Anatomy of the Abdomen II PDF

ANATOMY OF THE ABDOMEN Danny Strein ABDOMINAL VISCERA Viscera: The internal organs in the main cavities of the body: ABDOMINAL CAVITY: • Esophagus • Liver • Stomach • Spleen • Small Intestine • Kidneys • Large Intestine • Gallbladder • Rectum • Pancreas • Appendix • Adrenal Glands http://...

ANATOMY OF THE ABDOMEN Danny Strein ABDOMINAL VISCERA Viscera: The internal organs in the main cavities of the body: ABDOMINAL CAVITY: • Esophagus • Liver • Stomach • Spleen • Small Intestine • Kidneys • Large Intestine • Gallbladder • Rectum • Pancreas • Appendix • Adrenal Glands http://umm.edu/~/media/adam/images/en/19574.ashx ABDOMINAL VISCERA MESENTERY: • Double layer of peritoneum • The loose connecting tissues that suspend and hold together the organs of the gastrointestinal tract allow them to expand and to slide against each other • Allows for neurovascular communication between organs and body wall • Allows for mobility of viscera • Mesocolon – Colon invested in mesentery SUBDIVISIONS OF THE PERITONEAL CAVITY SUBDIVISIONS: Transverse mesocolon divides abdominal cavity into: • Supracolic compartment – contains stomach, liver and spleen • Infracolic compartment – contains small intestine, ascending and descending colon • Lies posterior to the greater omentum • Communication between these 2 compartments is accomplished via the paracolic gutters • Provides pathway for spread of infection and flow of ascites https://s3.amazonaws.com/classconnection/455/flashc ards/4844455/jpg/picture3-14FE67CB7AF66B5A8EC.jpg SUBDIVISIONS OF THE PERITONEAL CAVITY * ABDOMINAL VISCERA ALIMENTARY TRACT: • Mouth/Pharynx  Esophagus  Stomach  Small Intestine Large Intestine  Rectum  • Hollow muscular canal within the body but technically outside of it = external • THINK DOUGHNUT • Endocrine glands are those that release their products directly into the blood stream • Ex: adrenals, ovaries/testes, thyroid • Exocrine glands secrete their products into ducts, which typically make their way out of the body • Ex: sweat, salivary, mammary ABDOMINAL VISCERA ESOPHAGUS: • A muscular tube extending from pharynx to stomach • • • • 25 cm/10-12 in in length; diameter: 2 cm Lined by inner layer of mucosa Retroperitoneal Follows curvature of spine • Made up of circular and external longitudinal layers • Superior 1/3rd = voluntary striated muscle • Middle 1/3rd = both • Inferior 1/3rd = smooth involuntary muscle • Enters the abdomen through the Esophageal Hiatus • Terminates at the Esophagogastric Junction ABDOMINAL VISCERA TERMINAL ESOPHAGUS: • Esophagogastric Junction AKA Z-line: • Marked internally by abrupt transition from esophageal to gastric mucosa = squamous epithelium  columnar epithelium • Barrett’s Esophagus • Just superior to this junction diaphragmatic musculature at the esophageal hiatus functions as inferior esophageal sphincter • Sphincter is closed when not eating • Prevents regurgitation of gastric contents • Hiatal Hernia https://connection.asco.org/sites/asco_connection/files/styles/article_image/public/arti cles/images/AC-2015-09_747x556_CIO2.jpg?itok=oUEBPoPB BARRETT’S ESOPHAGUS http://agimedical.com/wp-content/uploads/2015/05/barretts_arrows.gif http://www.uhhospitals.org/~/media/UH/Images/services/Barretts-lesion-lg.jpg http://www.massgeneral.org/digestive/assets/images /interior/barretts_esophagus_300x224.jpg HIATAL HERNIA http://www.chestx-ray.com/images/igallery/resized/1100/69-78-500-500-100.jpg https://images.radiopaedia.org/images/220869/76052 f7902246ff862f52f5d3cd9cd_jumbo.jpg http://www.massgeneral.org/generalsurgery/assets/images/hiatal-hernia.jpg NORMAL CXR http://lifeinthefastlane.com/wp-content/uploads/2010/08/Normal-CXR-Labelled.jpg ABDOMINAL VISCERA ESOPHAGEAL NEUROVASCULATURE: • Arterial Supply: from esophageal branches of the Left gastric artery (branch of celiac trunk) and Left inferior phrenic artery • Venous Drainage: to portal venous system through Left gastric vein ESOPHAGEAL INNERVATION: • Innervation is from vagal trunk, thoracic sympathetic trunks via the greater and lesser splanchnic nerves and the esophageal nerve plexus ABDOMINAL VISCERA STOMACH: • Pear-shaped enlargement of the alimentary canal linking the esophagus to the small intestine • Located in the LUQ • Intraperitoneal • Food blender and reservoir • Chief function = enzymatic digestion • Gastric juice converts food bolus into semi-liquid – “chyme” • Passes from stomach into small intestine (duodenum) • Consists of 4 parts and 2 curvatures • Has 3 layers of smooth muscle ABDOMINAL VISCERA STOMACH: • 4 Parts: • Cardia: tumpet shaped opening of esophagus into stomach • Surrounds cardial orifice • Cardial notch between esophagus and fundus • Fundus: dilated superior portion • Reaches left 5th intercostal space • Body: lies between fundus and pyloric antrum • Pylorus: funnel shaped • Pyloric Antrum • Pyloric Canal • Pyloric Sphincter – thickening of circular layer of smooth muscle – closes off duodenum ABDOMINAL VISCERA STOMACH: • 2 Curvatures: • Lesser Curvature: • Shorter concave border • Lesser omentum attaches here * * * • Greater Curvature: • Longer convex border • Greater omentum attaches here • Interior of stomach = smooth when relaxed or distended