Chapter: Stomach & Lymphatic Drainage; Topic: Gastric Lymphatics; Subtopic: Nodal Stations & Clinical Relevance
Keyword Definitions:
Gastric lymphatics: Network of lymphatic vessels draining stomach towards regional nodal groups along arterial trunks.
Pyloric (infra-pyloric) nodes: Nodes around the pylorus and proximal duodenum receiving drainage from distal stomach and antral region.
Short gastric nodes: Nodes along the splenic artery and at the hilum of the spleen draining the fundus and upper greater curvature.
Gastroepiploic (right/left) nodes: Nodes along the gastroepiploic arcade draining the greater curvature regions.
Sentinel node: The first lymph node(s) receiving direct drainage from a primary tumour—important in staging and guiding surgery.
1) Lead Question – 2016
Stomach wall is mainly drained by all lymph nodes except?
a) Pyloric nodes
b) Short gastric vessel nodal group
c) Right gastroepiploic nodes
d) Inguinal nodes
Answer: d) Inguinal nodes
Explanation: Gastric lymphatic drainage follows the arterial supply: the left gastric nodes drain the lesser curvature and cardia, right gastric nodes drain the distal lesser curvature, gastroepiploic nodes (right and left) drain the greater curvature, and short gastric nodes along the splenic artery drain the fundus. Pyloric (infra-pyloric) nodes drain the antrum and pylorus. Inguinal nodes are superficial nodes of the lower limb and lower anterior abdominal wall and are not involved in primary gastric drainage. Therefore, the stomach is not drained by inguinal nodes—this makes (d) the correct answer, which is clinically relevant because inguinal nodal enlargement would not suggest primary gastric cancer spread.
2) Which nodal group is most commonly involved first in carcinoma of the gastric fundus?
a) Pyloric nodes
b) Left gastric (lesser curvature) nodes
c) Short gastric nodes along the splenic artery
d) Right gastroepiploic nodes
Answer: c) Short gastric nodes along the splenic artery
Explanation: The fundus of the stomach drains predominantly along the short gastric arteries toward nodes at the splenic hilum and along the splenic artery. In gastric fundus carcinoma these short gastric nodes are therefore commonly the first echelon of nodal spread. Left gastric (lesser curvature) nodes are more important for cardia and lesser curvature lesions; pyloric nodes drain the antrum; right gastroepiploic nodes drain distal greater curvature. Recognising the fundic drainage route is essential for surgical planning and nodal sampling during oncologic gastrectomy.
3) The nodes along the right gastroepiploic artery primarily receive lymph from which region of the stomach?
a) Cardia and upper lesser curvature
b) Antrum and distal greater curvature
c) Fundus
d) Posterior surface only
Answer: b) Antrum and distal greater curvature
Explanation: The right gastroepiploic artery runs along the distal greater curvature supplying the antral and adjacent greater curvature region; lymphatic vessels follow this artery to the right gastroepiploic (gastro-omental) nodes. Tumours located in the distal greater curvature or antrum will therefore commonly metastasise to these nodal stations. Understanding the artery–node correspondence helps in tailoring lymphadenectomy (D1/D2 dissections) for gastric cancer and improves staging accuracy.
4) Involvement of which nodal group suggests possible retroperitoneal or para-aortic spread of gastric cancer?
a) Left gastric nodes only
b) Splenic hilum nodes only
c) Superior mesenteric nodes and para-aortic nodes
d) Inguinal nodes
Answer: c) Superior mesenteric nodes and para-aortic nodes
Explanation: Advanced gastric cancer can spread beyond perigastric nodes to secondary stations including nodes along the common hepatic artery, celiac axis, superior mesenteric vessels and ultimately the para-aortic (lumbar) nodes—indicative of systemic dissemination and a worse prognosis. Para-aortic node involvement often implies retroperitoneal extension and may change management from curative to palliative. Inguinal nodes are not part of this route. Recognising para-aortic nodal disease on imaging impacts staging (often M1) and therapeutic decisions.
5) Sentinel node biopsy in early gastric cancer aims to identify which of the following?
a) The first lymph node(s) that receive drainage from the tumor
b) The largest lymph node in the abdomen
c) Inguinal nodes exclusively
d) Nodes in the porta hepatis only
Answer: a) The first lymph node(s) that receive drainage from the tumor
Explanation: Sentinel node biopsy identifies the initial draining lymph node(s) for a primary tumour; if these nodes are free of metastasis, the likelihood of further nodal involvement is low, potentially permitting less extensive lymphadenectomy. In early gastric cancer, sentinel node mapping using dyes or radiotracers can help tailor the extent of surgery while maintaining oncologic safety. It is not about the largest node or specific anatomical node groups like inguinal or porta hepatis unless they are sentinel nodes for that tumour location.
6) Which nodal station is most relevant when assessing lymphatic spread from a tumour located on the lesser curvature near the cardia?
a) Right gastroepiploic nodes
b) Left gastric nodes along the lesser curvature
c) Superior mesenteric nodes
d) Inguinal nodes
Answer: b) Left gastric nodes along the lesser curvature
Explanation: The left gastric nodes lie along the lesser curvature and the left gastric artery; they drain the cardia and upper lesser curvature. A carcinoma at the lesser curvature near the cardia will typically send lymph to these nodes early. Right gastroepiploic nodes drain distal greater curvature, superior mesenteric nodes are more distal secondary stations, and inguinal nodes are unrelated. Accurate knowledge of these relationships is crucial for proper nodal dissection around the lesser curvature during gastrectomy.
