Posterior Abdominal Wall — MCQs
A building contractor suddenly complains of lower backache which increases on bending down. He has:
Which structure lies midway between the anterior superior iliac spine and pubic symphysis?
Which of the following is not felt with a digital rectal examination?
Howship-Romberg sign is seen in
Which of the following statements about the Levator Ani is false?
All the following structures form boundaries of the epiploic foramen, except:
Which of the following structures does not pass through the greater sciatic foramen?
The structure which lies outside the femoral sheath is:
Which of the following statements about Sibson's fascia is correct?
Which of the following structures is separated from the left kidney by a peritoneal layer?
Posterior Abdominal Wall Indian Medical PG Practice Questions and MCQs
Question 1: A building contractor suddenly complains of lower backache which increases on bending down. He has:
- A. Fibrositis
- B. Disc prolapse (Correct Answer)
- C. Tuberculosis of spine
- D. Renal colic
Explanation: ***Disc prolapse*** - A building contractor's occupation involves frequent **bending and lifting**, which are common mechanisms leading to a **disc prolapse** [2], [3]. - Pain that **increases on bending down** is a classic symptom of disc prolapse, as this movement puts increased pressure on the affected intervertebral disc [2], [3]. *Fibrositis* - **Fibrositis** (now more commonly referred to as **fibromyalgia**) is characterized by widespread musculoskeletal pain, fatigue, and tender points [1]. - It does not typically present with pain exacerbated specifically by **bending down** in the way described for a localized backache. *Tuberculosis of spine* - **Tuberculosis of the spine (Pott's disease)** is a chronic infection that presents with more insidious symptoms like constitutional symptoms (fever, weight loss) and progressive neurological deficits [4]. - The sudden onset of backache and its exacerbation with bending are not typical primary symptoms, which often include bone destruction and **vertebral collapse** [4]. *Renal colic* - **Renal colic** is characterized by severe, spasmodic pain in the flank, often radiating to the groin, typically caused by kidney stones. - The pain is usually unrelated to movement and is not typically described as a "lower backache" that increases specifically with **bending down**.
Question 2: Which structure lies midway between the anterior superior iliac spine and pubic symphysis?
- A. Femoral artery (Correct Answer)
- B. Deep inguinal ring
- C. Superior epigastric artery
- D. Inguinal ligament
Explanation: ***Femoral artery*** - The **femoral artery** is a direct continuation of the external iliac artery and is the most reliable palpable pulse in the groin area. [1] - Its surface marking is clinically important as it's found midway between the **anterior superior iliac spine (ASIS)** and the **pubic symphysis**, specifically at the **mid-inguinal point**. [1] *Deep inguinal ring* - The **deep inguinal ring** is located at the **midpoint of the inguinal ligament** (midway between ASIS and pubic tubercle), which is approximately 1.5 cm above and lateral to the mid-inguinal point. - It marks the beginning of the **inguinal canal** and is the site where the vas deferens and gonadal vessels exit the abdominal cavity. *Superior epigastric artery* - The **superior epigastric artery** is a terminal branch of the internal thoracic artery and primarily supplies the upper abdominal wall. [2] - It is located in the anterior abdominal wall, far from the inguinal region and the midpoint between the ASIS and pubic symphysis. [2] *Inguinal ligament* - The **inguinal ligament** extends between the anterior superior iliac spine and the pubic tubercle, forming the inferior border of the anterior abdominal wall. - While relevant to the region, the ligament itself is a fibrous band, not a structure found *midway between* the ASIS and pubic symphysis in the same way the femoral artery is.
Question 3: Which of the following is not felt with a digital rectal examination?
- A. Seminal vesicles
- B. Prostate
- C. Rectovesical pouch
- D. Ureter (Correct Answer)
Explanation: ***Ureter*** - The **ureters** are too deep and medially located to be reliably palpated during a **digital rectal examination** (DRE). - They are typically not accessible through the rectal wall due to their anatomical position posterior to the urinary bladder and prostate (in males). *Seminal vesicles* - The **seminal vesicles** are located superior to the prostate and can sometimes be palpated, especially if enlarged or inflamed. - They are adjacent to the posterior surface of the bladder and anterior to the rectum. *Prostate* - The **prostate gland** is directly anterior to the rectum and is the primary structure evaluated during a **DRE**. - Its size, consistency, and any nodules or tenderness can be assessed. *Rectovesical pouch* - The **rectovesical pouch** is the peritoneal reflection between the rectum and the bladder in males. - While not a distinct organ to "feel," pathology within this space (e.g., fluid collections, masses) can sometimes be appreciated as a fullness or mass effect above the prostate via the DRE.