with food • Rugae: gastric folds that form during contraction • Most marked along greater curvature near pylorus ABDOMINAL VISCERA GASTRIC VASCULATURE: • Arterial supply: Gastric arteries from the celiac trunk and its branches: • Lesser Curvature: • *Left gastric artery arises directly from the celiac trunk • Right gastric artery arises from the hepatic artery • Greater Curvature: • Right gastro-omental artery (gastroepiploic artery) arises from gastroduodenal artery • Left gastro-omental artery arises from the splenic artery • Fundus and Upper Body: • Short gastric arteries (4 or 5 of them) arise from the splenic artery * * * * * * ABDOMINAL VISCERA GASTRIC VASCULATURE: • Venous Drainage: Gastric veins run parallel along the arteries • Left and Right gastric veins drain into the hepatic portal vein • *Short gastric vein and the Left gastro-omental vein drain into the splenic vein, which joins the Superior Mesenteric Vein (SMV) to form the hepatic portal vein • R. gastro-omental v. empties into the SMV * * * * * ABDOMINAL VISCERA GASTRIC INNERVATION: • Parasympathetic: from anterior and posterior vagal trunks • Sympathetic: from T6-T9 passes to celiac plexus via greater splanchnic nerves * * ABDOMINAL VISCERA SMALL INTESTINE: • 3 parts: • Duodenum • Jejunum • Ileum • Extends from the pylorus to the ileocecal junction • ~20 feet long • Suspensory ligament = Ligament of Treitz https://www.cancer.gov/images/cdr/live/CDR751388.jpg ABDOMINAL VISCERA SMALL INTESTINE: • Duodenum • First and shortest part of small intestine ~12 inches • Widest portion; C-shaped; most fixed • Four segments: • • • • Superior (1st)  has mesentery (duodenal mesocolon) = mobile Descending (2nd) Horizontal (3rd) Ascending (4th) • Distal 3 parts have no mesentery and are immobile because they are retroperitoneal • Iron absorbed here http://teachmeanatomy.info/wpcontent/uploads/Parts-of-the-Duodenum-SmallIntestine.jpg • Suspended by Ligament of Treitz at 3rd and 4th sections • Proximal to Ligament of Treitz = Upper GI tract • Distal to Ligament of Treitz = Lower GI tract ABDOMINAL VISCERA SMALL INTESTINE: • Duodenum 1. Superior  located at L1 • Free edge of lesser omentum attaches here = hepatoduodenal ligament = anterior boundary of the foramen of Winslow 2. Descending  L1-L3 – curves around head of pancreas • Ampulla of Vater (union of common bile duct and main pancreatic duct) located here • Sphincter of Oddi controls entry of bile and pancreatic juice 3. Horizontal  L3 • Anterior to IVC and aorta • Posterior to SMA and SMV 4. Ascending  L3-L2 • Ends at duodenojejunal junction  forms acute angle = duodenojejunal flexure • Flexure supported by Ligament of Treitz http://oddi.net/wp-content/uploads/2012/05/19214.jpg http://oddi.net/wp-content/uploads/2012/05/composite.jpg ABDOMINAL VISCERA DUODENAL VASCULATURE: • Arterial Supply: Duodenal arteries arise from celiac trunk and SMA • Celiac trunk  gastroduodenal artery and its branch superior pancreaticoduodenal artery Supplies the first (superior) and second (descending) portions of duodenum • SMA  inferior pancreaticoduodenal artery Supplies the third (horizontal) and fourth (ascending) parts of the duodenum SMA * * * * * http://images.slideplayer.com/19/5777955/slides/slide_22.jpg ABDOMINAL VISCERA DUODENAL VASCULATURE: • Venous Drainage: Duodenal veins follow the arteries and drain into the hepatic portal vein through the SMV and splenic veins DUODENAL INNERVATION: • Sympathetic: Greater and lesser splanchnic nerves via the celiac and superior mesenteric plexuses • Parasympathetic: Vagus nerve SMV http://www.daviddarling.info/images/portal_vein.gif ABDOMINAL VISCERA SMALL INTESTINE: • Jejunum • • • • • Proximal 2/5 Begins at duodenojejunal flexure at L2 Mainly in LUQ Intraperitoneal Absorption of majority of nutrients occurs in jejunum • Ileum • • • • • Distal 3/5 Longest portion RLQ Responsible for reabsorption of Vitamin B12 and bile salts Final portion of Small Intestine - ends at ileocecal junction ABDOMINAL VISCERA SMALL INTESTINE: • Jejunum vs. Ileum CHARACTERISTIC JEJUNUM ILEUM Color Deeper red Paler pink Caliber 2-4 cm 2-3 cm Wall Thick and heavy Thin and light Vascularity Greater Less Vasa Recta Long Short Arcades (arterial arches) Few large loops Many short loops Fat in Mesentery Less More Circular folds (plicae circulares) Large, tall, closely packed Low and sparse; absent in distal part ABDOMINAL VISCERA JEJUNAL/ILEAL VASCULATURE: • Arterial Supply: SMA from abdominal aorta supplies • jejunum and ileum SMA sends many branches to the jejunum/ileum which unite to form loops/arches = arterial arcades • Arcades give rise to straight arteries = vasa recta • Venous Drainage: SMV unites with the splenic vein to form the hepatic portal vein http://thoracickey.com/wpcontent/uploads/2016/08/B9781437715606000500_f050-0029781437715606.jpg ABDOMINAL VISCERA JEJUNAL/ILEAL INNERVATION: • SMA and its branches are surrounded by a perivascular nerve plexus • Sympathetic: T5-T9 segments of the spinal cord reach the celiac plexus through the sympathetic trunk and the thoracic splanchnic nerves • Reduce motility of intestine (making energy available for “fight or flight”  directs blood to more essential organs) • Parasympathetic: Posterior