7) A patient with distal gastric cancer undergoes D2 lymphadenectomy. Which node group is typically removed as part of a standard D2 dissection?
a) Only perigastric nodes (D1)
b) Perigastric nodes plus nodes along left gastric, common hepatic, splenic and celiac trunks
c) Only para-aortic nodes
d) Only inguinal nodes
Answer: b) Perigastric nodes plus nodes along left gastric, common hepatic, splenic and celiac trunks
Explanation: A D2 lymphadenectomy for gastric cancer includes removal of perigastric (D1) nodes and the second-tier nodes along the main supplying arteries: left gastric, common hepatic, splenic and celiac axis nodes. This extended nodal clearance aims to improve staging and oncologic control for resectable gastric cancers, though it requires surgical expertise due to increased operative complexity. Para-aortic nodes are beyond standard D2 unless specifically indicated; inguinal nodes are not part of gastric oncologic dissection.
8) Which statement about lymphatic drainage of the stomach and metastasis is TRUE?
a) Lymphatic spread always follows a single predictable path irrespective of tumor site
b) Drainage pathways correlate with arterial supply, but cross-drainage and skip metastases can occur
c) Superficial gastric veins determine lymphatic spread
d) Inguinal nodes are the common first station for all gastric tumors
Answer: b) Drainage pathways correlate with arterial supply, but cross-drainage and skip metastases can occur
Explanation: While gastric lymphatics broadly follow arterial routes (left gastric, right gastric, gastroepiploic, short gastric), considerable anatomical variation exists: cross-drainage between pathways and skip metastases (noncontiguous nodal involvement) can occur. Therefore, nodal spread is not absolutely predictable and justifies comprehensive staging and sometimes extended dissection. Superficial veins do not direct lymphatic spread, and inguinal nodes are not involved except in very unusual or metastatic contexts.
9) Which imaging modality is most useful to detect enlarged perigastric and celiac lymph nodes preoperatively?
a) Ultrasound of the groin
b) Contrast-enhanced CT abdomen and pelvis
c) Plain abdominal X-ray
d) Doppler study of the femoral vessels
Answer: b) Contrast-enhanced CT abdomen and pelvis
Explanation: Contrast-enhanced CT scanning of the abdomen and pelvis is the standard preoperative imaging modality to assess gastric wall thickening, regional perigastric, celiac and para-aortic nodal enlargement, and to evaluate resectability. It provides essential staging information. Ultrasound of the groin or plain X-rays are not appropriate for gastric nodal mapping; Doppler femoral studies assess vascular flow, not nodal disease.
10) A rare case of metastatic gastric carcinoma presenting with a palpable Virchow’s node (left supraclavicular) implies spread via which route?
a) Direct transperitoneal seeding only
b) Lymphatic route via thoracic duct to left supraclavicular nodes
c) Inguinal lymphatic pathway
d) Portal venous drainage only
Answer: b) Lymphatic route via thoracic duct to left supraclavicular nodes
Explanation: Virchow’s node (left supraclavicular) can become involved from abdominal malignancies due to lymphatic spread that reaches the thoracic duct and then drains into the left venous angle; tumour emboli can lodge in left supraclavicular nodes. This is a classic sign of advanced gastrointestinal cancer. Inguinal nodes are unrelated; portal venous spread leads to liver metastases rather than supraclavicular nodal enlargement. Therefore, the thoracic duct lymphatic route explains Virchow’s node involvement.
Chapter: Stomach & Lymphatic Drainage; Topic: Gastric Lymphatics; Subtopic: Final Drainage Pathways
Keyword Definitions:
Gastric lymphatics: Lymphatic vessels draining the stomach, following arterial supply.
Pyloric nodes: Nodes around the pylorus receiving drainage from distal stomach.
Short gastric nodes: Nodes along splenic artery draining the fundus and upper greater curvature.
Gastroepiploic nodes: Nodes along greater curvature near gastroepiploic vessels.
Celiac nodes: Final collecting nodes of gastric lymph before entering cisterna chyli.
1) Lead Question – 2016
All lymph of stomach drains into ?
a) Pyloric nodes
b) Short gastric vessel nodal group
c) Right gastroepiploic nodes
d) Coeliac nodes
Answer: d) Coeliac nodes
Explanation: Gastric lymph drainage begins in regional perigastric nodes, including left gastric, right gastric, short gastric, pyloric and gastroepiploic groups. Although these groups receive lymph from specific parts of the stomach, all gastric lymph ultimately converges into the coeliac lymph nodes. These central nodes lie around the coeliac trunk and act as the final collecting station before lymph enters the cisterna chyli. This anatomical fact is essential for understanding advanced gastric cancer spread and forms the rationale for extended lymphadenectomy in oncologic gastrectomy.
2) The first nodal group involved in carcinoma of the pylorus is?
a) Right gastric nodes
b) Pyloric (infra-pyloric) nodes
c) Short gastric nodes
d) Splenic hilum nodes
Answer: b) Pyloric (infra-pyloric) nodes
Explanation: The pyloric region drains lymph primarily to the pyloric or infra-pyloric nodes that lie near the origin of the gastroduodenal artery. Tumors arising in the antrum or pylorus therefore metastasize first to these nodes. Short gastric and splenic hilum nodes drain the fundus, while the right gastric nodes drain the lower lesser curvature. Understanding this first-echelon drainage is critical for accurate staging and surgical clearance during distal gastrectomy.
3) Which nodal group drains the fundus of the stomach?
a) Right gastric nodes
b) Left gastric nodes
c) Short gastric nodes
d) Pyloric nodes
Answer: c) Short gastric nodes
Explanation: The fundus of the stomach is supplied by and drains along the short gastric arteries. These lymphatics drain directly into nodes at the splenic hilum. This explains why fundal cancers frequently spread to splenic hilar nodes. Left gastric nodes drain lesser curvature regions near the cardia; pyloric nodes drain the antrum; right gastric nodes drain the lower lesser curvature. The short gastric pathway is therefore the primary route for fundal lymphatic drainage.
4) Blockage of which nodal group may result in splenic hilar adenopathy in fundic cancer?
a) Left gastric nodes
b) Short gastric nodes
c) Pyloric nodes
d) Pancreaticoduodenal nodes
Answer: b) Short gastric nodes
Explanation: Short gastric lymphatics drain directly into splenic hilar nodes. When these pathways are obstructed by malignant spread, splenic hilar nodal enlargement occurs. This finding is often associated with fundal tumors due to their drainage pattern. Other nodal groups are not typically involved early in fundic cancer. Recognition of splenic hilum nodal disease is important for planning extended lymphadenectomy (D2) when indicated.
