Abdomen 3، تفريغ PDF

‫بيض‬ Block 1.2 lectures 2024-2025 lecture Highlighter key Writer...

‫بيض‬ Block 1.2 lectures 2024-2025 lecture Highlighter key Writer Reviewer Doctor explanation Abbreviation Key information Book >> >> Alaa Alessa Ghassan Al-Nasser 221-222-223 notes References Student explaintion Deleted Abdomen 3 Dr. Omer Musa Mohamed Musa MBBS, MSc. PHD Assistant Professor Department of biomedical science Anatomy division  Theme 6 Intended learning outcomes: By the end of this session, every student should be able to : Describe the abdominal organs Know their relation, position, and parts. Understand their neurovascular supply. 04/11/2024 2 CONTENTS: Spleen. These organs are not necessarily part of the digestive system: Pancreas. Spleen: Reticuloendothelial and lymph Pancreas: Exocrine and Endocrine Liver Liver: Digestive Gall bladder and Biliary system Gallbladder: Digestive Kidneys: Excretory Kidneys Ureter: Excretory Suprarenal: Endocrine Ureter Suprarenal gland. During the second lab we will learn more about the organs (Kidneys specifically)  Important to know: The names of the regions The lines and planes The spleen is an ovoid, usually purplish, pulpy mass about the size and shape of one’s fist. It is relatively delicate and considered the most vulnerable abdominal organ. The spleen is located in the superolateral part of the left upper quadrant (LUQ), or hypochondrium of the abdomen, where it enjoys protection of the inferior thoracic cage. The spleen is highly vascularized; any blunt trauma or injury could cause internal bleeding. Therefore, it is, like the liver, covered by the ribs it is also intraperitoneal, for more protection and motility The relations of the spleen: io r er Posteriorly, the diaphragm, which separates en nt :a le Sto m ach Sp eni (spl c) it from the pleura, lung, and ribs 9–11. t ef flexure L Anteriorly, the stomach. Last lecture: the stomach bed Inferiorly, the left colic flexure Medially, the left kidney. The spleen varies considerably in size, weight, and n le e L eft K shape; however, it is usually approximately 12 cm long Sp and 7 cm wide. id ey n (A nonmetric memory device exploits odd numbers: the spleen is 1 inch thick, 3 inches wide, 5 inches long, Diaphragm and weighs 7 ounces.) S ple e n 9th 11 9 7 5 3 1 Mnemonic ‫طريقة حفظ‬ 10th 7 ounce 5 inches 3 inches 1 inch :‫الطحال يتعلق بالأرقام الفردية لأبعاده‬ 11th Ribs Ribs 9 to 11 wieght long Wide Thick Hilum: indent where blood vessels (artery and vein), lymphatics, innervation... etc., enter/exit the organ The liver, spleen, kidneys, and gallbladder all have hilums  The spleen does not need to be punctured for it to bleed. Blunt trauma (‫ إصابة‬/ ‫ )صدمة‬is enough to cause a vessel tear. One example is car accidents, sudden jutting movement makes a person’s spleen hit the abdominal wall. In case of any severe blood loss, constricting and closing the vessels is necessary to blood pressure and allow blood flow to the head and heart (splenic vasoconstriction) The image is explained more in depth in Histology Blood supply of the spleen The arterial supply of the spleen is from the splenic artery, the largest branch of the celiac trunk. Venous drainage from the spleen flows via the splenic vein, formed by several tributaries that emerge from the hilum. It is joined by the IMV and runs posterior to the body and tail of the pancreas throughout most of its course. The splenic vein unites with the SMV posterior to the neck of the pancreas to form the hepatic portal vein. The splenic vein contributes greatly to the hepatic portal The ‘splenic’ replaces the ‘celiac’ in the venous drainage. venous system (explained more later, at the liver) There is no ‘celiac vein,’ there is a ‘splenic vein’ instead. Therefore, the splenic vein is on of the important veins in the abdomen  Arterial & Venous of the Spleen: Abdominal Celiac Aorta Aorta artery Splenic Artery Spleen’s Hilum Heart Inferior Mesenteric v. Inferior Portal Vena hepatic Splenic v. cava vein Superior mesenteric v.  