Vagal trunk • Increase motility of intestine * * * CLINICAL PEARLS ISCHEMIC BOWEL: • Caused by occlusion of the vasa recta by an embolus https://www.gastrohep.com/images_pdfs/images/medium/pdevit t25.jpg • May result in necrosis • Symptoms include: pain, distention, vomiting, fever, dehydration • “Pain out of proportion to physical exam” • SURGICAL EMERGENCY! • Who is at risk for this? Patient population? CLINICAL PEARLS Meckel’s Diverticulum: • A true congenital diverticulum • Slight bulge in the small intestine • Present at birth and a vestigial remnant of the omphalomesenteric duct (yolk stalk) • ~2 feet from the ileocecal valve • Present in 2% of population MECKEL’S DIVERTICULITIS: • Infection of a Meckel’s diverticulum https://api.kramesstaywell.com/Conten t/6e06e751-71b1-40a9-a155a404014fcaa2/ucr-imagesv1/Images/image-97562 ABDOMINAL VISCERA LARGE INTESTINE: • Segments: • Cecum • Colon • • • • Ascending Transverse Descending Sigmoid • Rectum • Anal Canal http://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2013/08/26/10/23/ds00035_im01666_colon_gif.jpg ABDOMINAL VISCERA LARGE INTESTINE: • Distinguishing Characteristics: • Teniae coli – 3 superficial longitudinal bands of smooth muscle • Not present in appendix or rectum • Haustra – pouches of colon between teniae • Omental appendices – fatty projections of omentum • Caliber – larger diameter http://teachmeanatomy.info/wp-content/uploads/Features-of-LargeIntestine-Hausta-and-Tenia-Coli.jpg http://missinglink.ucsf.edu/lm/ids_106_lowergi/lower%20gi/ASSETS/COLON1.GIF ABDOMINAL VISCERA LARGE INTESTINE: • Length: 5 feet (1.5 meters) • Begins at the ileocecal junction; Ends at the rectum • CECUM: • 1st part of large intestine • Intraperitoneal • Blind sac into which the ileum opens (ileocecal orifice  ileocecal valve) • Located in RLQ • Primary water absorption site • APPENDIX: • AKA: vermiform appendix • Blind diverticulum • Attached to Cecum below ileocecal junction by mesoappendix • Position varies  65% retrocecal • McBurney’s Point CLINICAL PEARL McBurney’s Point: • Point over the right side of the abdomen that is one-third of the distance from the ASIS to the umbilicus • Roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum • PAIN ON PALPATION  APPENDICITIS http://img.webmd.com/dtmcms/live/webmd/consumer_as sets/site_images/media/medical/hw/hwkb17_007_09.jpg https://pbs.twimg.com/media/AmiY3l pCAAEST-5.jpg CLINICAL PEARL APPENDICITIS: • M/C cause of acute abdomen requiring surgery • M/C cause of appendicitis = Fecolith • Classic presentation: • Severe peri-umbilical pain that migrates to the RLQ • Can be confirmed with US or CT scan • Decision to go to OR is mainly clinical • Treatment: Surgical • Open vs. Laparoscopic https://scontent.cdninstagram.com/t51.288515/s640x640/sh0.08/e35/12798157_974118136028983_1955083406_n.jpg?ig_cache_key=MTIwNjg http://www.patient-help.com/wp-content/uploads/2015/07/Laparoscopic-appendix-surgery-in3ODU4NzY5NzQxNjQzNA%3D%3D.2 Bangalore.png ABDOMINAL VISCERA APPENDICEAL/CECAL VASCULATURE: • Arterial Supply: • Cecum  ileocolic artery – terminal branch of SMA • Appendix by appendicular artery – branch of ileocolic • Venous Drainage: • Ileocolic vein branch of SMV drains both APPENDICEAL/CECAL INNERVATION: • nerve supply derives from sympathetic and parasympathetic nerves of superior mesenteric plexus • Sympathetic: lower thoracic part of spinal column (T10-T12) • Parasympathetic: derive from vagus nerve https://www.google.com/search?q=vascular+supply+of+appendix&safe=off&rlz=1C1CHBF_enUS726US726&espv=2&biw=642& bih=712&source=lnms&tbm=isch&sa=X&ved=0ahUKEwitmeKW957SAhWG4IMKHZAIDE4Q_AUIBigB#imgrc=GlWQ Xh8bKP-M: ABDOMINAL VISCERA LARGE INTESTINE: • ASCENDING COLON: • Retroperitoneal – does not have a mesentery • On Right side of abdomen • Extends from the cecum to the right colic flexure called the hepatic flexure • Separated from anterolateral abdominal wall by greater omentum • Paracolic gutter lies lateral to ascending colon • ASCITES http://images.slideplayer.com/13/4156882/slides/slide_6.jpg Paracolic Gutters ABDOMINAL VISCERA LARGE INTESTINE: • TRANSVERSE COLON: • Intraperitoneal – has a mesentery called the transverse mesocolon • Transverse mesocolon adherent to posterior wall of omental bursa (lesser sac) • Largest and most mobile part • Extends from hepatic flexure to the left colic flexure called the splenic flexure ABDOMINAL VISCERA LARGE INTESTINE: • DESCENDING COLON: • • • • Retroperitoneal – does not have a mesentery On Left side of abdomen Extends from the splenic flexure to the sigmoid colon Paracolic gutter lies lateral to descending colon • ASCITES • SIGMOID COLON: • Intraperitoneal - has a mesentery called the sigmoid mesocolon • Links descending colon with rectum • S – shaped; long mesentery • Extends to the rectosigmoid junction • Signified by termination of teniae coli • Major site of Diverticulitis DIVERTICULITIS: https://www.mayoclinic.org/diseasesconditions/diverticulitis/symptoms-causes/syc-20371758 CLINICAL PEARLS https://www.researchgate.net/figure/Remaining-barium-in-thediverticula-at-48-h-post-procedure-After-48-h-of-liberaloral_fig2_233336569 ABDOMINAL VISCERA RECTUM: • Distal to recto-sigmoid junction • Starts at S3 • No