Question 4: Howship-Romberg sign is seen in
- A. Spigelian hernia
- B. Femoral hernia
- C. Inguinal hernia
- D. Obturator hernia (Correct Answer)
Explanation: ***Obturator hernia*** - The **Howship-Romberg sign** is characterized by **medial thigh pain** on hip extension, adduction, and internal rotation, which is indicative of an obturator hernia. - This symptom arises from compression of the **obturator nerve** as it passes through the obturator canal alongside the hernia sac. *Spigelian hernia* - A Spigelian hernia presents as a **ventrolateral abdominal wall defect**, typically between the rectus abdominis muscle and linea semilunaris. - It usually causes localized pain and a palpable lump but does not involve **obturator nerve compression**. *Femoral hernia* - A femoral hernia manifests as a bulge in the **groin region** below the inguinal ligament, often presenting as an emergent strangulated hernia. - While it can cause groin pain, it does not typically involve the **obturator nerve** or present with the **Howship-Romberg sign**. *Inguinal hernia* - Inguinal hernias are common, presenting as a bulge in the groin, either **direct or indirect**, above the inguinal ligament. - Symptoms include a palpable mass and discomfort, but not the specific **medial thigh pain** associated with obturator nerve compression.
Question 5: Which of the following statements about the Levator Ani is false?
- A. Converges downwards & medially
- B. Attached to the pelvic brim. (Correct Answer)
- C. Made up of iliococcygeus, pubococcygeus, and puborectalis.
- D. Supports pelvic viscera.
Explanation: Attached to the pelvic brim - This statement is **false** because the levator ani does not attach to the pelvic brim (the inlet of the true pelvis). - The levator ani originates from: the **posterior surface of the body of pubis**, the **tendinous arch of obturator fascia** (thickening of obturator fascia on lateral pelvic wall), and the **ischial spine**. - All these attachments are on the **lateral pelvic wall below the pelvic brim**, not at the pelvic brim itself. - The muscles insert into the **perineal body**, **anococcygeal ligament**, and walls of pelvic viscera. *Converges downwards & medially* - This statement is **true** - the levator ani muscles arise from lateral attachments on the pelvic sidewalls and converge **medially and downward** toward the midline. - This creates the characteristic **funnel-shaped pelvic diaphragm** that narrows inferiorly. - The fibers run inferomedially to form a muscular sling supporting pelvic structures. *Supports pelvic viscera* - This is the **primary function** of the levator ani muscle group [1]. - It forms a muscular floor that supports the **bladder, uterus/prostate, and rectum**, preventing prolapse. - The muscle maintains the position of pelvic organs against intra-abdominal pressure. *Made up of iliococcygeus, pubococcygeus, and puborectalis* - This statement is **correct** - the levator ani consists of three main components [1]: - **Puborectalis** - forms a sling around the anorectal junction, important for fecal continence [1]. - **Pubococcygeus** - middle portion, supports pelvic viscera [1]. - **Iliococcygeus** - most posterior portion, extends from ischial spine to coccyx [1].
Question 6: All the following structures form boundaries of the epiploic foramen, except:
- A. Inferior vena cava
- B. First part of duodenum
- C. Quadrate lobe of liver (Correct Answer)
- D. Portal vein
Explanation: ***Quadrate lobe of liver*** - The **quadrate lobe of the liver** forms part of the visceral surface of the liver and is located between the gallbladder and the round ligament, but it does not directly form a boundary of the **epiploic foramen** [1]. - The **epiploic foramen** (Foramen of Winslow) is an opening between the greater and lesser sacs of the peritoneum, whose boundaries are primarily formed by specific ligamentous and vascular structures [1]. *Portal vein* - The **portal vein** is a component of the **portal triad** (which also includes the proper hepatic artery and common bile duct) that forms the **anterior boundary** of the epiploic foramen. - These structures are enclosed within the **hepatoduodenal ligament**, a crucial part of the anterior boundary. *Inferior vena cava* - The **inferior vena cava (IVC)** forms the **posterior boundary** of the epiploic foramen [1]. - It runs along the posterior abdominal wall, behind the structures of the epiploic foramen [1]. *First part of duodenum* - The **first part of the duodenum** forms part of the **inferior boundary** of the epiploic foramen. - Specifically, the superior border of the first part of the duodenum helps define the lower aspect of the foramen's entrance.
Question 7: Which of the following structures does not pass through the greater sciatic foramen?