The splenic artery is tortuous (twisted) behind Gilroy’s anatomy the stomach, because the stomach may expand atlas: p.210 ry en r te A c io r) n i t er ta e p l (pos S ple l A or S m in a Abdo o r) h nk C e li a c t r u nt a c (A o m e ri Splenic artery St The splenic lymphatic vessels leave the lymph nodes in the splenic hilum and pass along the splenic vessels to the pancreaticosplenic lymph nodes and then to the celiac nodes. The nerves of the spleen, are derived from the celiac plexus, are distributed mainly along branches of the splenic artery, and are vasomotor in function Thoracic Cisterna Celiac Splenic Lymph Duct Chyli L.N. nodes  Student’s explanation Central Nervous System (CNS) General Information: Autonomic NS Voluntary NS (skeletal muscles mostly) The central nervous system controls all of the body. It is split to voluntary and autonomic. Parasympathetic NS Sympathetic NS The autonomic has to parts: Sympathetic and Parasympathetic, if one part does something, the Cephalic nerve ten other counteracts it. (the vagus nerve) Or via the Appropriate nerves E.g., the parasympathetic opens a sphincter, then from spinal cord the sympathetic is what will close it. The sacral nerves (Splanchnic nerves) Specific Information: In the thorax and abdomen, most of the Parasympathetic is from the Vagus nerves (Cephalic nerve ten)(which come from the brain), while the Sympathetic is from the spinal cord (there is branches from the spinal cord for all the organs) The lower abdomen and the sacrum / pelvis has the sacral nerve instead of the vagus nerve, for the parasympathetic, but the same sympathetic innervation. The pancreas is an elongated, accessory digestive gland that lies retroperitoneally, overlying and transversely crossing the bodies of the L1 and L2 vertebra (the level of the transpyloric plane) on the posterior abdominal wall. It lies posterior to the stomach between the duodenum on the right and the spleen on the left. Sp c h lee a S t o m r) o ( A n t e ri n The pancreas is: ncreas a denum endocrine: a small amount of it’s cells (Islets of Langerhans) P produce hormones(insulin, glucagon...) Endocrine: direct into blood o exocrine: a majority of the pancreas is exocrine, u D Exocrine: into lumen/duct producing enzymes for digestion For descriptive purposes, the pancreas is divided into four parts: A tumor in head of the pancreas can cause a obstruction in the biliary system. The neck is where the splenic and superior mesenteric veins merge and become the hepatic vein. Also, the neck passes the transpyloric plane that is at L1, so the portal vein is also at L1 The tail is pronated (pointed) towards the hilum of the spleen Tail Body Therefore, during a splenectomy, we have to Head. Neck put great care into isolating the pancreas tail and not affecting it.  ‫الصفحة التالية مصححة ومأشرة‬ The main pancreatic duct unites with the main pancreatic duct to form the short, dilated hepatopancreatic ampulla (of Vater), which opens into the descending part of the duodenum at the summit of the major duodenal papilla. At least 25% of the time, the ducts open into the duodenum separately. The hepatopancreatic sphincter (of Oddi) around the hepatopancreatic ampulla is smooth muscle sphincters that control the flow of bile and pancreatic juice into the ampulla and prevent reflux of duodenal content into the ampulla. The main pancreatic duct unites with the common bile duct to form the short, dilated hepatopancreatic ampulla (of Vater), which opens into the descending part of the duodenum at the summit of the major duodenal papilla. At least 25% of people have the ducts open into the duodenum separately. the pancreas also has a The hepatopancreatic sphincter (of Oddi) around the alternate accessory hepatopancreatic ampulla is smooth muscle sphincters that process that drains control the flow of bile and pancreatic juice into the through the minor papilla ampulla and prevent reflux of duodenal content into the ampulla. This is the most important du n part of the lecture o ct Bi mm A dumb mnemonic (‫)طريقة حفظ‬: Duodenum (second part) co le Hepato- Oddi pancreatic Main Sphincter of Oddi Ampulla of Vater Ampulla Pancreatic = Odie from Garfield = Darth vader Blood supply of the pancreas The arterial supply of the pancreas is derived mainly from the branches of the markedly tortuous splenic artery, and branches of the gastroduodenal and superior mesenteric arteries. Venous drainage from the pancreas occurs via corresponding pancreatic veins.  