teniae coli • Retroperitoneal • Innervated by parasympathetic fibers for relaxation • Rectal Ampulla: dilated terminal portion where stool accumulates • As rectal walls expand stretch receptors stimulate urge to defecate • If not acted upon more water is reabsorbed – if prolonged, feces can harden  CONSTIPATION • Aganglionic – Hirschprung’s Disease • Sigmoid unable to relax (constricted) – can’t pass stool  MEGACOLON • Typically congenital https://i.ytimg.com/vi/kb_RXbthr64/hqdefault.jpg https://images.radiopaedia.org/images/16823266/a390e8266ef263ab83d3841ad993b5_j umbo.jpeg ABDOMINAL VISCERA ANAL CANAL: • Terminal part of large intestine – extends from anorectal junction to anus • Terminates at the dentate line • HEMORRHOIDS – dilated blood vessels AKA varicosities • Above = Internal  Not Painful • Below = External  Painful https://image.slidesharecdn.com/haemorrhoidspiles-130411123145phpapp02/95/haemorrhoids-piles-3-638.jpg?cb=1365684186 ABDOMINAL VISCERA COLIC VASCULATURE: • Arterial Supply: Superior Mesenteric Artery (SMA) • Supplies the pancreas, duodenum, jejunum, ileum, ascending colon and right side of the transverse colon • Arises from the aorta at L1 Branches of the SMA: • Before entering the mesentery it gives off branches to the duodenum and the pancreas to the right • Jejunal and ileal arteries number up to 20 • Each divides and anastomoses with its neighbors; forms arterial arcades from which straight arterioles extend to the gut SMA ABDOMINAL VISCERA COLIC VASCULATURE: • Arterial Supply: Superior Mesenteric Artery (SMA) / Inferior Mesenteric Artery (IMA) Branches to large intestine: • Ascending colon  Ileocolic and Right colic • Ileocolic branches to the appendix  appendicular artery • Transverse colon • Middle colic  proximal 2/3 • Left colic (branch of IMA)  distal 1/3 • IMA Arises at L3 • Descending colon  branches of IMA  Left colic a d n Superior sigmoid artery • Sigmoid colon  Same as Descending • Rectum  Superior rectal SMA * IMA * * * * * ABDOMINAL VISCERA COLIC VASCULATURE: • Arterial Supply: The Marginal Artery (of Drummond) • A continuous arterial channel around the inner margin of the large intestine from the cecocolic junction to the rectosigmoid junction • All arteries of the colon contribute to it • Connects the IMA to the SMA • Just before splenic flexure, blood supply shifts: • SMA = proximally • IMA = distally https://s3.amazonaws.com/classconnection/630/flashcards/9446630/png/screen_shot_2016-0205_at_43825_pm-152B35F4D8E78F0B8AD.png ABDOMINAL VISCERA COLIC VASCULATURE: • Venous Drainage: Superior Mesenteric Vein (SMV) / Inferior Mesenteric Vein (IMV) • SMV drains the pancreas, duodenum, jejunum, ileum, ascending colon and proximal transverse colon • Runs parallel and to the right side of the SMA • IMV drains distal transverse colon, descending colon, sigmoid and rectum • IMV drains into the splenic vein, which drains into the portal vein • IMV does not run parallel to the IMA, it diverges to the left and superiorly • SMV joins with the splenic vein behind the neck of the pancreas to form the Portal vein which enters the porta hepatis SMV * * http://www.daviddarling.info/images/portal_vein.gif https://classconnection.s3.amazonaws.com/962/flashcards/3550962/jpg/portal_vein-141C966A2463D7B54FE.jpg ABDOMINAL VISCERA COLIC VASCULATURE: • Venous Drainage: Hepatic Portal Vein • Confluence of the splenic vein and the superior mesenteric vein • Lies posterior to the hepatic artery and medial to the common bile duct • Lymphatic Drainage: • Drainage of ascending and transverse colon is into the superior mesenteric nodes • Drainage of descending colon and sigmoid drain into the inferior mesenteric nodes • Lymphatics converge to form the intestinal lymphatic trunk which empties into a saccular enlargement at the end of the thoracic duct called the cisterna chyli ABDOMINAL VISCERA COLIC INNERVATION: • MIDGUT structures supplied by Superior Mesenteric Plexus • Ascending colon: Superior mesenteric plexus • Transverse colon: proximal 2/3 – Superior mesenteric plexus; distal 1/3 – Inferior mesenteric plexus • HINDGUT structures supplied by Inferior Mesenteric Plexus • Descending colon: • Sympathetic: Inferior mesenteric plexus, lumbar splanchnic nerves • Parasympathetic: Pelvic splanchnic nerves to Vagus • Sigmoid colon: • Same innervation as Descending SPLEEN: ABDOMINAL VISCERA • Mobile lymphatic organ responsible for: • RBC production and breakdown • Synthesizing antibodies • Removing antibody-coated bacteria, etc. • Intraperitoneal  Posteriorly located in the left upper quadrant, it extends forward to the midaxillary line http://images.slideplayer.com/15/4556738/slides/slide_21.jpg • Associated posteriorly with 9th – 11th ribs • LUQ  size of clenched fist • Traube’s (semilunar) space • Percuss for splenomegaly  Mono, trauma, infection, Sickle Cell Disease ABDOMINAL VISCERA SPLEEN: • Connected to greater curvature of stomach by gastrosplenic ligament and to L kidney by splenorenal ligament • Gastrosplenic: AKA Gastrolienal • Extends from the stomach to spleen, contains short gastric arteries* • Deceleration injury  rupture of gastrosplenic ligament  massive hemorrhage • Fractured 10th/11th ribs can lacerate the spleen • Splenorenal: AKA Lienorenal • Extends from left kidney to spleen • Contains the tail of the pancreas and splenic vessels ABDOMINAL VISCERA SPLENIC NEUROVASCULATURE: • Arterial Supply: Splenic Artery • Largest branch of celiac trunk • Venous Drainage: Splenic Vein • IMV branches off of it • Joins SMV to form Hepatic Portal Vein • Innervation: • Celiac plexus PANCREAS: ABDOMINAL VISCERA • Elongated accessory digestive gland • Retroperitoneal • Shape similar to the Letter J • Posterior to stomach; between duodenum on right and spleen on left • Endocrine and Exocrine functioning: • Endocrine: glucagon and insulin(somatostatin) from pancreatic islets of Langerhans that enter blood • Exocrine: pancreatic juice containing digestive enzymes from acinar cells that enter duodenum directly ABDOMINAL VISCERA PANCREAS: • Divided into 4 parts: 1. Head • Contains uncinate process – projection from inferior portion • behind superior mesenteric artery and vein • Bile duct lies in a groove on the posterosuperior surface • Surrounded by duodenum 2. Neck • Overlies superior mesenteric vessels which form a groove posteriorly 3. Body • Largest part of pancreas • Located between neck and tail 4. Tail • Extends into the hilum of the spleen through the lienorenal ligament https://image.slidesharecdn.com/dk-141230014009-conversion-gate02/95/anatomyof-pancreas-7-638.jpg?cb=1473659958 PANCREAS: ABDOMINAL VISCERA • Ducts of the Pancreas • Main Pancreatic Duct AKA Duct of Wirsung • Begins in the tail and runs to the head  turns inferiorly and merges with the common bile duct (CBD) forming the hepatopancreatic ampulla or ampulla of Vater • Empties into the Descending Duodenum at Major Duodenal Papilla • Allows for exocrine release of pancreatic juices • Clinical significance: obstruction or inflammation of the pancreatic duct may lead to acute pancreatitis • M/C cause for obstruction is choledocholithiasis, or gallstones in the CBD * https://s-media-cache-ak0.pinimg.com/564x/11/f0/f4/11f0f4e070f1b2184c7e453209e1cd9a.jpg * http://cfile5.uf.tistory.com/image/2545F84351BDC3222E3C4E PANCREAS: ABDOMINAL VISCERA • Ducts of the Pancreas • Accessory Duct AKA Duct of Santorini • Drains the uncinate process and inferior part of the head of the pancreas • Opens into the duodenum at the Minor Duodenal Papilla of descending duodenum • Usually communicates with main pancreatic duct but in some people = separate duct • Allows for direct exocrine release ABDOMINAL VISCERA PANCREATIC VASCULATURE: • Arterial Supply: • Body of the pancreas supplied by small branches of the splenic artery off celiac trunk • Head and neck of the pancreas supplied by anterior and posterior superior pancreaticoduodenal artery (branches of the gastroduodenal artery) and the anterior and posterior inferior pancreaticoduodenal artery (branches of the SMA) Ampulla of Vater: • Important landmark: halfway along the second part of the duodenum (descending) • Marks the anatomical transition from foregut to midgut = the point where the celiac trunk stops supplying the gut and the SMA takes over Celiac Trunk * * https://www.researchgate.net/profile/Alper_Cesmebasi/publication/265646348/figure/fi g4/AS:272620557959180@1442009214110/Figure-1-The-vasculature-of-the-pancreas-Thearterial-supply-is-derived-from-branches.png ABDOMINAL VISCERA PANCREATIC VASCULATURE: • Venous Drainage: • Pancreatic veins = tributaries of the splenic vein, SMV, and portal vein – but most empty into splenic vein https://d1yboe6750e2cu.cloudfront.net/i/fb6db655a43fe5dff95056b1fa36d0f526be919b ABDOMINAL VISCERA PANCREATIC INNERVATION: • Nerves derived from the vagus and abdominopelvic splanchnic nerves passing through the diaphragm • Parasympathetic and sympathetic reach the pancreas through the celiac plexus and the superior mesenteric splanchic plexus https://bedahunmuh.files.wordpress.com/2010/10/innervation-of-the-pancreas.jpg ABDOMINAL VISCERA LIVER: Facts: • Largest internal organ of human body - 1500g • Surrounded by Glisson’s capsule • Intraperitoneal • Lies in RUQ, inferior to diaphragm • Receives 25% of cardiac output and has greatest blood reserve • Except for lipids, every substance absorbed by the alimentary tract is received first by the liver • Stores glycogen; secretes bile • Can regenerate  transplants http://biomechanical.asmedigitalcollection.asme.org/data/journals/jbendy/27171/002009jby1.jpeg LIVER: ABDOMINAL VISCERA Surfaces of Liver: • Diaphragmatic Surface: • Convex diaphragmatic surface is separated from diaphragm by subphrenic space, which is separated by the falciform ligament into R and L subphrenic spaces • Falciform Ligament extends between liver and anterior abdominal wall • Diaphragmatic surface is covered by peritoneum, except for posterior bare area, which is in direct contact with diaphragm https://d1yboe6750e2cu.cloudfront.net/i/3c50629109fdf8dab749d2851cb698991c504f33 ABDOMINAL VISCERA LIVER: Surfaces of Liver: • Visceral Surface: • Hepatorenal recess (Morrison’s pouch) • Subhepatic space of peritoneal cavity inferior to liver and anterior to Right kidney and adrenal gland • Communicates anteriorly with R subphrenic space  fluid from omental bursa flows into this space • Gravity dependent when person is supine • Visceral