5) Which of the following is classified as a second-tier (D2) node in gastric cancer surgery?
a) Perigastric right gastric nodes
b) Splenic artery nodes
c) Pyloric nodes
d) Short gastric nodes
Answer: b) Splenic artery nodes
Explanation: D1 nodes include the perigastric nodal stations surrounding the stomach. D2 nodes are second-tier nodes along the major arterial trunks such as the splenic artery, left gastric artery, and common hepatic artery. Splenic artery nodes receive lymph from the fundus and upper greater curvature region. Removal of these nodes is part of an extended D2 dissection that improves staging and may improve survival in selected gastric cancer patients.
6) Which region of the stomach drains predominantly into the left gastric nodes?
a) Fundus
b) Cardia and lesser curvature
c) Distal antrum
d) Greater curvature
Answer: b) Cardia and lesser curvature
Explanation: The left gastric artery runs along the lesser curvature toward the cardia, and lymphatic drainage from these regions follows the same path. Cardia cancers, especially near the gastroesophageal junction, typically involve left gastric nodes early. The fundus drains to short gastric nodes; the greater curvature drains to gastroepiploic nodes, while the distal antrum drains toward pyloric nodes. Understanding each region’s drainage helps refine surgical lymphadenectomy.
7) Virchow’s node involvement in gastric cancer indicates spread by which route?
a) Direct peritoneal invasion
b) Lymphatic spread via thoracic duct
c) Portal venous spread to liver
d) Systemic arterial spread
Answer: b) Lymphatic spread via thoracic duct
Explanation: Metastasis to Virchow’s node (left supraclavicular) occurs when gastric lymph reaches the cisterna chyli and travels superiorly through the thoracic duct before draining into the left venous angle. Tumor cells may lodge in nearby supraclavicular nodes, producing this classical clinical sign of advanced gastrointestinal malignancy. It reflects extensive lymphatic spread rather than direct local invasion or portal venous dissemination.
8) Right gastroepiploic nodes are located along which vessel?
a) Left gastric artery
b) Right gastroepiploic artery
c) Splenic artery
d) Inferior phrenic artery
Answer: b) Right gastroepiploic artery
Explanation: The right gastroepiploic artery runs along the distal portion of the greater curvature. Its associated nodes drain the antrum and distal greater curvature. These nodes are removed in standard gastric oncologic dissections. The splenic artery supplies fundal short gastric branches; the left gastric artery supplies the lesser curvature; the inferior phrenic artery has no major gastric lymphatic association.
9) Which lymph node group is closest to the gastroesophageal junction?
a) Left gastric nodes
b) Pyloric nodes
c) Short gastric nodes
d) Para-aortic nodes
Answer: a) Left gastric nodes
Explanation: The gastroesophageal junction lies adjacent to the left gastric artery and its accompanying lymph nodes. These nodes often form the primary drainage route for cancers at or near the cardiac region. Short gastric nodes are more lateral toward the fundus; pyloric nodes lie distally, and para-aortic nodes are secondary stations involved in advanced disease stages.
10) The final common pathway for all gastric lymph before entering systemic circulation is?
a) Cisterna chyli
b) Para-aortic nodes
c) Coeliac nodes
d) Splenic hilum nodes
Answer: c) Coeliac nodes
Explanation: Regardless of its starting point—whether short gastric, pyloric, gastroepiploic or left gastric—gastric lymph ultimately converges into the celiac node group. These nodes sit around the celiac trunk and form the central collecting drainage of the entire stomach. From here, lymph flows into the cisterna chyli and then the thoracic duct. This makes the celiac nodes the key nodal basin for staging advanced gastric cancer.
11) A tumor located on the distal greater curvature will most likely spread first to?
a) Left gastric nodes
b) Short gastric nodes
c) Right gastroepiploic nodes
d) Para-aortic nodes
Answer: c) Right gastroepiploic nodes
Explanation: The distal greater curvature receives arterial supply from the right gastroepiploic artery, and lymphatics follow this route to its nodal group. These nodes, located along the greater curvature near the gastroepiploic arcade, therefore represent the first site of lymphatic spread in cancers of the distal greater curvature. Para-aortic involvement occurs only in advanced metastatic disease, while left gastric and short gastric nodes drain different regions.
Chapter: Hepatobiliary System; Topic: Liver Segmentation; Subtopic: Segmental Anatomy & Relations
Keyword Definitions:
Liver segments: Functional subdivisions of the liver based on vascular inflow, outflow, and biliary drainage.
Gallbladder fossa: Depression on the inferior surface of the liver where the gallbladder lies.
Segment IV: Medial segment of the left lobe, divided into IVa and IVb.
Portal vein branches: Vascular structures supplying specific liver segments.
Hepatobiliary relations: Anatomical connections between liver and biliary structures.
1) Lead Question – 2016
Gall bladder is related to which segment of the liver?
a) I
b) II
c) III
d) IV
Answer: d) IV
Explanation: The gallbladder lies in the gallbladder fossa between **Segment IV (medial segment of left lobe)** and **Segment V (anterior segment of right lobe)**. Functionally, its major anatomical relation is with Segment IV, as the medial left lobe forms the superior surface of the fossa. Understanding segmental anatomy is crucial for hepatobiliary surgeries, including cholecystectomy, hepatic resections, and management of biliary injuries. Segment IV receives its blood supply from the left hepatic artery and portal vein, further supporting its close relationship to the gallbladder bed.
2) Which segment contains the caudate lobe?
a) I
b) II
c) III
d) IV
Answer: a) I
Explanation: The caudate lobe corresponds to Segment I, which is unique due to its dual venous drainage to the IVC and portal vein.