Arterial supply of the pancreas Dorsal pancreatic artery Splenic Greater pancreatic artery Artery Celiac Inferior pancreatic artery artery Anterior Superior Heart pancreatico- duodenal artery Superior Hepatic Abdominal pancreatico- Posterior Artery duodenal artery Aorta Superior pancreatico- The pancreas is part of both: duodenal artery Foregut, and Anterior Midgut, Inferior pancreatico- Superior Inferior duodenal artery almost all of these arteries Mesenteric pancreatico- anastomose together duodenal artery Posterior artery Inferior pancreatico- duodenal artery  Inferior Mesenteric v. Inferior Heart Portal Vena hepatic Splenic v. cava vein Superior mesenteric v. Venous drainage of the pancreas: The splenic and SMV fuse behind the neck of the pancreas The pancreatic lymphatic vessels follow the blood vessels. to the superior mesenteric lymph nodes or the celiac lymph nodes via the hepatic lymph nodes. The nerves of the pancreas are derived from the vagus and abdominopelvic splanchnic nerves via the celiac plexus and superior mesenteric plexus Celiac Thoracic Cisterna L.N. Splenic Duct Chyli Lymph Superior nodes mesenteric L.N.  The liver Is the largest gland in the body and, after the skin, the Fat is taken largest single organ. It weighs approximately 1500 g. 1.5kg by the lymph Except for fat, all nutrients absorbed from the system gastrointestinal tract are initially conveyed to the liver by the portal venous system. In addition to its many metabolic activities, the liver stores glycogen and secretes bile, a yellow-brown or green fluid that aids in the emulsification of fat. all the venous drainage of The most important the digestive system goes organ in terms of: Because fat doesn’t through the liver clinical study The largest organ: skin, enter the liver, it has to histological study the largest internal organ: liver, be metabolized in the chemical study the largest gland: liver tract by a specialized The liver metabolizes all the drug study fluid, called bile nutrients before they go to diabetic studies the rest of the body The liver lies mainly in the right upper quadrant of the abdomen, where it is protected by the thoracic (rib) cage and the diaphragm. The normal liver lies deep to ribs 7–11 on the right side and crosses the midline toward the left nipple. The liver occupies most of the right hypochondrium and upper epigastrium and extends into the left hypochondrium. The Liver goes from the fourth Because the liver is totally covered So, the liver is examined by intercoastal space (at the nipple) by the ribs in adults, it should not percussion for what is called to the subcoastal line (normally) be able to be palpated the Liver span The liver moves with respiration of the lungs, because it follows the diaphragm The liver has a convex diaphragmatic surface (anterior, superior, and some posterior) and a relatively flat or even concave visceral surface (postero-inferior), which are separated anteriorly by its sharp inferior border that follows the right costal margin inferior to the diaphragm. su rface Imaginary ti c a separating The diaphragmic surface touches gm margin the diaphragm, a flat muscle, so a ce urfa the surface is flat and smooth r S ph a l er Dia While the visceral surface Organs touches many different organs, sc Vi so it is bumpy and uneven  Bile passes from the liver via the biliary ducts -right and left hepatic ducts - that join to form the common hepatic duct, which unites with the cystic duct to form the (common) bile duct. The liver produces bile continuously; however, between meals, it accumulates and is stored in the gallbladder, which also concentrates the bile by absorbing water and salts. der ct Right Lobe du lad ic Gallb exce at ss bi p from le goes he li gallb ver to t ct ladde gh u r Ri d duct Left Lobe, mostly gallblad he c atic on hep der du on Cysti ft ts t m Le o m duct c Bile exi atic p he ct Bi mm co le Hepato- pancreatic Ampulla This is the most important