sem 2_Anatomy-1-45.pdf

ANATOMY 2ND SEMESTER DIGESTIVE SYSTEM RESPIRATORY SYSTEM CARDIO-CIRCULATORY SYSTEM RENAL SYSTEM GENITAL SYSTEM Corina Beiușanu 2018 1 DIGESTIVE SYSTEM Digestive system is formed by the organs which have function in digestion and absorption of food. These organs are: oral cavity (mouth); pharynx; eso...

ANATOMY 2ND SEMESTER DIGESTIVE SYSTEM RESPIRATORY SYSTEM CARDIO-CIRCULATORY SYSTEM RENAL SYSTEM GENITAL SYSTEM Corina Beiușanu 2018 1 DIGESTIVE SYSTEM Digestive system is formed by the organs which have function in digestion and absorption of food. These organs are: oral cavity (mouth); pharynx; esophagus; stomach; small intestine – duodenum, jejunum and ileum; large intestine – caecum, colon, rectum; salivary glands, liver, pancreas. 2 ORAL CAVITY ( THE MOUTH ) It is the first part of the digestive tube. Functions: - mastication; - insalivation; - deglutition; - speaking; It is formed by: - a skeleton part – represented by mandible and maxillas; - soft parts : - superficial parts – lips, the menton (chin), the cheek, maseterin region; - profound parts – palatine region, the tongue, salivary glands. Oral cavity communicates : - in front - with the exterior of the body –– the limit of the mouth is rima oris = the orifice of the mouth; - behind – with the pharynx; Oral cavity is divided by alveolar arches into two parts: - in front – the vestibule; - behind – the mouth cavity proper; When the jaws are closed these parts communicate one to another through the spaces between the teeth and one vertical space placed behind the last molar (on each side of alveolar arches). THE VESTIBLE - it is like a horseshoe with posterior opening; - it is limited by: - in front – by the lips and cheeks; - behind – by the alveolar arches; - above and below – by the reflection of the mucous membrane which goes from the lips and cheeks to the gums; - it receives the secretion of the parotid salivary glands (the orifice of this gland is near the second upper molar – on each side). 3 THE MOUTH CAVITY PROPER - it is oval and limited : - in front and laterally by the alveolar arches; - behind and laterally by the mandible rami and pharynx; - above by the palatine arch; - below by the tongue and salivary glands. THE SOFT PARTS OF THE ORAL CAVITY 1. THE LIPS - “mobile walls” which close the oral cavity in front; - they are 2 in number ; one superior and one inferior; - they determine rima oris; - at the lateral ends of each lip, the upper lip is united with the lower lip and forms the labial commissure. Superior lip: - it is situated below of the nasal region; - between the nose and the cheek there is a groove – nasogenian groove which limits the superior lip laterally; - between the upper lip and the nose there is a groove which is called filtrum; the lower end of this filtrum is a prominence = median tubercle; - in the inner side of the lip there is the frenulum. Inferior lip: - it is situated a little behind of the upper lip (often); - it is limited inferiorly by a transversal groove = the mentolabial groove; - this lip presents in the inner side the frenulum which is smaller then the frenulum from the upper lip. STRUCTURE OF THE LIP: - skin at the exterior side; - cellular tissue – fat tissue – exception the labial commissures; - muscles – orbicularis oris (constrictor muscle), fibers from zygomatic muscle, buccinator muscle, mental muscle, etc; !!!!! – muscular plane contains numerous small labial glands; - mucous membrane – with vessels and nerves. VASCULARIZATION - labial arteries from facial artery; - the veins collects the blood into facial vein; INNERVATION - facial nerve (motor nerve); - trigeminal - maxillary sensitive nerves - mandible 4 2. THE MENTON - it is limited: - above by the lower lip; - below by the inferior border of the mandibles’ body Structure: - skin; - cellular tissue; - muscles – platisma, mental muscle; - mucous membrane. 3. THE CHEEK – it is the lateral wall of the oral cavity; – it is limited: - above by the inferior border of the orbit; - below by the inferior border of mandible; - in front – nasolabial groove; - behind – masetery muscle; - it has – an external surface represented by the skin; - an internal surface = oral surface represented by the mucous membrane. STRUCTURE: - skin – in the upper half without hair, but in the lower half it is rich in hair; - fat cellular tissue which form a ball of fat = “Bichat ball”; - muscles – zygomatic muscle, ryzorius muscle, platisma, buccinator muscle, the common elevator of the nose and lip, etc. !!!!! – in this space there are vessels and Stenon canal (from parotid gland); - mucous membrane with many glands; - skeleton – maxilla and mandible. VASCULARIZATION - facial artery and vein. 4. THE MASETERIN REGION - it is situated behind the cheek; - it is limited: - above – zygomatic arch; - below – inferior border of maseter muscle; - in front – anterior border of masseter muscle; - behind – posterior border of the mandible rami; - structure: - skin; - cellular tissue – with transversal artery of the face and Stenon canal, and nerves; - maseter aponeurosis; - maseter muscles. 5 I. PROFOUND PART OF THE ORAL CAVITY The floor of the mouth is represented by the soft parts which are situated between the body of mandible and hyoid bone. These parts are the tongue and salivary glands. 