surface is covered with peritoneum except at the bed of the gallbladder and at the PORTA HEPATIS MORRISON’S POUCH https://en.wikipedia.org/wiki/Hepatorenal_recess_of_subhepatic_space#/media/ File:Morison003.jpg https://en.wikipedia.org/wiki/Hepatorenal_recess_of_subhepatic_space#/med ia/File:Morrisons-with-fluid.jpg ABDOMINAL VISCERA LIVER: Porta Hepatis “Doorway to the Liver” • Deep fissure in the inferior surface of the liver through which the hepatic portal vein, hepatic artery, hepatic nerve plexus, hepatic ducts, and lymphatic vessels pass • Allows passage of PORTAL TRIAD • Porta Hepatis = hilum = an indentation through which arteries, duct, nerves, etc. can enter/exit an organ • Located between the quadrate and the caudate lobes • Lesser omentum attaches here; continuous with visceral peritoneum of the liver What enters the porta hepatis? 1. Portal vein 2. Right and Left hepatic arteries 3. Nerve fibers What exits via the porta hepatis? 1. Right and Left hepatic ducts 2. Lymphatic vessels LIVER: ABDOMINAL VISCERA Portal “Triad” • MISNOMER • Traditionally only included: • Hepatic Artery • Hepatic Portal Vein • Bile Duct • Lymphatics and branch of Vagus Nerve also included http://www.knowyourbody.net/wp-content/uploads/2013/01/Porta-hepatis-Picture.jpg • Enclosed by the lesser omentum  *hepatoduodenal ligament* LIVER: ABDOMINAL VISCERA Lobes of Liver: • Based on external features the liver is described as having four lobes: • • • • Right Left Caudate Quadrate • Functionally, however, liver is divided into independent Right and Left lobes based on blood supply and glandular secretion  portal lobes http://www.knowyourbody.net/wp-content/uploads/2013/01/Porta-hepatis-Picture.jpg * http://1.bp.blogspot.com/-bREg9NKydk/UcgBkcS77_I/AAAAAAAAAuM/v2vOqxe806Q/s400/liver1b.gif Anterior * LIVER: ABDOMINAL VISCERA Lobes of Liver: • Anatomical large Right Lobe is separated from the smaller Left lobe by the Falciform Ligament and Left Sagittal Fissure • Right Sagittal Fissure = continuous groove formed by the fossa for the gallbladder anteriorly and the groove for the IVC posteriorly • Right Lobe: • Caudate Lobe: posterior and superior • Quadrate Lobe: anterior and inferior ABDOMINAL VISCERA LIVER: Lobes of Liver: • Anatomical Left lobe divided from caudate and quadrate on the visceral surface by: • Left Sagittal Fissure = fissure for the Round Ligament (Ligamentum Teres) + fissure for the Ligamentum Venosum • Round Ligament = the remains of the umbilical vein • Round ligament (Ligamentum teres) can lacerate liver in deceleration trauma • Ligamentum Venosum = the remnant of the fetal ductus venosus • The attachment of the Falciform Ligament on the diaphragmatic surface divides Right lobe from Left ABDOMINAL VISCERA LIVER: Lobes of Liver: • Right and Left lobes can also be divided by Cantlie’s line • An imaginary line that runs from the gallbladder to the IVC • Lobes are further divided into 8 segments, which has important surgical implications • Each segment supplied by a portal triad (artery, vein, duct)  liver has 8 hilums • Segment V contains fossa of Gallbladder http://www.radiologyassistant.nl/data/bin/a5635d0f0862a0_Liver-real-Cantlie's-line.jpg http://www.nature.com/nrclinonc/journal/v11/n8/images/nrclinonc.2014.90-f1.jpg ABDOMINAL VISCERA HEPATIC VASCULATURE: • Arterial Supply: • Liver receives blood from 2 sources • Hepatic Portal Vein • Supplies 75-80% • Hepatic Artery • Supplies 20-25% • Venous Drainage: • Hepatic Veins (Right, Intermediate/Middle, Left) open into the IVC inferior to diaphragm • Attachments of these veins help to hold liver in position https://image.slidesharecdn.com/cirrhosis-140123035051-phpapp01/95/cirrhosis-8638.jpg?cb=1390449163 ABDOMINAL VISCERA HEPATIC INNERVATION: • Nerves from hepatic nerve plexus • Sympathetic: from celiac plexus (AKA solar plexus) • Parasympathetic: from anterior and posterior vagal trunks ABDOMINAL VISCERA GALLBLADDER: • Pear shaped “storage sack,” adherent to segment V of the liver • Resides in the gallbladder fossa on the visceral surface • Bound to liver by peritoneum = Intraperitoneal • Drains stored bile via the cystic duct into the common hepatic duct that becomes the common bile duct • Receives arterial blood supply via the cystic artery • Contracts when stimulated by CCK (cholecystokinin) from the pancreas ABDOMINAL VISCERA GALLBLADDER: • Made up of 3 parts: • Fundus • Body • Neck • S-shaped • Joins cystic duct • Cystic duct connects the neck of gallbladder to the common hepatic duct, which it joins, forming the common bile duct http://www.healthhype.com/wp-content/uploads/gallbladder_anatomy.jpg ABDOMINAL VISCERA CHOLECYSTIC VASCULATURE: • Arterial Supply: • Cystic artery supplies the gallbladder and cystic duct arising from the Right hepatic artery • Venous Drainage: • Cystic veins drain the biliary ducts and neck of gallbladder • May pass to liver directly or drain through the hepatic portal vein to the liver • Veins from the fundus and body of the gallbladder pass directly into the visceral surface of the liver and drain into the hepatic sinusoids GALLBLADDER: ABDOMINAL VISCERA • Triangle of Calot: Common Hepatic Duct • AKA Cystohepatic triangle or Hepatobilliary triangle • Anatomic triangle