part of the lecture  Gilroy’s anatomy: p.198 Fig. 15.27 Extrahepatic bile ducts Anterior view. Opened: Gallbladder and duodenum. Right Left hepatic hepatic duct duct Cystic duct Common hepatic duct Neck Infundibulum Duodenum, Gall- superior part bladder Body Bile duct Fundus Accessory pancreatic duct Pancreatic Minor duodenal papilla duct Major duodenal papilla Duodenum, Duodenum, descending part horizontal part  Gilroy’s anatomy: p.195 In addition to the fissures, impressions on (areas of) the visceral surface reflect the liver’s relationship to Fig. 15.18 Relations of the liver Visceral (inferior) surface, inferior view. the: Right side of the anterior aspect of the stomach (gastric and pyloric areas). Suprarenal impression Renal Superior part of the duodenum (duodenal area). impression Lesser omentum (extends into the fissure for the Gastric Duodenal Colic ligamentum venosum). impression impression impression Gallbladder (fossa for gallbladder). Liver, right lobe Falciform lig. of liver Liver, left lobe Right colic flexure and right transverse colon (colic Gallbladder area). Hepato- duodenal lig. Stomach, body Lesser omentum Right kidney and suprarenal gland (renal and Hepato- gastric lig. suprarenal areas) Right kidney Right colic flexure Duodenum The relations are similar to those of the spleen, except on the right side of the body It is called caudate because it looks like a tail (remember caudal = ‫)ذيل‬  The liver can be split by many methods, e.g.: Right and left lobes: this is according to the anterior diaphragmatic surface e This is because of the be ob L L e ft Lo t teres hepatis ligament Rig h Round lig. of liver (ligamentum teres hepatis) Right, left, caudate, and quadrate lobes: this is from the inferior visceral surface This is because the Biliary duct and hepatic vein make grooves (next slide) Some people may ignore the caudate and quadrate lobes. only leaving: the left (smaller) lobe and the right (larger) lobe) blood supply of the liver The liver has a dual blood supply (afferent vessels): The hepatic portal vein brings 75–80% of the blood to the liver and carries virtually all of the nutrients absorbed by the alimentary tract to the sinusoids of the liver. Arterial blood from the hepatic artery, accounting for only 20–25% of blood received by the liver, is distributed initially to nonparenchymal structures, particularly the intrahepatic bile ducts. Normally, veins only recieve and drain (afferent), The only purpose for the arteries is oxygen, however in the liver the veins bring in nutrients they do not supply nutrients or any other from the digestive tract (efferent) necessary chemicals  Arterial & Venous Supply of liver: Abdominal Celiac Hepatic Aorta artery Artery Circulatory Heart System: Porta hepatis Oxygen (the liver’s hilum) Inferior Mesenteric v. Portal Digestive hepatic Splenic v. System: Nutrients vein Superior mesenteric v.  Venous drainage of the liver: Right Middle Left Hepatic v. Hepatic v. Hepatic v. Inferior Heart Portal Vena hepatic cava vein from hepatic veins to directly into the inferior vena cava  Normal hepatic tissue, when sectioned, is traditionally described as demonstrating a pattern of hexagonal-shaped liver lobules when viewed under low magnification. Each lobule has a central vein running through its center from which sinusoids (large capillaries) and plates of hepatocytes (liver cells) radiate toward interlobular portal triads (terminal branches of the hepatic portal vein and hepatic artery and initial branches of the biliary ducts). Branch Tributary Supply (afferent) Drain (efferent) all arteries most veins Splits from original vessel Group up into larger vessel  Bile: between the hepatocytes (functional liver cells) the bile is produced, and sent to the bile duct tributary Blood Filtration: the blood comes in from the hepatic portal vein’s branches (and also some blood from the hepatic artery branches), goes through the sinusoids and is filtered by hepatocytes. It continues until the central vein, then collecting into the hepatic veins, then Hepatic artery Hepatic Triad into the inferior vena cava branch Hepatic portal Sinusoid Hepatic