3) The right hepatic duct drains which segments?
a) II and III
b) IV only
c) V and VIII
d) I only
Answer: c) V and VIII
Explanation: Segments V and VIII form part of the right anterior sector, draining into the right hepatic duct.
4) Which lobe lies to the left of the falciform ligament?
a) Segment VI
b) Segment II
c) Segment VII
d) Segment V
Answer: b) Segment II
Explanation: Segments II and III lie left of the falciform ligament and belong to the left anatomical lobe.
5) A tumor in segment IVb primarily affects which surface?
a) Superior
b) Inferior
c) Posterior
d) Lateral
Answer: b) Inferior
Explanation: Segment IVb forms the inferior medial portion of the left lobe, in direct relation to the gallbladder.
6) Which vascular structure divides the liver into right and left functional lobes?
a) Falciform ligament
b) Middle hepatic vein
c) Ligamentum venosum
d) Ligamentum teres
Answer: b) Middle hepatic vein
Explanation: The middle hepatic vein is the functional divider, not the falciform ligament.
7) Segment VII lies in which anatomical region?
a) Left medial lobe
b) Right posterior lobe
c) Quadrate lobe
d) Caudate lobe
Answer: b) Right posterior lobe
Explanation: Segment VII is superior and posterior, part of the right posterior sector.
8) Which segment is directly related to the porta hepatis?
a) III
b) IV
c) V
d) VI
Answer: b) IV
Explanation: Segment IV lies adjacent to the porta hepatis and is central in liver vascular planning.
9) A lesion near the gallbladder fossa most likely involves which segments?
a) II and III
b) IV and V
c) VII and VIII
d) I and II
Answer: b) IV and V
Explanation: The gallbladder fossa sits between segments IV (medial left lobe) and V (right anterior lobe).
10) Segment III corresponds to which part of the liver?
a) Right inferior anterior
b) Left inferior lateral
c) Caudate region
d) Right posterior
Answer: b) Left inferior lateral
Explanation: Segment III lies on the left inferior surface lateral to the falciform ligament.
11) The quadrate lobe corresponds to which Couinaud segment?
a) I
b) II
c) III
d) IVb
Answer: d) IVb
Explanation: The quadrate lobe is anatomically Segment IVb, located inferiorly and related to the gallbladder bed.
Chapter: Hepatobiliary System; Topic: Liver Segmentation; Subtopic: Venous Drainage of Liver Segments
Keyword Definitions:
Couinaud Segments: Functional liver divisions based on portal inflow, outflow, and biliary drainage.
Segment I (Caudate lobe): A unique liver segment with independent inflow and outflow.
Hepatic veins: Major veins draining liver segments into the IVC.
Dual drainage: A segment draining into more than one hepatic vein.
IVC (Inferior Vena Cava): Large vein receiving hepatic venous return.
1) Lead Question – 2016
Which segment of liver drains on both sides?
a) I
b) II
c) III
d) IV
Answer: a) I
Explanation: Segment I, the **caudate lobe**, is unique due to its **dual venous drainage**. It drains directly into the inferior vena cava and also receives venous outflow into both the right and left hepatic veins. Unlike other segments that follow sectoral venous drainage, Segment I has independent inflow from both left and right portal venous systems and independent biliary drainage. This dual drainage explains why the caudate lobe may hypertrophy in chronic liver disease and why it must be separately addressed during hepatic resections.
2) Which segment functionally corresponds to the quadrate lobe?
a) I
b) II
c) IVb
d) V
Answer: c) IVb
Explanation: The quadrate lobe is segment IVb, located inferiorly and related closely to the gallbladder fossa.
3) Which hepatic vein is the main divider of right and left functional lobes?
a) Left hepatic vein
b) Right hepatic vein
c) Middle hepatic vein
d) Accessory hepatic vein
Answer: c) Middle hepatic vein
Explanation: The middle hepatic vein divides the liver into functional right and left lobes, unlike the falciform ligament.
4) Segment VII drains into which hepatic vein?
a) Left hepatic vein
b) Middle hepatic vein
c) Right hepatic vein
d) IVC directly
Answer: c) Right hepatic vein
Explanation: Segment VII lies posteriorly in the right lobe and drains predominantly into the right hepatic vein.
5) A lesion in segment II is located in which portion of the liver?
a) Right anterior
b) Right posterior
c) Left superior lateral
d) Caudate region
Answer: c) Left superior lateral
Explanation: Segment II lies superiorly and laterally in the left lobe, above segment III.
6) Tumor involving the caudate lobe may compress which structure?
a) Portal vein
b) IVC
c) Hepatic artery
d) Cystic duct
Answer: b) IVC
Explanation: Segment I lies directly adjacent to the IVC and may compress it in cases of enlargement.
7) Segment V is located in which part of the liver?
a) Left lateral
b) Right anterior inferior
c) Right posterior superior
d) Caudate region
Answer: b) Right anterior inferior
Explanation: Segment V is part of the right anterior sector and lies inferiorly.
8) Which segment lies posterior to the portal hepatis?
a) I
b) II
c) III
d) IVb
Answer: a) I
Explanation: The caudate lobe (Segment I) sits posterior to the porta hepatis.
9) Segment III drains into which hepatic vein?
a) Left hepatic vein
b) Middle hepatic vein
c) Right hepatic vein
d) Directly to IVC
Answer: a) Left hepatic vein
Explanation: Segments II and III drain into the left hepatic vein, as they form the true left lobe.
10) Segment VIII lies:
a) Superior right anterior
b) Inferior left anterior
c) Inferior right posterior
d) Superior left posterior
Answer: a) Superior right anterior
Explanation: Segment VIII overlies segment V and is part of the right anterior superior sector.
11) Which segment lies closest to the ligamentum venosum?
a) II
b) III
c) I
d) V
Answer: c) I
Explanation: The caudate lobe is bordered by the ligamentum venosum on the left, reflecting its central and unique position.
Chapter: Hepatobiliary System; Topic: Liver Anatomy; Subtopic: Caudate Lobe (Segment I)
Keyword Definitions:
Caudate Lobe: Segment I of the liver with independent vascular supply and venous drainage.