used during laparoscopic cholecystectomy to locate the cystic artery, which is found within it • Borders: • Inferior border of the Liver – superiorly • Common Hepatic Duct – medially Cystic Duct • Cystic Duct – inferiorly Cystic Artery ABDOMINAL VISCERA CHOLECYSTIC INNERVATION: • Sympathetic: Nerves to the gallbladder and the cystic duct pass along the cystic artery from the celiac plexus • The celiac plexus innervates the organs of the upper abdominal cavity • Parasympathetic: Vagus nerve • Sensory: Right phrenic nerve BILIARY DUCTS: ABDOMINAL VISCERA • Bile = produced in the liver, stored in the Gallbladder • Bile breaks down lipids • When food enters the duodenum, the gallbladder sends bile through cystic and bile ducts to the duodenum • The right and left hepatic ducts drain their respective parts of the liver http://www.mumbaicancer.com/images/bile-duct1.jpg ABDOMINAL VISCERA BILIARY DUCTS: • After leaving the hepatic portal, these ducts join to form the common hepatic duct, which is joined by the cystic duct to form the bile duct (common bile duct) • Common bile duct travels behind the first part of the duodenum and the head of the pancreas, joins with the main pancreatic duct to empty posteromedially at the main duodenal papilla (Ampulla of Vater) into the 2nd part of the duodenum http://www.mumbaicancer.com/images/bile-duct1.jpg BILIARY DUCTS: ABDOMINAL VISCERA • Sphincter of Oddi: • AKA Hepatopancreatic Sphincter • Smooth muscle sphincter that controls the flow of bile and pancreatic juices into the duodenum • When it contracts bile cannot enter the duodenum • Backs up along cystic duct to gallbladder where it is stored http://www.mumbaicancer.com/images/bile-duct1.jpg CLINICAL PEARL GALLBLADDER: • Cholelithiasis AKA Gallstones • 85% are cholesterol stones = radiolucent • Won’t show up on an Xray • 15% are pigmented stones = radiopaque • Usually as a result of a hemolytic anemia • Will show up on an Xray https://upload.wikimedia.org/wikipedia/commons/d/d0/Porcelain_gallbladder.png • Cholecystitis • Inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gallbladder • Choledocholithiasis • Gallstone becomes lodged in CBD https://image.slidesharecdn.com/l30gallstonesstudent-140523060734phpapp01/95/l30-gallstones-student-25-638.jpg?cb=1400825342 http://image.wikifoundry.com/image/1/Lkuv5qcXc x7aRfmRaHNVIw512095/GW570H493 ABDOMINAL VISCERA VASCULATURE OF THE CBD: • Arterial Supply: • Cystic artery supplies the proximal part of the duct • Right hepatic artery supplies the middle part • Posterior superior pancreaticoduodenal artery off the gastroduodenal artery supplies the retroduodenal part • Venous Drainage: • Veins from the proximal part of the duct and the hepatic ducts empty into the liver directly • The posterior superior pancreaticoduodenal vein drains the distal part of the bile duct and empties into the Portal vein ABDOMINAL VISCERA PORTAL VENOUS SYSTEM: • Hepatic Portal Vein is the main channel of the portal venous system • Collects poorly oxygenated but nutrient rich blood from the GI tract and spleen carries it to the liver where it filters through the sinusoids and collects in the IVC  heart • Gallbladder, pancreas, spleen • Not a true vein, because it does not conduct blood directly to the heart but instead feeds capillaries • Formed by the confluence of the superior mesenteric and splenic veins • The portal venous system communicates with the systemic venous system in the following locations: GI tract, spleen, SMV, IMV, gastric and sometimes cystic veins * * * * * * http://radiologykey.com/wp-content/uploads/2015/12/B9781416053354000794_f1.jpg ABDOMINAL VISCERA PORTAL VENOUS SYSTEM: Portal-Systemic Anastamoses: • Areas in which the portal venous system communicates with the systemic venous system: • Between the esophageal veins draining into either the azygos (systemic) or the L gastric vein (portal) • When dilated these cause esophageal varices * * * ABDOMINAL VISCERA PORTAL VENOUS SYSTEM: • Portal-Systemic Anastamoses: • Between the rectal veins the inferior and middle veins which drain into the IVC (systemic); and the superior rectal vein continuing as the IMV (portal) • When dilated these cause hemorrhoids • Paraumbilical veins of the anterior abdominal wall (systemic) anastomosing with superficial epigastric veins (portal) • When dilated these produce caput medusa • Lower abdominal organs (Female Reproductive) drain into left and right common iliac veins http://www.etsu.edu/com/medicalmystery/pictures/caput_medussa.jpg Caput Medusa CLINICAL PEARL • “Head of Medusa" • The appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins • The umbilical vein carries oxygenated blood from mother to fetus in utero, and normally closes within one week of birth • In portal hypertension the umbilical vein can become re-canalized https://www.google.com/search?q=medusa&safe=off&rlz=1C1CHBF_enUS726US726&sxsrf=ACYBGNTTe3woULfEt9g9zdt TGlwEIQQHIg:1580794745643&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjwipuql7fnAhXGmnIEHSNnCjsQ_AUoAXoEC BEQAw&biw=1243&bih=700#imgrc=rFPAEeLI8Tx-tM http://www.etsu.edu/com/medicalmystery/pictures/caput_medussa.jpg ABDOMINAL VISCERA KIDNEYS: • Retroperitoneal • Level of T12-L3 • Remove excess