This is the only time: Central vein vein branch (a type of capillary) vein veins have branches. Normally, they have tributaries Biliary duct Bile canaliculi tributary + perisinusoidal spaces Efferent lymphatic vessels from the hepatic nodes drain into celiac lymph nodes, which in turn drain into the cisterna chyli (chyle cistern), a dilated sac at the inferior end of the thoracic duct. The liver represents 25-50% of all lymphatic secretions in the body Thoracic Cisterna Celiac hepatic Lymph Duct Chyli L.N. nodes The nerves of the liver are derived from the hepatic plexus, the largest derivative of the celiac plexus. This plexus consists of sympathetic fibers and parasympathetic fibers from vagal trunks. The nerves in the abdomen are almost always going to be: two parasympathetic vagus nerves sympathetic spinal plexus Gallbladder and the biliary systems The biliary ducts convey bile from the liver to the duodenum. Bile is produced continuously by the liver and stored and concentrated in the gallbladder. The right and left hepatic ducts drain the right and left (parts of the) liver, respectively. Shortly after leaving the porta hepatis, these hepatic ducts unite to form the common hepatic duct, which is joined on the right side by the cystic duct to form the common bile duct (CBD). Go to slide.33 The gallbladder : Is (7–10 cm long) lies in the fossa for the gallbladder on the visceral surface of the liver. The relationship of the gallbladder to the duodenum is so intimate, that in its natural position, the body of the gallbladder lies anterior to the superior part of the duodenum, and its neck and cystic duct are immediately superior to the duodenum.  left h e p a Rig h ti c tH uc d t ep ace.Du f Cy r ct ti su r Neck cd s Common The gallbladder has three parts: uct l Hepatic Duct ra live Body f Co Fundus: the wide blunt end that usually projects from Stomach ce mm cavity o Vis on Bile Du the inferior border of the liver at the tip of the right 9th costal cartilage in the MCL. MCL = MidClavicular Line ct Fu ndus Body: the main portion that contacts the visceral Minor duodenal papilla surface of the liver, transverse colon, and superior part of the duodenum. Midclavicular line Neck: narrow, tapering end, opposite the fundus and directed toward the porta hepatis; it typically makes an S-shaped bend and joins the cystic duct. 8th The cystic duct (3–4 cm long) connects the neck of the gallbladder to the common hepatic duct. The mucosa of the neck spirals into the spiral fold. Body 9th undu s F 10th The arterial supply of the gallbladder and cystic duct is from the cystic artery. The cystic artery commonly arises from the right hepatic artery in the triangle between the common hepatic duct, cystic duct, and visceral surface of the liver, the cystohepatic triangle (of er uct liv of Calot). Variations occur in the ile d ce rfa The cystohepatic triangle of calot su nb origin and the course of the ior is important for surgeries. mo fer The cystic artery commonly goes In cystic artery. Com Cystic duct into this triangle Jaundice is yellow discoloration of the skin. it can be split into three types (based upon locus): Pre-hepatic jaundice Pre-hepatic jaundice Hepatic jaundice Pre-hepatic jaundice Post-hepatic jaundice (a.k.a. obstructive jaundice): obstruction of the biliary system, most commonly: 1. tumor of the head of the pancreas 2. gallbladder stones (Cholelithiasis), no effect until reaching common bile duct Ways of visualizing the gallbladder and CBD: endoscope of the stomach, injecting dye through the sphincter of Oddi into the gallbladder this is called ERCP(Endoscopic Retrograde CholangioPancreatography) ‫قال نصا أنه مستحيل يسأل عنه‬  Abdominal Celiac Hepatic Cystic Aorta artery Artery Artery Cystohepatic triangle of calot Heart Nothing was mentioned about the venous, lymphatics, nor innervation. : ‫ فهو‬،‫ رغم أنه غير مهم‬،‫إذا صحيح ناويين تعرفون‬ cystic ____ goes to hepatic ____ to _____ ‫لجميعهم‬  More discussion about these in the second practical The kidneys, the ureters, and suprarenal gland. The kidneys produce urine that is conveyed by the ureters to the urinary bladder in the pelvis. The