GIT - Abdominal Viscera 1 and 2 2024 Presentation Upload.pdf

Abdominal Viscera (1 and 2) Dr Rex Barton-Smith BSc (Clin Sci), MHSc (Osteo), Grad.Cert.Tert.Ed 1  Learning Outcomes Describe the location of abdominal viscera with respect to abdominal quadrants, anatomical relationships Describe th...

Abdominal Viscera (1 and 2) Dr Rex Barton-Smith BSc (Clin Sci), MHSc (Osteo), Grad.Cert.Tert.Ed 1  Learning Outcomes Describe the location of abdominal viscera with respect to abdominal quadrants, anatomical relationships Describe the major anatomical relationships of each abdominal viscus Identify and describe the major features of each abdominal viscus Orientate each abdominal viscus and describe their functions with reference to major features Comprehend and identify potential visceral variations with reference to the typical appearance Comprehend basic clinical examples relating to the abdominal viscera 2  Abdominal Overview 3 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.31 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.2 Abdominal Quadrants Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #260A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #260B 4 Abdominal Regions and Planes 5 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Tab 2.1  Abdominal Oesophagus Oesophagus enters the abdominal cavity by passing through the diaphragm at the level of T10 Oesophagus is surrounded by the right crus – functional sphincter Anterior and posterior vagal trunks travel with the oesophagus from the thorax to the abdominal cavity Oesophagus The ‘Z-line’ indicates the clinically significant transition from oesophageal Diaphragm to stomach mucosa ‘Z-line’ Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.33 6 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #229  Abdominal Oesophagus Abdominal oesophagus enters the left upper quadrant of the Oesophagus abdominal region Abdominal oesophagus is surrounded by the right crus of the diaphragm When the diaphragm contracts, what change in the abdominal cavity results in the need for the functional sphincter? 7 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #255  Stomach Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.37 The most dilated part of the gastrointestinal tract, largely located within the left upper quadrant While relatively fixed at either end, the stomach is intraperitoneal, mobile and anchored by omenta along each major curvature Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p294 Size and shape variable between individuals. Gastric rugae accommodate large expansion Contents emptying from the stomach to the duodenum are controlled by the pyloric sphincter Muscular wall of pyloric canal thickens to create a firm, palpable sphincter 8 9 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig B2.8  Variations Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #267B Stomach Shape 10 Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p294 & p295  Stomach Relations – Superficial view 11 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of 7th Ed. Wolters Kluwer, 2014, Fig 2.31 Learning Systems Plate #267A the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p292 Abdominal Overview – Donor Contrast Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of 12 the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p291 Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p292  Stomach Relations – Deeper Perspective Stomach reflected What viscera can you see and label? Stomach Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #265 13 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #264 Stomach – Barium Swallow Radiograph Fundus Gas bubble in cardia Peristaltic contraction Pyloric sphincter Small Intestine 14 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.37  Duodenum Bile duct within Pyloric hepatoduodenal sphincter ‘C’ shaped loop traversing multiple quadrants to ligament Pancreas connect the stomach with the remaining small intestine Internal surface has circular folds of mucous membrane or ‘plicae circulares’ to aid absorption. Comprised of 4 parts with many anatomical relationships 1st part is initially intraperitoneal then dives right and posteriorly Plicae circulares 2nd part descends and receives bile 3rd part traverse the midline horizontally Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #271 4th part ascends to duodenojejunal flexure 15 Duodenum Relations Pancreas IVC Superior mesenteric vessels Right kidney Left psoas Right psoas Aorta 16 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #270  Duodenum Relations Where is the duodenum on the right image? Consider the information presented on the previous two slides Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #270 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #335 17  Duodenum Relations and Ulcers Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #270 Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 3rd Ed. Churchill Livingstone Elsevier, 2015 Fig 4.112 18  Jejunum and Ileum Jejunum begins at the duodenojejunal flexure Clear demarcation from duodenum by mesenteric attachment Collectively, the remaining small intestine comprises of ~ 5-6m with 40% jejunum and 60% Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. ileum Wolters Kluwer, 2014, Fig 2.47 Both components of the small intestine are anchored to the posterior abdominal wall via ‘the