Hepatic Arteries: Vessels supplying oxygenated blood to the liver segments.
Ligamentum Venosum: Fibrous remnant of ductus venosus separating caudate lobe from left lobe.
Portal Triad: Hepatic artery, portal vein, and bile duct supplying liver segments.
IVC (Inferior Vena Cava): Major venous structure receiving hepatic venous drainage.
1) Lead Question – 2016
Caudate lobe of the liver – True is?
a) It receives blood supply from both right and left hepatic arteries
b) It is Segment II of the liver
c) It is situated on the anterior surface of liver
d) It lies between the aorta and ligamentum venosum
Answer: a) It receives blood supply from both right and left hepatic arteries
Explanation: The caudate lobe is **Segment I** of the liver and is unique because it receives **dual blood supply from both right and left hepatic arteries**, as well as dual portal venous supply. It lies on the **posterior surface of the liver**, positioned between the **IVC and ligamentum venosum**, not the aorta. This segment also drains directly into the IVC, giving it functional independence. These characteristics make it clinically significant, especially in cirrhosis where the caudate lobe often hypertrophies due to preserved vascularity.
2) Which segment corresponds to the caudate lobe?
a) Segment I
b) Segment II
c) Segment III
d) Segment IVa
Answer: a) Segment I
Explanation: The caudate lobe is anatomically and functionally defined as Segment I according to Couinaud classification.
3) Caudate lobe drains into?
a) Left hepatic vein
b) Right hepatic vein
c) Directly into IVC
d) Portal vein
Answer: c) Directly into IVC
Explanation: Segment I uniquely drains directly into the inferior vena cava through multiple small hepatic veins.
4) Structure present left to caudate lobe?
a) IVC
b) Ligamentum venosum
c) Falciform ligament
d) Gallbladder
Answer: b) Ligamentum venosum
Explanation: The ligamentum venosum marks the left boundary of the caudate lobe.
5) Enlargement of caudate lobe may compress?
a) Hepatic artery
b) IVC
c) Portal vein
d) Aorta
Answer: b) IVC
Explanation: Since the caudate lobe lies directly anterior to the IVC, enlargement may lead to IVC compression.
6) Caudate lobe receives portal venous supply from?
a) Only right portal vein
b) Only left portal vein
c) Both right and left portal veins
d) None
Answer: c) Both right and left portal veins
Explanation: Dual portal venous inflow is a hallmark of the caudate lobe.
7) Which statement about Segment I is true?
a) It lies inferior to the gallbladder
b) It is separated from left lobe by ligamentum venosum
c) It lies anterior to the stomach
d) It drains only into right hepatic vein
Answer: b) It is separated from left lobe by ligamentum venosum
Explanation: The ligamentum venosum forms the left boundary of the caudate lobe.
8) Caudate process connects which structures?
a) Left lobe and quadrate lobe
b) Right lobe and caudate lobe
c) Quadrate lobe and right lobe
d) Left lobe and right lobe
Answer: b) Right lobe and caudate lobe
Explanation: The caudate process bridges the caudate lobe with the right lobe of the liver.
9) Which lobe lies anterior to the caudate lobe?
a) Quadrate lobe
b) Left lobe
c) Right lobe
d) No lobe anterior
Answer: a) Quadrate lobe
Explanation: The quadrate lobe lies inferior-anterior, while the caudate lies posterior to the porta hepatis.
10) Which lobe shows hypertrophy in cirrhosis commonly?
a) Left lobe
b) Caudate lobe
c) Quadrate lobe
d) Right lobe
Answer: b) Caudate lobe
Explanation: Due to its preserved dual vascular supply, the caudate lobe often hypertrophies in advanced liver disease.
11) Caudate lobe lies between?
a) Falciform ligament and IVC
b) IVC and ligamentum venosum
c) Gallbladder and porta hepatis
d) Right lobe and falciform ligament
Answer: b) IVC and ligamentum venosum
Explanation: This anatomical positioning is a major identifying feature of Segment I.
Chapter: Peritoneum & Mesenteries; Topic: Epiploic (Winslow’s) Foramen; Subtopic: Boundaries
Keyword Definitions:
Epiploic Foramen: Opening connecting greater and lesser sacs.
Caudate Lobe: Segment I of the liver forming superior boundary of epiploic foramen.
Hepatoduodenal Ligament: Contains portal triad forming anterior boundary.
Portal Triad: Hepatic artery proper, portal vein, bile duct.
IVC: Forms posterior boundary of the foramen.
1) Lead Question – 2016
Superior border of epiploic foramen formed by -
a) Caudate lobe
b) Hepatic artery
c) Bile duct
d) IVC
Answer: a) Caudate lobe
Explanation: The epiploic foramen (foramen of Winslow) connects the greater and lesser peritoneal sacs. Its superior boundary is formed by the **caudate lobe of the liver**. The anterior boundary contains the **portal triad** inside the hepatoduodenal ligament. Inferiorly lies the first part of the duodenum, while posteriorly lies the **inferior vena cava**. Knowing these boundaries is essential for surgical procedures such as the Pringle maneuver, which compresses the portal triad to control hepatic bleeding. Therefore, the correct answer is the **caudate lobe**.
2) Inferior boundary of the epiploic foramen is?
a) Caudate lobe
b) Duodenum (1st part)
c) IVC
d) Hepatogastric ligament
Answer: b) Duodenum (1st part)
Explanation: The first part of the duodenum forms the inferior margin of the foramen.
3) Anterior boundary of epiploic foramen contains?
a) IVC
b) Caudate lobe
c) Portal triad
d) Duodenum
Answer: c) Portal triad
Explanation: The anterior boundary is the hepatoduodenal ligament containing the portal vein, hepatic artery proper, and bile duct.
4) Posterior boundary of epiploic foramen is?
a) Aorta
b) IVC
c) Caudate lobe
d) Stomach
Answer: b) IVC
Explanation: Inferior vena cava lies directly posterior to the epiploic foramen.