- A. Piriformis
- B. Superior gluteal nerve
- C. Inferior gluteal nerve
- D. Obturator nerve (Correct Answer)
Explanation: ***Obturator nerve*** - The **obturator nerve** passes through the **obturator foramen** into the medial compartment of the thigh, not the greater sciatic foramen. - Its primary function is to innervate the **adductor muscles** of the thigh and provide sensory innervation to the medial thigh. *Piriformis* - The **piriformis muscle** passes through the **greater sciatic foramen**, dividing it into suprapiriform and infrapiriform spaces. - It runs from the anterior surface of the **sacrum** to the greater trochanter of the femur. *Superior gluteal nerve* - The **superior gluteal nerve** passes through the **suprapiriform part** of the greater sciatic foramen. - It innervates the **gluteus minimus**, **gluteus medius**, and **tensor fasciae latae muscles**. *Inferior gluteal nerve* - The **inferior gluteal nerve** passes through the **infrapiriform part** of the greater sciatic foramen. - It specifically innervates the **gluteus maximus muscle**.
Question 8: The structure which lies outside the femoral sheath is:
- A. Genitofemoral nerve
- B. Femoral vein
- C. Femoral artery
- D. Femoral nerve (Correct Answer)
Explanation: ***Femoral nerve*** - The **femoral nerve** lies lateral to the femoral artery and is therefore situated outside the **femoral sheath**, which encloses the femoral artery, femoral vein, and lymphatic vessels [2]. - It originates from the lumbar plexus (L2-L4) and provides motor innervation to the quadriceps femoris and sensory innervation to the anterior thigh and medial leg. *Femoral artery* - The **femoral artery** is a primary content of the **femoral sheath**, occupying the most lateral compartment. - It is a continuation of the external iliac artery and is a major blood supply to the lower limb. *Femoral vein* - The **femoral vein** lies within the **femoral sheath**, positioned medial to the femoral artery. - It is the primary vein responsible for draining blood from the lower limb and eventually becomes the external iliac vein. *Genitofemoral nerve* - The **genitofemoral nerve** typically emerges on the anterior surface of the psoas major muscle and then usually divides into genital and femoral branches [1]. - While its femoral branch supplies sensory innervation to the skin over the femoral triangle, it does not course within the femoral sheath itself but rather anterior to it or outside its immediate vicinity [1].
Question 9: Which of the following statements about Sibson's fascia is correct?
- A. Part of scalenus anterior muscle
- B. Vessel pass above the fascia
- C. Covers apical part of lung (Correct Answer)
- D. Attached to the inner border of 2nd rib
Explanation: ***Covers apical part of lung*** - **Sibson's fascia**, also known as the **suprapleural membrane**, is a dense fascial layer that covers and reinforces the **apex of the lung** and pleura. - It protects the lung apex and helps to support structures in the **root of the neck**. *Part of scalenus anterior muscle* - Sibson's fascia is a **separate fascial structure** extending from the first rib to the C7 transverse process, and is not a part of the scalenus anterior muscle. - The **scalenus anterior muscle** is one of the muscles of the neck, and while anatomically related by proximity to the fascia, it is not structurally part of it. *Vessel pass above the fascia* - Key neurovascular structures like the **subclavian artery** and the **brachial plexus** pass *below* Sibson's fascia, as the fascia protects the lung apex. - The fascia acts as a barrier, separating the lung apex from the more superficial structures of the neck. *Attached to the inner border of 2nd rib* - Sibson's fascia is primarily attached to the **inner border of the first rib** and the transverse process of the seventh cervical vertebra. - Its attachment to the first rib is crucial for its supportive role over the lung apex.
Question 10: Which of the following structures is separated from the left kidney by a peritoneal layer?
- A. Pancreas
- B. Jejunum (Correct Answer)
- C. Splenic flexure
- D. Splenic vessels
Explanation: ***Jejunum*** - The **jejunum**, being part of the intraperitoneal small intestine, is separated from the left kidney by a layer of **peritoneum** as it lies anterior to the kidney. - While the left kidney is retroperitoneal, the jejunum is intraperitoneal and separated by the **peritoneum** that lines the posterior abdominal wall. - This is the **most consistent and complete peritoneal separation** among the options. *Pancreas* - The **pancreas** (tail and body) lies anterior to the left kidney and is **retroperitoneal** [1]. - It is not separated from the left kidney by a peritoneal layer; instead, it is situated in the **anterior pararenal space** along with the kidney [1]. - Only the anterior surface of the pancreas is covered by peritoneum. *Splenic flexure* - While the **splenic flexure** is intraperitoneal and technically has peritoneum between it and the kidney, it often has **direct contact** with the kidney's lower pole via peritoneal reflections [2]. - The **phrenicocolic ligament** creates a shelf-like structure that can bring the splenic flexure into close proximity with the kidney. - The peritoneal separation is **less consistent** compared to the jejunum, making it a less ideal answer. *Splenic vessels* - The **splenic vessels** (artery and vein) run along the superior border of the pancreas, anterior to the left kidney, within the **retroperitoneal space** [1]. - These vessels are located in the **anterior pararenal space** and are not separated from the kidney by peritoneum [1].
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