mesentery’ Jejunum is largely in the superior portion of the ‘infracolic region’ (inferior to transverse colon) while the ileum is in the inferior portion of this region and pelvis 19  Jejunum Ileum Longitudinal muscle Circular muscle Lymphoid patch Larger diameter Thicker wall More fat within mesentery More prominent and prevalent plicae circulares ‘Peyer’s patches’ of lymphoid tissue 20 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #272A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #272B  Ileocaecal Junction Ileocaecal orifice Distal ileum protrudes into a ‘blind pouch’ of the colon known as the caecum The ileocaecal junction is commonly revered to as a ‘valve’ and as a ‘sphincter’ Caecum Ileum 21 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #274A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #274C  Large Intestine Located in multiple quadrants, typically tracing an outline or framing the small intestine Comprised of multiple parts which interchange between intra and retroperitoneal Intraperitoneal segments can greatly vary in location Major site for ion and water absorption 22 Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 3rd Ed. Churchill Livingstone Elsevier, 2015 Fig 4.74  Large Intestine - Distinctive Features Teniae Coli Three longitudinal bands Haustra Omental Converge at appendix base and rectosigmoid junction appendices Shortened length of these fibres with respect to the overall large intestine creates pouches known as haustra Tenaie Coli Haustra Sacculated component of the large intestine Peristaltic contractions to pass contents Omental Appendices Fat filled peritoneal pouches Longitudinal muscle of rectum Potential site of diverticula 23 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #276 Ileum → Large Intestinal Muscle Layers Taenia coli Longitudinal muscle Circular muscle Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #272B Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #274C 24  Appendix Small wormlike blind pouch in the lower right quadrant Jersey, Icon Learning Systems Plate #282 and 275B Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Opens into the posteromedial wall of the caecum, a few centimetres below the ileocaecal junction Intraperitoneal viscus with variable orientation What method could help find the appendix Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.53 Moore KL, Dalley AF & Agur AMR. Clinically Oriented consistently? McBurney’s point is the typical site for palpation and surgical incision to perform an appendectomy 2/3rds along oblique line from the umbilicus to right ASIS 25  Large Intestine – Variable Positions Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.57 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.52 26  Sigmoid Colon – Variable Positions Which example represents a ‘typical’ path? Do you notice anything consistent in all images? Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #277A 27 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #277B  Volvulus What anatomical structures are likely to be impacted in this example of a ‘twisted bowel’? 28 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig B2.18  Wedge shaped mass primarily in the right upper quadrant Liver Largest gland in the body, variable size (~ 1.5kg) Significant anatomical and peritoneal relationships Vast array of functions with heavy involvement in digestion and nutrient processing via the biliary and the portal systems respectively Two distinct surfaces demarcated by a sharp border Diaphragmatic surface –anterosuperior (primarily) Visceral surface – posteroinferior Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.31 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.63 29  Liver Topography Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #278B Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.36 30  Liver Lobes and Surfaces ANTERIOR VIEW - PART OF DIAPHRAGMATIC SURFACE POSTERO-INFERIOR VIEW - VISCERAL SURFACE Diaphragm Caudate lobe Left lobe Left lobe Right lobe Right lobe Porta Hepatis Portal vein Falciform Hepatic artery ligament Bile duct Quadrate Nerves and lymphatics lobe Round ligament of the liver or ligamentum teres hepatis Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #279 31  STRUCTURES WITHIN GROOVES Liver Lobes and Grooves ‘FUNCTIONAL’ DIVISION OF LOBES ‘ANATOMICAL’ DIVISION OF LOBES Left Right Left Right C C Q Q Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #279 Caudate and quadrate are Caudate and quadrate may be considered ‘functionally left’ mentioned as ‘anatomically right’ Explored more in our Best comprehended from an neurovasculature lecture anterior and posterior view 32 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig 2.65  Liver Relations Lateral view of a sagittal section Falciform ligament Peritoneal reflections Bare Area Round ligament of the liver Peritoneal reflections Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 3rd Ed. Churchill Livingstone Elsevier, 2015 Fig 4.93 33 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #280  Liver Segments Posteroinferior View Posteroinferior View Anterior View - Visceral Surface - Visceral Surface - Diaphragmatic Surface Just as in the kidney, each segment has its own vascular supply and can be independently resected 34 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #281C Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #281B Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #281A