5) Epiploic foramen communicates with?
a) Pericardial cavity
b) Lesser sac
c) Pleural cavity
d) Pouch of Douglas
Answer: b) Lesser sac
Explanation: It is the only natural communication between greater and lesser sacs.
6) During Pringle maneuver, which structure is compressed?
a) IVC
b) Hepatoduodenal ligament
c) Gastrosplenic ligament
d) Ligamentum venosum
Answer: b) Hepatoduodenal ligament
Explanation: Clamping this ligament occludes inflow via portal vein and hepatic artery proper.
7) Which vein is posterior to the epiploic foramen?
a) Portal vein
b) IVC
c) Short gastric vein
d) Splenic vein
Answer: b) IVC
Explanation: The IVC forms the posterior limit of the foramen.
8) The epiploic foramen lies behind which structure?
a) Hepatoduodenal ligament
b) Falciform ligament
c) Coronary ligament
d) Gastrohepatic ligament
Answer: a) Hepatoduodenal ligament
Explanation: The foramen is immediately posterior to the hepatoduodenal ligament.
9) In portal hypertension, the foramen may enlarge due to?
a) Dilated portal vein
b) Dilated hepatic veins
c) Splenic rupture
d) Inferior phrenic artery enlargement
Answer: a) Dilated portal vein
Explanation: The portal vein, located anterior to the foramen, may enlarge and distort surrounding structures.
10) The foramen of Winslow is located?
a) Between liver and stomach
b) Behind portal triad
c) In lesser omentum
d) Between pancreas and spleen
Answer: b) Behind portal triad
Explanation: It lies directly posterior to the hepatoduodenal ligament containing the portal triad.
11) Which structure forms the roof of the lesser sac continuous with superior boundary of the foramen?
a) Caudate lobe
b) Quadrate lobe
c) Left lobe
d) Body of stomach
Answer: a) Caudate lobe
Explanation: The caudate lobe forms both the superior boundary of the foramen and part of the roof of the lesser sac.
Chapter: Gastrointestinal Tract – Anal Canal; Topic: Anal Sphincters; Subtopic: Internal Anal Sphincter
Keyword Definitions:
Internal Anal Sphincter: Involuntary smooth muscle continuation of circular muscle layer of rectum.
External Anal Sphincter: Voluntary skeletal muscle sphincter surrounding the anal canal.
Puborectalis: Part of levator ani; forms anorectal angle.
Circular Muscle Layer: Inner smooth muscle coat of GI tract providing sphincteric action.
Longitudinal Muscle Layer: Outer smooth muscle layer aiding peristalsis.
1) Lead Question – 2016
Internal anal sphincter is formed by ?
a) Puborectalis
b) Circular muscles from lower rectum
c) Longitudinal involuntary muscles
d) None
Answer: b) Circular muscles from lower rectum
Explanation: The internal anal sphincter is derived from the **thickened continuation of the circular smooth muscle layer** of the lower rectum, making it involuntary and autonomic-controlled. It maintains resting anal tone and prevents involuntary leakage. It relaxes reflexively during defecation via parasympathetic input. Puborectalis, a skeletal muscle, forms the anorectal sling and is part of the external mechanism but not the internal sphincter. Longitudinal muscle fibers contribute to canal support but do not form the sphincter. Thus, the correct structure forming the internal anal sphincter is the **circular muscle of the lower rectum**.
2) Internal anal sphincter is supplied by?
a) Pudendal nerve
b) Pelvic splanchnic nerves
c) Lumbar sympathetic trunk
d) Obturator nerve
Answer: c) Lumbar sympathetic trunk
Explanation: Sympathetic fibers maintain tonic contraction of the internal sphincter.
3) Relaxation of internal anal sphincter occurs due to?
a) Sympathetic stimulation
b) Parasympathetic stimulation
c) Somatic stimulation
d) None
Answer: b) Parasympathetic stimulation
Explanation: Pelvic splanchnics (S2–S4) mediate involuntary relaxation during defecation.
4) Which sphincter is voluntary?
a) Internal
b) External
c) Both
d) Neither
Answer: b) External
Explanation: External sphincter is skeletal muscle under pudendal nerve control.
5) Puborectalis forms which angle?
a) Costophrenic
b) Anorectal
c) Sacral
d) Obturator
Answer: b) Anorectal
Explanation: It maintains continence by pulling anorectal junction forward.
6) Damage to internal anal sphincter causes?
a) Fecal incontinence
b) Constipation
c) Hematemesis
d) Ascites
Answer: a) Fecal incontinence
Explanation: Loss of resting tone results in passive leakage.
7) Which layer contributes to longitudinal anal muscle?
a) Circular smooth muscle
b) Longitudinal smooth muscle
c) Skeletal muscle only
d) None
Answer: b) Longitudinal smooth muscle
Explanation: Longitudinal fibers aid canal support but do not form the sphincter itself.
8) The transition zone between rectum and anal canal is called?
a) Dentate line
b) Pectineal line
c) White line
d) None
Answer: a) Dentate line
Explanation: It marks change in nerve supply, epithelium, and lymph drainage.
9) Nerve supply below dentate line?
a) Autonomic only
b) Pudendal nerve
c) Vagus nerve
d) Obturator nerve
Answer: b) Pudendal nerve
Explanation: Somatic pain and voluntary control occur below this line.
10) Internal sphincter surrounds?
a) Upper 1/3 of anal canal
b) Lower 1/3 of anal canal
c) Entire length
d) Only rectum
Answer: a) Upper 1/3 of anal canal
Explanation: It covers proximal two-thirds but most thick in upper portion.
11) Hypertrophy of internal anal sphincter seen in?
a) Achalasia
b) Hirschsprung disease
c) Fistula in ano
d) Hemorrhoids
Answer: b) Hirschsprung disease
Explanation: Failure of relaxation due to absent ganglion cells leads to sphincter hypertonicity.
