Clinical Anatomy and Embryology I

Exam II

1. Describe the motor, secretomotor, and sensory innervation of the abdominal esophagus
and stomach.

2. Describe the relationships of the different portions of the duodenum.

3. Describe the margins and relationships of the superficial inguinal ring
4. Describe the arterial anastomoses on the anterior abdominal wall.
5. Describe the criteria used to distinguish direct and indirect inguinal hernias.
6. Describe how to locate the appendix.
7. Describe the relationships of the spleen and the structures that limit its mobility.
8. Describe the distribution of branches of the superior and inferior mesenteric artery and
how they anastomose.

Superior Mesenteric Artery

SMA
SPD @ IPD
J
# MC

I
# RC

# IC
A

• SMA – superior mesenteric artery • @ - anastamosis between celiac

• IPD – inferior
pancreaticoduodenal
• J - jejunal
• I – ileal
• IC - ileocolic
• RC – right colic
• MC – middle colic
• A - appendicular
trunk and superior mesenteric
artery
• # - along with anastamosis from
the left colic and sigmoidal
branches from the inferior
mesenteric artery this forms the
marginal artery
 Inferior Mesenteric Artery
IMA

LC #

S#

SR MR
• IMA – inferior mesenteric artery
• LC – left colic @ IR
• S – sigmoidal branches
• SR – superior rectal
• MR – middle rectal
• IR – inferior rectal
• # - anastamosis with ileocolic, right colic and middle colic branches of
the SMA, forming the marginal artery
• @ - rectal anastamosis with middle rectal (branch of anterior branch of
internal iliac) and inferior rectal (branch of internal pudendal)

• What does the SMA provide blood to? Name the organs from
proximal to distal along with their respective arterial branches.
• Inferior aspect of pancreas and distal portion of duodenum – inferior
pancreaticoduodenal artery
• Jejunum – jejunal branches
• Ileum – ileal branches and ilecolic artery at its distal portion
• Cecum – ileocolic artery
• Appendix – appendicular artery
• Ascending colon – right colic artery
• Transverse colon (proximal 2/3) – middle colic artery
• Where is the transition point between the celiac trunk and the
SMA?
• Between parts 1 and 2 of the duodenum
• Where is the transition point between the SMA and the IMA?
• On the transverse colon
• Is there an anastamosis between the parts of the colon?
• Yes. The marginal artery links all parts of the colon together.

9. Describe the location and relations of the parts of the pancreas.

10. Describe the boundaries of the cystohepatic triangle (the triangle of Calot).
11. Describe the movements of the ribs and how they contribute to inspiration and expiration.
12. Describe the branching pattern of the trachea and its role in aspirating foreign objects.
13. Describe the defects that can lead to enlargement of individual chambers of the heart.
14. Describe relationships of the different lobes of the lungs and the symptoms associated with
compression of structures related to the lung when there is a tumor in a specific lobe on
each side.
15. Describe the course and relationships of the vagus nerve on each side.

Right Vagus Nerve

• Enters the thorax anterior to the right subclavian artery, where it gives rise to the right recurrent
laryngeal nerve.
• The right recurrent laryngeal nerve hooks around the right subclavian artery and ascends
between the trachea and esophagus to supply the larynx.
• RVN then passes posterior to the right brachiocephalic vein, SVC, and root of the right lung.
• Gives branches that contribute to the pulmonary, esophageal and cardiac plexus.
Left Vagus Nerve
• LVN descends in the neck posterior to the left common carotid artery.
• As the LVN curves medially at the inferior border of the arch of the aorta, it gives off the left
recurrent laryngeal nerve.
• LVN passes inferior to the arch of the aorta, immediately lateral to the ligamentum arteriosum,
it gives off the left recurrent laryngeal nerve.
• LRLN ascends to the larynx in the groove between the trachea and the esophagus.
16. Describe the motor and sensory innervation of the abdominal muscles.
Cutaneous nerves