Liver variations In this anterior view of the liver, what could these grooves on the diaphragmatic surface be caused by? (Answer presented in the recording) 35 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #280B  Hepatic ducts Gall Bladder R L Cystic duct Pear shaped hollow viscus wedged Relations Neck in a fossa between the right and quadrate liver lobes Body Liver Common Stores (~50ml) and concentrates bile duct bile secreted by the liver Peritoneum overlying liver passes Peritoneum over the exposed gall bladder Fundus Transverse Palpatory landmark = junction of colon Lat. Border of Rt. Rectus sheath Costal Margin Duodenum Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #285A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #285B 36 Gall Bladder – Gallstones 37 Moore KL, Dalley AF & Agur AMR. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2014, Fig B2.27-2.28  Pancreas Composite gland with strong digestive role Exocrine function – release juices into duodenum to aid digestion Endocrine function – involved in carbohydrate metabolism ‘Comma’ or hook shaped gland with distinctive lobulated external surface Great aid for reviewing body donor anatomy Nestled deep on the posterior abdominal wall (retroperitoneal) with significant peritoneal and anatomical relationships 38 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #288A  Pancreas – Parts and Relations Spleen Common bile duct Mesenteric reflections 39 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #288A Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 3rd Ed. Churchill Livingstone Elsevier, 2015 Fig 4.98  Pancreas Ducts and Histology Acini – Exocrine functional tissue Islets – Endocrine functional tissue 40 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #288C Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #288B  Pancreatic and Bile Ducts Bile duct Right and left hepatic ducts Cystic duct Minor duodenal papilla Liver Gall Bile Bladder Duct Main Accessory pancreatic pancreatic Gall duct duct Bladder Major duodenal papilla Hepatopancreatic Main Entry into duodenum ampulla pancreatic duct 41 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #285 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #271  Hepatopancreatic Ampulla and Sphincter Right and left hepatic ducts Cystic duct Gall Bile Bladder Duct Main pancreatic duct Main pancreatic duct Hepatopancreatic Entry into duodenum ampulla 42 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #285 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #287B  Bile System Variations – Don’t memorise these! Remember – We aren’t memorising variations! Learn the ‘typical’ anatomy and then investigate donors, resources and simply take note if you spot a variation from what you expected. 43 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #286B Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #286A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #287D  Spleen Largest lymphoid organ in the body, often referred to as ‘size of a clenched fist’, however, it commonly varies in size and shape Tucked deep in the upper left quadrant in close proximity with the multiple viscera and ribs 9-11 (clinically significant) Intraperitoneal with multiple peritoneal ‘ligaments’ branching from its hilum Parenchyma is comprised of ‘white’ and ‘red pulp’ White pulp – lymphoid function Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #289C Red pulp – RBC function 44 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #289B  Spleen Features and Relations VISCERAL SURFACE DIAPHRAGMATIC SURFACE Antero – superior Gastric border impression Renal impression Colic impression Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #289A 45 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #289C  Spleen – Rib Relations and Variable Shape Morphological Variations of Spleen: A Cadaveric Study Chidambaram RS, Sridhar S, (2015) Journal of Evidence Based Medicine and Healthcare. 2(29) p4248-4254 Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p300 46 Donor Overview and Tips for Prac Class 47 Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p301  Revision Suggestions Below are images and activities suggested for your revision When revising, consider what activities help you understand the content to be able to reproduce your knowledge 48 Identify and Justify 3 1 Use these images to practice identification of structures, and importantly, justify your answer You can justify any viscera of course, some labels are here as a prompt 2 4 5 49  Describing Visceral Relations – Test yourself! 50 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #336 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #335  Explore different learning activities and resources: e.g Complete Anatomy Reflecting on your learning and associated activities is invaluable feedback to ensure you remain engaged and learn at an appropriate level for you. For example, engaging with complete anatomy to explore general anatomical relationships could be useful, particularly prior to attending the laboratory classes. Remember, you don’t need to learn everything from each resource. Each learning activity or resource is best undertaken with a clear purpose. 51 3D4Medical Ltd (2021) Complete anatomy (8.0.0) (Computer App) 3D4Medical Ltd (2021) Complete anatomy (8.0.0) (Computer App)