Chapter: Gastrointestinal Tract; Topic: Duodenum; Subtopic: Parts & Features of Duodenum
Keyword Definitions:
Duodenum: First part of small intestine, retroperitoneal except 1st part.
Ampulla of Vater: Union of common bile duct and pancreatic duct opening in D2.
Major Duodenal Papilla: Opening of hepatopancreatic ampulla in second part.
Minor Duodenal Papilla: Opening of accessory pancreatic duct.
Duodenal Cap: Smooth bulb-like first part on barium swallow.
1) Lead Question – 2016
All of the following are true about duodenum except?
a) Fourth part is the shortest part
b) Ampulla of Vater opens through the second part
c) Minor duodenal papilla is in the third part
d) First part appears like a duodenal cap on barium studies
Answer: c) Minor duodenal papilla is in the third part
Explanation: The minor duodenal papilla is located in the **second part (D2)**, slightly superior to the major papilla, not in the third part. The 4th part (D4) is indeed the shortest and ascends to the duodenojejunal flexure. The Ampulla of Vater opens into the posteromedial wall of the second part. The first part (D1) appears as a smooth “duodenal cap” on barium studies. Therefore statement **c is false**, making it the correct answer.
2) The duodenum develops from?
a) Foregut and midgut
b) Hindgut
c) Midgut only
d) Foregut only
Answer: a) Foregut and midgut
Explanation: Duodenum up to major papilla is foregut-derived, distal portion from midgut.
3) Which artery mainly supplies D2?
a) Left gastric artery
b) Superior pancreaticoduodenal artery
c) Inferior mesenteric artery
d) Cystic artery
Answer: b) Superior pancreaticoduodenal artery
Explanation: Branch of gastroduodenal artery supplying upper duodenum and head of pancreas.
4) Which part of duodenum is intraperitoneal?
a) D1 first inch
b) Entire D2
c) Entire D3
d) Entire D4
Answer: a) D1 first inch
Explanation: Only the proximal segment of D1 is intraperitoneal; rest is retroperitoneal.
5) Compression of third part (D3) is commonly by?
a) Aorta
b) SMA
c) SVC
d) Renal artery
Answer: b) SMA
Explanation: SMA syndrome results from compression of D3 between SMA and aorta.
6) Accessory pancreatic duct drains into?
a) Major papilla
b) Minor papilla
c) Ampulla of Vater
d) Cystic duct
Answer: b) Minor papilla
Explanation: The duct of Santorini opens at the minor papilla in D2.
7) Which structure lies posterior to first part of duodenum?
a) Portal vein
b) CBD and gastroduodenal artery
c) Left gastric artery
d) Celiac trunk
Answer: b) CBD and gastroduodenal artery
Explanation: Ulcer perforation here may erode GDA leading to bleeding.
8) Duodenojejunal flexure is supported by?
a) Pectineal ligament
b) Ligament of Treitz
c) Lacunar ligament
d) Inguinal ligament
Answer: b) Ligament of Treitz
Explanation: A suspensory muscle anchoring DJ flexure to diaphragm.
9) Posterior duodenal ulcer commonly erodes?
a) Splenic artery
b) Gastroduodenal artery
c) Renal artery
d) Celiac trunk
Answer: b) Gastroduodenal artery
Explanation: Ulcers on posterior wall of D1 lie adjacent to GDA.
10) Which part crosses the vertebral column?
a) D1
b) D2
c) D3
d) D4
Answer: c) D3
Explanation: Third part is horizontal and crosses anterior to aorta and IVC.
11) Which nerve plexus lies between duodenal muscle layers?
a) Auerbach’s
b) Meissner’s
c) Carotid plexus
d) Pudendal plexus
Answer: a) Auerbach’s
Explanation: Myenteric plexus located between circular and longitudinal muscle layers controlling motility.
Chapter: Abdominal Blood Supply; Topic: Inferior Mesenteric Artery; Subtopic: Branches and Distribution
Keyword Definitions:
Inferior Mesenteric Artery (IMA): Artery supplying hindgut derivatives including distal transverse colon, descending colon, sigmoid colon, rectum.
Sigmoid Arteries: Branches of IMA supplying sigmoid colon.
Marginal Artery: Continuous arterial arcade along colon linking SMA and IMA branches.
Hindgut: Embryological region giving rise to distal GI structures supplied by IMA.
Superior Rectal Artery: Terminal branch of IMA supplying rectum.
1) Lead Question – 2016
Which of the following is a branch of the inferior mesenteric artery?
a) Sigmoid artery
b) Middle colic artery
c) Renal artery
d) Right colic artery
Answer: a) Sigmoid artery
Explanation: The inferior mesenteric artery (IMA) supplies hindgut derivatives and gives rise to three major branches: left colic artery, sigmoid arteries, and the superior rectal artery. The sigmoid arteries (usually 2–4 in number) specifically supply the sigmoid colon, making option A correct. Middle colic artery and right colic artery arise from the superior mesenteric artery (SMA), not the IMA. Renal arteries originate directly from the abdominal aorta. Therefore, among the options listed, only the sigmoid artery is a true branch of the IMA.
2) The terminal branch of the IMA is?
a) Left colic artery
b) Middle rectal artery
c) Superior rectal artery
d) Inferior rectal artery
Answer: c) Superior rectal artery
Explanation: Superior rectal artery is the direct continuation of the IMA and supplies the upper rectum.
3) Which artery forms part of the marginal artery of Drummond?
a) Left colic artery
b) Gonadal artery
c) Cystic artery
d) Left renal artery
Answer: a) Left colic artery
Explanation: Left colic artery participates in marginal artery formation supplying colon.
4) Which structure is primarily supplied by IMA?
a) Splenic flexure
b) Cecum
c) Appendix
d) Duodenum
Answer: a) Splenic flexure
Explanation: Splenic flexure is watershed area with supply from both SMA and IMA.