superomedial aspect of each kidney normally contacts a suprarenal gland, A weak fascial septum separates the glands from the kidneys; thus they are not actually attached to each other. they are on the posterior there is a pleura around the they receive about 10% of all cardiac about abdominal wall. lungs that has to be cared for through their renal arteries, which are during kidney surgeries. directly branched from the aorta. most kidney surgeries are Costodiaphragmatic recesses done from the behind and the Costamediastinal recesses of the pleura of the thorax the hila (plural of hilum) of the kidneys are medially orientated The kidneys remove excess water, salts, and wastes of protein metabolism from the blood while returning nutrients and chemicals to the blood. They lie retroperitoneally on the posterior abdominal wall, one on each side of the vertebral column at the level of the T12–L3 vertebrae.  During life, the kidneys are reddish brown and measure approximately 10 cm in length, 5 cm in width, and 2.5 cm in thickness. in inches: 1", 2", 4" Superiorly, the posterior aspects of the kidneys are associated with the diaphragm, which separates them from the pleural cavities and the 12th pair of ribs. Reminder: all unspecified measurements are for healthy normal adults. Unless if stated for children of in cases of inflammation, assume it is talking about adults The renal arteries arise at the level of the IV disc between the L1 and L2 vertebrae. The longer right renal artery passes posterior to the IVC. Typically, each artery divides close to the hilum into five segmental arteries which are end arteries.  The kidney itself is divided into the cortex and medulla.  the pelvis: the region where the ureter joins the kidney The renal pelvis is the flattened, funnel- shaped expansion of the superior end of the ureter. The apex of the renal pelvis is continuous with the ureter. The renal pelvis receives two or three major calices (calyces), each of which divides into two or three minor calices. Each minor calyx is indented by a renal papilla, the apex of the renal pyramid, from which the urine is excreted. The ureters are muscular ducts (25– 30 cm long) with narrow lumen that carry urine from the kidneys to the urinary bladder. They run inferiorly from the apices of the renal pelvis at the hila of the kidneys, passing over the pelvic brim at the bifurcation of the common iliac arteries. This is what the ureter looks like on The ureter has three imaging or a pyelogram. Stones in the constrictions: 1st, where it joins ureter are very common. the renal pelvis; 2nd, where it is crossed by the external iliac artery, causing a narrowing; and 3rd, where it enters the bladder. The bladder is mostly in the pelvis but when it is full it may extend to the anterior surface of the abdomen this is why we call it an abdominopelvic organ  The suprarenal gland is divided into the cortex and medulla. The suprarenal (adrenal) glands, yellowish in living persons, are located between the superomedial aspects of the kidneys and the diaphragm, where they are surrounded by connective tissue containing considerable perinephric fat. The suprarenal glands are enclosed by renal fascia by which they are attached to the crura of the diaphragm. Although the name “suprarenal” implies that the kidneys are their primary relationship, their major attachment is to the diaphragmatic crura.  The medulla is a modified They receive arterial blood sympathetic ganglion. supply from a pair of The cortex has three layers: the suprarenal arteries and they zona glomerulosa, zona will drain on the right side the fasciculata, and zona reticularis. right suprarenal vein to (the details in histology) inferior vena cava and on the left side the left suprarenal vein will drain into the left renal Each layer produces different types of hormones Gilroy’s anatomy: p.217 “The medulla is a modified sympathetic ganglion”, ‫موسى‬ meaning it functions like a sympathetic ganglion (a cluster of nerve cells in the sympathetic nervous system), but instead of transmitting nerve signals, it releases hormones directly into the bloodstream.  team Wishes you the best