17. Describe the anastomoses between branches of the13 celiac truck and the superior
mesenteric artery
18. Describe the transpyloric plane and list the structures found at that level.
19. Describe the sites of porta-caval anastomoses and list the vessels involved at each site.
20. Describe the location and relations of the origin of the inferior mesenteric artery.
21. Describe the relationships of the ureter
22. Describe the contributions of the abdominal muscles to the rectus sheath at various
locations from the pubic crest to the rib cage.
23. Describe the veins that drain into the renal veins on each side.
24. Describe the blood supply to the stomach and how each vessel reaches the stomach.
Left gastric:
Esophageal

Common hepatic-
right gastric
gastroduodenal Splenic;
Right and left hepatic Posterior gastric
Short gastrics
Left gastro-omental
Gasroduodenal:
1. Supraduodenal
2. Superior-pancreatico- duodenal
3. Right gastro epipoloic

25. Describe the lymphatic drainage of the gonads.

26. Describe the relationships of the inferior vena cava at different vertebral levels.
27. Describe the relationship of the epiploic foramen to the surrounding structures.
 • What structures make up the hepatic portal triad?
• Proper hepatic artery, common bile duct, hepatic portal vein
• What ligament is the portal triad located in?
• Lesser omentum, specifically the hepatoduodenal ligament
• What opening is found immediately inferior to this ligament?
• Epiploic foramen
• This opening allows for communication between what two spaces?
• Allows communication between the greater and lesser sac of the abdomen

28. Describe the tissues surrounding the kidney, the relationships of the kidney, and the
relationships of the renal vessels.
29. Describe the boundaries of the lesser sac.
 Parts of lesser omentum

30. Recognize the blood vessels of the abdomen on CT and MRI

31. Recognize the different biliary ducts on xRay
32. Describe the layers of the spermatic cord and the layers of the abdomen that contribute to
them.

33. Describe the locations on the anterior chest wall where you place a stethoscope to hear
normal heart sounds associated with specific valves.
 Valve Surface Projection Best Heard
Tricuspid (right Inferior middle sternum Over inferior middle
atrioventricular) valve sternum

Bicuspid (left Fourth costal cartilage and Over apex of heart (5th
atrioventricular) valve 4th intercostal space intercostal space at
midclavicular line)

Pulmonary valve Third left costal cartilage Second left intercostal

space, just lateral to
sternum

Aortic valve Fourth left costal cartilage Second right intercostal

space, just lateral to
sternum
34. List the paired vessels on the surface of the heart, their names and locations.

35. Describe the contributions of the heart chambers of the heart to the surfaces of the heart.
36. Describe the sternal angle and list the structures found at this level.
37. Describe the upper and lower boundaries of the costo-diaphragmatic recess and where
thoracentesis would be performed with respect to this recess

38. Describe the relationship of the ribs to the different heart chambers.
39. Describe the relationship of the structures at the hilum of the left lung and at the hilum of
the right lung.
40. Describe the vertebral levels associated with the structures that pass through the
diaphragm and list the structures that pass through each opening in the diaphragm.

41. Describe the position of the heart chambers on a normal lateral radiograph.
42. Describe the areas of the heart that each of the coronary arteries supplies blood to.
 Arteries of the Heart
• What are the two main arteries of the heart that stem from the ascending
aorta?
• Right and left coronary arteries

• Name each of their branches.

• Right Coronary: SA node branch, AV node branch, right marginal artery, posterior
interventricular artery
• Left Coronary: SA node branch (40%) of people, left anterior descending/anterior
interventricular artery, circumflex artery, left marginal artery

• Which of the above branches anastamose with each other?

• Anterior and posterior interventricular arteries (A)
• Right coronary and circumflex arteries (B)

• Which sulci are the above branches located in?

• Interventricular sulcus (A)
• Coronary sulcus (B)

• Draw a simplified line diagram of the heart.

 Arteries of the Heart

43. Describe the structures in the thorax that receive the motor and sensory innervation from
the phrenic nerve.

44. Describe the venous drainage patterns of the intercostal spaces on the left and right.
45. Describe the lymphatic drainage of the lung.