water, salts, and wastes from blood, which are then converted into urine which drains through the ureters, which are inferior to kidneys, to the urinary bladder • The superomedial aspect of each kidney contacts a suprarenal gland, which function as part of the endocrine system, completely separate from the kidneys https://image.slidesharecdn.com/unit13genitourinarysystem-140218075545-phpapp02/95/unit-13-genitourinary-system-3-638.jpg?cb=1392710958 ABDOMINAL VISCERA KIDNEYS: • Location: • Two kidneys: • Located on each side of the spine • Right kidney usually slightly lower than the Left • L1-L4 • Left kidney usually slightly more medial than the Right • T12-L3 • Due to asymmetry of abdominal cavity • Bean-shaped – with medial concave and lateral convex border KIDNEYS: ABDOMINAL VISCERA • Structure: • Surrounded by tough fibrous tissue known as the renal capsule • Surrounded by Gerota’s fascia • Renal Hilum: • Entrance to the Renal Sinus • Located at the concave medial margin of each kidney • Parenchyma made up of fat in which, renal pelvis, calyces, vessels and nerves are embedded • Point where renal artery and nerves enter kidney and renal vein and ureter exit • Renal vein is anterior to renal artery at the hilum ABDOMINAL VISCERA KIDNEYS: • Structure: • Parenchyma of kidney made up of two major structures: • Renal Cortex (outer) • Renal Medulla (inner) • Renal Pyramids divided by Renal Columns • Nephrons  urine-producing functional structures of the kidney • Span the cortex and medulla • Initial filtering portion of a nephron is the renal corpuscle which is located in the cortex • Renal corpuscle connects to renal tubule that passes from the cortex deep into the medullary pyramids then rebounds and eventually connects to the collecting duct • The tip, or papilla, of each pyramid empties urine into a minor calyx • Minor calyces empty into major calyces • Major calyces empty into the renal pelvis, which becomes the ureter KIDNEYS: • Structure: • Renal Pelvis: ABDOMINAL VISCERA • Formed by 2-3 major calices, which are formed by 2-3 minor calices • Superior expanded end of the ureter • The kidneys receive blood from the paired renal arteries and drain into the paired renal veins • Cycle through 100% of the blood supply multiple times/day • Each kidney then excretes urine into a ureter, itself a paired structure that empties into the urinary bladder • Function: • • • • Homeostasis – regulation of electrolytes, fluid balance Maintenance of Acid-Base balance Regulation of Blood Pressure Filter the blood and remove wastes URETER: ABDOMINAL VISCERA • Muscular (smooth) ducts that carry urine from the kidney to the bladder • Superior, expanded end = renal pelvis made up for 2-3 major calices • Usually 10-12 inches long • Normally constricted at 3 places: • Junction of the ureter and the renal pelvis • Where the ureters cross the brim of the pelvic inlet • During their passage through the wall of the urinary bladder • Potential sites of obstruction by kidney stones • Most stones = calcium oxalate • Treatment options: • Pass them • Lithotripsy • Surgery http://images.medicinenet.com/images/appictures/kidney-stones-s2-illustration.jpg ABDOMINAL VISCERA ADRENAL/SUPRARENAL GLANDS: • Retroperitoneal • Triangular Right gland and semilunar Left gland • Endocrine glands • Two distinct structures: • • Suprarenal cortex secretes corticosteroids, in response to stress, and androgens Suprarenal medulla secretes catecholamines • Epinephrine and Norepinephrine • “Fight or flight” • The adrenal glands affect kidney function through the secretion of aldosterone ABDOMINAL VISCERA RENAL VASCULATURE: • Arterial Supply: • Each Renal artery divides into 5 segmental arteries, that are distributed to the segments of the kidney • Venous Drainage: • Renal vein lies anterior to arteries and drains into the IVC http://mandevillehigh.stpsb.org/teachersites/laura_decker/renal_circ.GIF ABDOMINAL VISCERA URETERAL VASCULATURE: • Arterial Supply: • Arteries to the ureters arise mainly from 3 sources: • Renal artery • Testicular or ovarian artery • Abdominal aorta • Venous Drainage: • Veins of the ureters drain into the renal and testicular or ovarian veins http://vignette2.wikia.nocookie.net/analytical/images/9 /96/Ureter.jpg/revision/latest?cb=20100828022735 ABDOMINAL VISCERA ADRENAL VASCULATURE: Endocrine function makes abundant blood supply necessary: • Arterial Supply: • Superior suprarenal artery (6-8) from the inferior phrenic artery • Middle suprarenal artery (1 or more) from aorta • Inferior suprarenal (one or more) from the renal artery • Venous Drainage: • Right suprarenal vein into IVC* • Left suprarenal vein, often joined by inferior phrenic vein, empties into Left renal vein* ** ** http://histonano.com/books/Junqueira's%20Basic%20Histology%20PDF%20WHOLE%20BOOK/New%20folder%2020/loadBinary_013.gif ABDOMINAL VISCERA RENAL, URETERAL AND SUPRARENAL INNERVATION: • Renal comes from the renal plexus, which is supplied by the fibers from the thoracic splanchnic nerves • Ureteral derive from the renal, abdominal aortic, and superior hypogastric plexuses • Suprarenal (Adrenal)comes from the celiac plexus and thoracic splanchnic nerves https://s32.postimg.org/7jw6kgmwl/ureteric_nerves.jpg FIN.