5) A patient with IMA occlusion is least likely to have ischemia in?
a) Sigmoid colon
b) Descending colon
c) Rectum
d) Jejunum
Answer: d) Jejunum
Explanation: Jejunum is supplied by SMA, not IMA; hence unaffected.
6) Which artery supplies descending colon?
a) Ileocolic artery
b) Left colic artery
c) Middle sacral artery
d) Superior epigastric artery
Answer: b) Left colic artery
Explanation: Left colic artery is a branch of IMA supplying descending colon.
7) A 60-year-old with atherosclerosis develops pain in left lower abdomen. Which vessel likely narrowed?
a) Superior mesenteric artery
b) Inferior mesenteric artery
c) Celiac trunk
d) Renal artery
Answer: b) Inferior mesenteric artery
Explanation: IMA stenosis causes ischemia in descending and sigmoid colon.
8) Which artery anastomoses with superior rectal artery?
a) Middle rectal artery
b) Left gastric artery
c) Ovarian artery
d) Splenic artery
Answer: a) Middle rectal artery
Explanation: Middle rectal (from internal iliac) contributes to rectal anastomoses.
9) Bleeding from sigmoid colon branches is controlled by ligating?
a) SMA
b) IMA
c) Celiac trunk
d) Inferior epigastric artery
Answer: b) IMA
Explanation: Sigmoid arteries arise directly from IMA.
10) Which organ lies closest to origin of IMA?
a) Duodenum
b) Pancreas
c) Left kidney
d) Cecum
Answer: c) Left kidney
Explanation: IMA originates at L3, adjacent to lower pole of left kidney.
11) IMA arises at which vertebral level?
a) T12
b) L1
c) L3
d) L5
Answer: c) L3
Explanation: Classical anatomical landmark: IMA emerges from aorta at L3.
Chapter: Pelvic Anatomy; Topic: Fascia of the Pelvis; Subtopic: Waldeyer’s Fascia (Rectosacral Fascia)
Keyword Definitions:
Waldeyer’s Fascia: A fibrous fascial layer anchoring the rectum to the sacrum.
Rectosacral Fascia: Posterior support fascia of rectum; synonymous with Waldeyer’s fascia.
Pelvic Fascia: Fascial layers supporting pelvic organs.
Denonvilliers’ Fascia: Fascia between rectum and prostate/uterus.
Mesorectum: Fatty tissue surrounding rectum containing lymphatics and vessels.
1) Lead Question – 2016
Waldeyer's fascia connects ?
a) Rectum to sacrum
b) Rectum to uterus
c) Rectum to lateral wall of pelvis
d) Rectum to bladder
Answer: a) Rectum to sacrum
Explanation: Waldeyer’s fascia, also known as rectosacral fascia, is a dense fibrous band extending from the posterior surface of the rectum to the sacrum. It supports the rectum and forms an important surgical landmark during total mesorectal excision (TME). It is not related to the uterus, bladder, or pelvic sidewall structures; those are associated with Denonvilliers’ fascia or lateral ligaments. Therefore, the correct and only anatomical connection of Waldeyer’s fascia is between the rectum and the sacrum.
2) Denonvilliers’ fascia lies between?
a) Rectum and sacrum
b) Rectum and prostate
c) Sacrum and bladder
d) Uterus and abdominal wall
Answer: b) Rectum and prostate
Explanation: Denonvilliers’ fascia separates rectum from prostate/seminal vesicles.
3) Which fascia is encountered posteriorly during rectal mobilization in TME?
a) Camper’s fascia
b) Scarpa’s fascia
c) Waldeyer’s fascia
d) Iliac fascia
Answer: c) Waldeyer’s fascia
Explanation: Waldeyer’s fascia lies posterior to rectum and is divided during TME.
4) Lateral ligament of rectum contains?
a) Gonadal vessels
b) Middle rectal artery
c) Superior rectal vein
d) Internal pudendal artery
Answer: b) Middle rectal artery
Explanation: Middle rectal artery passes via lateral ligaments providing rectal support.
5) Which nerve is closely related to rectosacral fascia during surgery?
a) Pudendal nerve
b) Pelvic splanchnic nerves
c) Femoral nerve
d) Obturator nerve
Answer: b) Pelvic splanchnic nerves
Explanation: Pelvic splanchnic nerves lie nearby and must be preserved during surgery.
6) Denonvilliers’ fascia in females separates the rectum from?
a) Uterus
b) Vagina
c) Ovary
d) Bladder
Answer: b) Vagina
Explanation: In females, it separates rectum from posterior vaginal wall.
7) A surgeon identifies a thick posterior fascial layer behind rectum. This is?
a) Denonvilliers’ fascia
b) Rectosacral fascia
c) Endopelvic fascia
d) Lateral umbilical ligament
Answer: b) Rectosacral fascia
Explanation: Posterior rectal fascia is Waldeyer’s (rectosacral) fascia.
8) Major lymph drainage of rectum above pectinate line goes to?
a) Superficial inguinal nodes
b) Internal iliac nodes
c) Pararectal + inferior mesenteric nodes
d) External iliac nodes
Answer: c) Pararectal + inferior mesenteric nodes
Explanation: Upper rectum drains to pararectal → IMA nodes.
9) The fascia forming the pelvic diaphragm is?
a) Obturator fascia
b) Endopelvic fascia
c) Prevertebral fascia
d) Transversalis fascia
Answer: b) Endopelvic fascia
Explanation: Endopelvic fascia invests levator ani and pelvic organs.
10) Damage to Denonvilliers’ fascia during prostatectomy may affect?
a) Hearing
b) Urinary continence
c) Knee extension
d) Vision
Answer: b) Urinary continence
Explanation: Injury affects neurovascular bundle crucial for continence.
11) Which structure forms part of mesorectum?
a) Gastric lymph nodes
b) Rectal lymphatics
c) Testicular vessels
d) Hepatic ducts
Answer: b) Rectal lymphatics
Explanation: Mesorectum contains fat, lymphatics, superior rectal vessels.