46. Describe the sensory innervation of the pleura.

47. Describe the vertebral articulations of the rib.
48. Describe the lymphatic drainage of the breast.

49. Describe the common appearance of the skin over a tumor of the breast and describe the
structure of the breast that is responsible for this appearance.
50. Describe the blood supply to the conducting system of the heart.

Coronary arteries
• Typically, the RCA supplies :
• The right atrium.
• Most of right ventricle.
• Part of the left ventricle (the diaphragmatic surface).
• Part of the IV septum, usually the posterior third.
• The SA node (in approximately 60% of people).
• The AV node (in approximately 80% of people).

Pg 65
51. Describe the relationships of the esophagus in the thorax and abdomen.
52. Describe the locations of the different portions of the conducting system of the heart with
respect to the chambers of the heart.
53. Describe the structures that have relationships to the pericardial sinuses.
 Lift the apex of the heart and
place your fingers posterior to
the heart to identify the oblique
pericardial sinus and examine its
borders. On the right side, the
oblique sinus is bounded by the
lines of reflection of the serous
pericardium onto the inferior
vena cava and the right
pulmonary veins. On the left,
the sinus is bounded only by the
lines of reflection of serous
pericardium onto the left
pulmonary veins. Observe that
the two sinuses are not
continuous with one another

54. Describe the common variations of the branching patterns of the coronary arteries

Embryology
1. Describe the development of the tissues of the trachea
2. Where and by which cell type(s) is surfactant produced?
3. Describe the different tracheoesophageal congenital malformations.
 Esophageal atresia &
Tracheoesophageal tracheoesophageal fistula
Fistula (TEF)
Features:
• Failure of proper partitioning of
primordial pharynx and larynx by the
tracheoesophageal septum
• Fistula = abnormal passage between H-type tracheoesophageal fistula
two organs
• 1:3000 to 1:4500 live births
• Males more often afflicted
• Esophageal atresia (obstruction of
lumen) common
• 4 varieties

Esophageal atresia & Esophageal atresia & tracheoesophageal

tracheoesophageal fistula at fistula at proximal & distal ends
proximal end

Clinical Correlates
• Esophageal atresia – blockage of the esophagus
– Can occur due to abnormal division of the trachea and esophagus, usually terminating
one or both ends of the esophagus in a blind pouch
– Can also occur during normal gut tube proliferation (will talk more about this during GI
development)
• Tracheoesophageal fistula – incomplete separation of trachea from the esophagus
which can lead to aspiration of both food and/or stomach acid
• Often happen together

A is the most
frequent type,
accounting for 90%
of cases

About 33% of cases

also associated with
cardiac abnormalities
 TEF

Diagnosis:
Presentation:
• Prenatal ultrasound
• Excess saliva in the mouth (fine • Polyhydramnios
white frothy bubbles of mucus in • Lack of air in fetal stomach
the mouth and nose) and upper
• Low fetal weight
airway.
• Secretions recur after suctioning • Most however are Dx after birth
(birth-12 days)
• Gagging and cyanosis after
feeding • Inability to pass catheter from
mouth to stomach
• Milk regurgitation (atresia)
Treatment:
• Reflux of stomach contents into
lungs (aspiration pneumonia • Surgical correction
and/or pneumonitis) • May be postponed in cases of
severe low weight or other
complications (e.g. pneumonia)
4. Describe the developmental contributions of the aortic arches to the arteries of the
superior mediastinum.

