophagus to take images of the heart with
no sternum or ribs getting in the way. Takes
advantage of the anatomy that esophagus is
immediately posterior to heart
Right- or Left-sided heart failure
When right or left sides of the heart fail to
When heart is on the right side of the chest
and you can feel the strongest heart sounds to
the right of the sternum.
When other organs in addition the heart are
similarly reversed in orientation. First sign of
is seen by looping of heart
Dominance of heart
Clinically important because during heart
attacks, many times the blockage occurs at the
Left coronary artery. However, since most
hearts (2/3rds of the time) hearts are Right-
dominant, people can survive heart attacks.
Ischemia Inadequate blood supply to an organ
Infarction Extreme ischemia, implying permanent injury
Arteriosclerosis Most common cause of infarction
Scarring of heart valves
Valves may be permanently scarred following
infections (like rheumatic fever) and become
narrowed (stenosis) resulting in retrograde
leakage of blood.
Mitral valve prolapsed
Usually a benign condition of incompetency of
leaflets of mitral valve. Present in up to 10% of
Heart sounds (lub-dub)
First sound is due to the bi/tricuspid valves
closing and pumping blood out of the heart
(beginning of systole). The second sound is
due to the pulmonary/aortic valves closing and
the heart filling up with blood (beginning of
Heart attack. Referred pain from heart includes
“crushing, tightening” chest pains and also
pain to the arm, neck or jaw.
Respiratory Distress Syndrome
(“Hyaline Membrane Syndrome”)
Developes in premature infants due to
inadequate levels of surfactant in the lungs.
Type II pneumocytes produce surfactant
beginning at month 6, with sufficient levels at
month 7. Accounts for 20% of neonatal deaths.
Can be treated with artificial surfactant and
glucocorticoids to stimulate the cells to make
Defects of atrial septation
1) Failure to close - can cause higher
blood pressure on left side of heart can
cause left-right blood flow between
atria, overburdening the right side of
the heart and leading to cardiac failure
2) Patent foramen ovale – when foramen
ovale didn’t seal after birth and blood
continues to be shunted through it.
3) Left heart hypoplasia – premature
closing of the foramen ovale during
fetal life, causing underdevelopment of
the left side of the heart. Incompatible
with postnatal life since there isn’t
enough blood flow from aorta to rest of
Ostium primum atrial septal defect
Failure of final closure of atrial septum due to
inadequate development of endocardial
Membranous ventricular septum defect
Failure of final closure of ventricular septum.
Most common congenital heart defect. Formed
when muscular and membranous septal
portions fail to fuse with each other.
Persistant AV canal
Most severe defect involving endocardial
cushion development. Common in Down
Syndrome, causes significant Left-Right blood
flow due to large hole.
Tetralogy of Fallot
Over-riding aorta (receiving blood from both
right and left sides)
Ventricular septal defect (in the membranous
pulmonary stEnosis (narrowing of the
veNtricular hypertrophy (really big
Irreversible pulmonary hypertension
When the ductus arteriosus doesn’t close and
after birth, blood is shunted from the aorta to
the lungs. Sometimes can be life-saving by
allowing a shunt when other congenital heart
disorders are associated with it.
Ductus arteriosus persists after birth, causing
flow to the descending aorta to be entirely
deoxygenated blood from the right side of the
heart. Requires surgical correction.