Abdomen with questions .pdf

Stomach, Spleen, Liver and Gall Bladder Arunabh Bhattacharya, PhD Office B256 Phone: 283-6356 Email: [email protected] Wednesday, September 27, 2023 May not be used or reproduced without written permission from the SOM Introduction The viscera of the abdomen constitute the majority of the alimen...

Stomach, Spleen, Liver and Gall Bladder Arunabh Bhattacharya, PhD Office B256 Phone: 283-6356 Email: [email protected] Wednesday, September 27, 2023 May not be used or reproduced without written permission from the SOM Introduction The viscera of the abdomen constitute the majority of the alimentary system: the terminal part of the esophagus and the stomach, intestines, spleen, pancreas, liver, gallbladder, kidneys, and suprarenal glands. During this session, the learners will be introduced to the gross anatomy and function of stomach, spleen, liver and gall bladder, their relationships to other structures, their vasculature and finally, their nerve supply. Session Outcomes 1. Describe the gross anatomy of the abdominal viscera (stomach, spleen, liver and gall bladder) and their relationship with surrounding structures. 2. Discuss the vasculature and nerve supply of the stomach, spleen, liver and gall bladder. Recommended Reading Moore, et al. Clinically Oriented Anatomy. 9th Ed. Chapter 5 Abdomen, Sections: Stomach, Spleen, Liver, Gall bladder and ducts; pg. 454-457, 458-466, 493-494, 497-509. 1. Is the stomach intra- or retroperitoneal? intraperitoneal 2. What are the vessels that supply the lesser curvature of the stomach? What are the origin of the vessels? left and right gastric a. left gastric a. – celiac trunk right gastric a. – proper hepatic a. 3. What are the vessels that drain the greater curvature of the stomach? These vessels are tributaries of what veins? left and right gastroepiploic v. left gastroepiploic v. – splenic v. right gastroepiploic v. - SMV 4. What is the location of cell bodies of pre-ganglionic and post-ganglionic sympathetic neurons that cause constriction of vessels that supply the stomach? lateral horn T6-T9 celiac ganglion 5. Which of the following organs/muscle lies posterior to the stomach? (a) pancreas (b) liver (c) diaphragm (d) transverse colon pancreas Stomach – Gross Anatomy and Relationships Function: enzymatic digestion Location: RUQ and LUQ Relationships: anterior: diaphragm, liver, anterior abdominal wall posterior: pancreas, omental bursa (lesser sac) inferior and lateral: transverse colon Arterial Supply of the Stomach Lesser Curvature – left and right gastric a. Greater curvature – left and right gastroepiploic a. Fundus, posterior wall – short gastric a., posterior gastric a. Venous Drainage of the Stomach Lesser Curvature – left and right gastric v. (hepatic portal v.) Greater curvature – left gastroepiploic v. (splenic v.) and right gastroepiploic v. (superior mesenteric v.) Fundus – short gastric v. (splenic v.) Innervation of the Stomach Parasympathetic (dorsal motor nucleus - vagus n.) Sympathetic (lateral horn T6-T9 – greater splanchnic n. – celiac ganglion) 1. Is the spleen intra- or retroperitoneal? intraperitoneal 2. What is the blood supply to the spleen? What is the origin of the vessel? splenic a., celiac trunk 3. What is the location of cell bodies of post-ganglionic sympathetic neurons that produce contraction of spleen to release RBCs into circulation? celiac ganglion Spleen - Gross Anatomy and Relationships Function: Part of the immune system Location: Intraperitoneal, located in the greater sac of the peritoneum between diaphragm and the stomach, left upper quadrant anterior: stomach posterior: left part of diaphragm inferior: left colic flexure medial: left kidney, tail of pancreas Vasculature of the Spleen Innervation of the Spleen spleen Purely sympathetic: produces contraction of spleen to release RBCs into circulation 1. What structure attaches the liver to the anterior abdominal wall? falciform ligament 2. The fossa for gallbladder lies between which two lobes of the liver? quadrate and right lobes 3. The right and left hepatic arteries arise from the _____________? hepatic artery proper Liver • • Attached to the inferior surface of the diaphragm Moves with respiration Functions • Drug metabolism • Bile production • Glycogen storage • Gluconeogenesis • Blood clotting factors Liver - Diaphragmatic surface Right • Smooth, dome shaped • Covered by peritoneum • Diaphragmatic surface Left Falciform ligament • Right lobe (larger) • Left lobe • Falciform ligament Round ligament of the liver • Falciform ligament – Attaches liver to anterior abdominal wall and diaphragm – Remnant from the ventral mesentery of the fetal stomach – Contains round ligament of the liver (ligamentum teres hepatis) in free edge - remnant of left umbilical vein Liver - Diaphragmatic surface Coronary ligament – Reflection of the peritoneum which attaches the liver to the diaphragm – Has anterior lamina and posterior lamina which are joined laterally by the right and left triangular ligaments – Bare area is bounded by these lamina and ligaments and is not covered with peritoneum Coronary ligament Left triangular ligament Inferior border Separates diaphragmatic from visceral surface Liver: Visceral Surface Visceral surface • Quadrate lobe • Caudate lobe • Left lobe • Right lobe Relations to the visceral surface • Stomach • Duodenum • Gallbladder • Right colic flexure • Right kidney THE “H” OF THE VISERAL SURFACE Fissure for ligamentum venosum Fossa for inferior vena cava L Inferior vena Ligamentum venosum cava (fibrous remnant of ductus venosus) C R Q Fissure for round ligament of liver Porta hepatis Fossa for gallbladder Round ligament of liver (remnant of the umbilical vein) Gallbladder -contains fissure for round ligament of the liver and Porta Hepatis: Rightofside contains ligament the portal vein, proper hepatic artery, attachment falciform hepatic-Fissure ducts, vagal -fossa nerves for theand gallbladder lymphaticand vessels for ligamentum venosum attachment of -attachment -fossafor forhepatoduodenal inferior vena cava ligament hepatogastric ligament Blood Supply of the Liver Common hepatic artery Proper hepatic artery Right and left hepatic arteries ~30% of the blood is delivered to the liver by the hepatic arteries. Hepatic Portal System System of veins taking blood from parts of the GI tract to the liver -beginning and ending in capillary like vessels ~70% of the blood is delivered to the liver by the portal vein and its branches The portal and arterial blood mix Venous blood is drained from the liver directly into the inferior vena cava by the hepatic veins Hepatic Portal Venous System RA spleen IMV Innervation of the Liver • Hepatic plexus (part of celiac plexus) – sympathetic + parasympathetic (vagus) • Accompanies hepatic artery and hepatic portal vein • Vasoconstriction 1. What vessel is ligated within the triangle of Calot for laparoscopic cholecystectomy (removal of the gall bladder)? A. cystic artery B. common hepatic artery A C. gastroduodenal artery 2. The hepatopancreatic ampulla opens via the major duodenal papilla into the _________ part of the duodenum. A. 1st B B. 2nd C. 3rd Gallbladder-Location and Function • Located on visceral surface of liver in the fossa for gallbladder • Stores and concentrates bile • Expels bile into duodenum - bile emulsifies fats (lipids) Gallbladder-Duct system Right hepatic duct Liver makes bile Left hepatic duct Cystic duct Common hepatic duct Bile duct Hepatopancreatic ampulla Main pancreatic duct Rt & Lf hepatic ducts Common hepatic duct Enter gallbladder through cystic duct Or Enters bile duct Empties in 2nd part of Duodenum • Bile is secreted by liver continuously • Hepatopancreatic (Vater) ampulla – common bile + main pancreatic duct meet and enter duodenum – Sphincter of Oddi around it – closed when bile not needed for digestion • Bile then backs up into gallbladder via cystic duct • When needed gallbladder contracts, sphincters open Blood Supply of the Gallbladder/Ducts • cystic artery: supplies the proximal part of the bile duct, gall bladder and cystic duct. • right hepatic artery: supplies the middle part of the duct. • posterior superior pancreaticoduodenal artery and gastroduodenal artery: supplies the retroduodenal part of the duct. Veins and Nerves of the Gallbladder/Ducts The venous drainage from proximal bile duct, hepatic ducts, cystic duct and neck of gallbladder enter the liver directly via cystic veins. Body and fundus of gallbladder – drain into hepatic sinusoids Distal part of bile duct is drained via posterior superior pancreaticoduodenal vein, typically into hepatic portal vein. posterior superior pancreaticoduodenal vein not shown here Nerves to the gallbladder and cystic duct - sympathetic - vasoconstriction - parasympathetic (vagus) - contractions of the gallbladder and relaxation of the sphincters at the hepatopancreatic ampulla - afferent for pain (e.g. gallbladder inflammation, right phrenic nerve) – referred pain