Circulatory System Development

• The three main pairs of veins will give rise to a
great portion of the SVC, IVC and ligaments of the
anterior abdominal wall and liver
• 6 pairs of aortic arches will stem from the aortic
roots of the primitive heart tube
– 3rd arch – common carotid arteries
– 4th arch right side – proximal part of right subclavian
artery
– 4th arch left side – aortic arch
– 6th arch – pulmonary arch

5. Describe the septation of the atria and ventricles during development and the common
causes of congenital septal defects.
 Atrial Septation

• Septum primum forms and anchors on the

endocardial cushion forming foramen primum
• Foramen primum seals off, foramen secundum
starts forming, septum secundum originates

Atrial Septation

• Foramen ovale forms in septum secundum

• Upon first breath, septum primum and secundum fuse
and fully separate atria
• Foramen ovale becomes the fossa ovalis
 Ventricular Septation
• Interventricular septum
has two parts
– Muscular
– Membranous
• Membranous stems from
the endocardial cushion,
therefore problems with
interventricular
septation are often due
to incomplete
membranous part of the
septum

Clinical Correlates
• Atrial septal defects • !!Tetralogy of Fallot!!
• Ventricular septal defects – Overriding aorta
• Persistent truncus – Pulmonary stenosis
arteriosus – VSD
– Rt ventricular hypertrophy
• Great vessels transposition
 • Persistent
truncus
arteriosus

Transposition of the great vessels

6. List the fetal vascular shunts and vessels, their locations, and adult derivatives.
7. Describe the most common result of duodenal atresia in the fetus.
• What is atresia? – Full blockage
• What is stenosis? – Narrowing of a lumen
• What is a diverticulum? – An outpouching
• What does polyhydramnios usually indicate? –
Blockage of the GI tract which renders the fetus
incapable of swallowing the amniotic fluid.
• What happens to the foregut during the rapid
growth of the embryo?
• Foregut gets occluded due to rapid proliferation of its
epithelium
• Needs to recanalize through epithelial apoptosis
• Failure to do so can lead to either an atresia or a
stenosis
8. List the retroperitoneal and secondarily retroperitoneal organs.
 • What does it mean to be intraperitoneal?
• Developed inside of the mesentery, covered by peritoneum all
around.
• What does it mean to be primary retroperitoneal?
Developed posterior to the peritoneum from the
beginning.
• What organs are primary retroperitoneal?
• Kidneys, suprarenal glands, ureters
• What does it mean to be secondary retroperitoneal?
Develop inside of mesentery but due to the GI tube
rotation, get pressed against the posterior abdominal
wall and lose peritoneal covering on the posterior
surface.
• What organs are secondary retroperitoneal?
• Duodenum parts 2-4, pancreas (except its tail), ascending and
descending colon
• What tissue gives rise to primary retroperitoneal organs?
• Intermediate mesoderm

9. List the derivatives of the different regions of the developing gut tube.
Partitioning of gut tube
 • Name the foregut derivatives.
• Pharynx, respiratory tract, esophagus, stomach, duodenum,
liver, gallbladder, bile duct, pancreas
• What organs don’t derive from the foregut fully? Spleen,
liver, duodenum
• Where do they develop and what tissue do they develop
from? Spleen develops in the mesogastrium from
mesenchyme. Duodenum develops from both the foregut
and midgut. The liver develops in the ventral mesentery,
and develops in part from the septum transversum.
• Name the midgut derivatives.
• Distal portion of the duodenum, jejunum, ileum, cecum,
appendix, ascending colon, proximal 2/3 of the transverse
colon.
• Name the hindgut derivatives.
• Distal 1/3 of transverse colon, descending colon, sigmoid
colon, rectum, proximal 2/3 of anal canal, cloaca.
10. Describe Meckel’s diverticulum.
• What is Meckel’s diverticulum and where is it located?
– Outgrowth of the ileum
• What process puts us at risk to develop Meckel’s
diverticulum? – return of the intestines back into the
abdominal cavity of the embryo
• How many variations of Meckel’s diverticulum are
there? – 2 major variations : ligamentous or fistula

11. Describe the developmental origin of the tissues of the anal canal and how that relates
to the sensory innervation of the canal.
• Superior 2/3 – endodermal
in origin from the cloaca
(hindgut)
• Autonomic innervation
• Inferior 1/3 – ectodermal
in origin from the rupture
of the cloacal membrane
(around end of week 7,
beginning of week 8) and
invagination of the
epithelium
• Somatic innervation