1. THE TONGUE - it is a musculo-cutaneus organ covered by a mucous membrane, and fixed at the floor of the mouth; - it is situated between palatine arch and alveolar arches; - it is – the principal organ of the sense of the taste ; - an important organ of speech; - assist in mastication and deglutition of the food; - it has – a root; - an apex; - two surfaces; - two borders. SURFACES: a) Superior or dorsal surface - it has a median groove which divides it into symmetrical halves; the end of this groove is a depression called foramen caecum; - in front of this surface there are the papillae of the tongue; the varieties of papillae met are: vallate, fungiformes, filiformes, simplices; - behind there are numerous glands and lymph follicles = lingual tonsil; here are 3 glosso-epiglotical folds (one is median and two are laterally). b) Inferior surface or ventral surface - in the median line it has the lingual frenulum; - laterally – there are the orifices of the sublingual glands (salivary glands). THE BORDERS – are thin; THE APEX – is the most mobile part of the tongue. STRUCTUREthe tongue presents muscles divided in : - extrinsic muscles: - genioglossus – from mandible to the root of the tongue; it draws the apex of the to forward - styloglossus – from the styloid process of the temporal bone to the tongue; it draws the tongue backward; - hyoglossus - from hyoid bone to the tongue; it draws the tongue downward. 6 - palatoglossus – from palatine arch to the tongue; it draws the root of the tongue upward - amygdaloglossus – it draws the tongue upward; - pharyngoglossus – it draws the tongue backward; - intrinsic muscles: - longitudinal superior muscle; - longitudinal inferior muscle; - transversal muscle; - vertical muscle. VASCULARIZATION - arteries: - lingual artery, palatine artery, pharyngeal artery. There are 2 triangular formations for finding these arteries and they are called Beclard triangle and Pirogoff triangle; - veins – lingual vein which collects the blood from: - dorsal vein of the tongue; - lingual profound veins; - sublingual vein; - lingual vein is opened into internal jugular vein; - lymphatics – there are 3 groups - the group of: - the base of the tongue; - the dorsal surface; - the apex. INNERVATION - sensitive nerves: trigeminal, lingual, glossopharyngial, vagus; - sensory nerves: Wriesberg nerve (VII bis), lingual, glossopharyngian, vagus; - motor nerves: hypoglossal and glossopharyngian nerve. THE SUPERIOR WALL OF THE ORAL CAVITY - it is formed by: - an anterior part (horizontally) = bony part = hard palate; - a posterior part ( obliquely) = soft palate; this part is soft, mobile and membranous; STRUCTURE - palatine region is formed by 4 layers: - mucous in the mouth – is digestive type; - a glandular layer; - a skeleton layer – represented by: - the palatine process of maxilla – in case of hard palate; - a fiber-muscular plane in case of soft palate; - mucous in the nasal cavity – is respiratory type. 7 HARD PALATE - the mucous - is thick and united with the periostum of maxilla; - it has 3 – 7 transversal folds on the borders, in the first two thirds; -in the posterior part it has numerous glandular Orifices; - on the median line it has a white line called palatine rapheus and it ends behind of median interincisors space; this end is called palatine tubercle. - - glandular layer – it is situated on each side of the median line, like a parallel bands (2-3 mm); skeleton – represented by the palatine process of the maxilla (on each side); !!!! between the 2 halves ( left and right ) of palate there are 2 sutures: - one is antero-posterior suture called median palatine suture; - one is transversal between the processes of maxillas and processes of palatine bones; nasal mucous VASCULARIZATION - palatine artery and branches from nasal septum arteries and sphenopalatine arteries; - veins collect the blood into the nasal mucous veins and pterygoidian plexus; - lymph is collected in the lymph nodes of the neck; INNERVATION - branches from maxillary nerve ; - !!! – the incisor orifice is small and it is situated behind of medial incisors at 1 cm and it is divided in “Y” or in “V” being opened in the floor of the nose; - !!! – the palatine orifice is situated near the gums between the second molar and the third molar. SOFT PALATE - it is a aponeurotique muscular formation situated between nasopharinx and oropharinx so that in the deglutition time it becomes obturator; - it is continues the hard palate and it is prolonged by the uvula; - it is connected with the root of the tongue by 2 paired muscular arches: - one is anterior = palatogllossal arch; - one is posterior = palatopharyngeal arch. 8 STRUCTURE - aponeurosis – it is a fibrous triangular band united with the hard palate; - muscles: - the levatore of palatine arch – draws the palatine arch upward; - the tensor of palatine arch – it actions in deglutition time; - pharyngopalatine muscle – draws the pharynx upward or draw the palatine arch downward; - palatogllossus – the same action with pharyngopalatine; - the muscle of uvula; - mucous – it is thin and soft. PALATIN TONSIL - it is formed by lymphatic follicles situated on the pharyngian wall in tonsillar fossa(pit); - it is paired, and it is an ovalar formation; - medial surface is covered by pharyngian mucous and it has 18 – 20 orifices = amygdalian vaults; - lateral surface is surrounded by a capsule formed by conjunctive tissue; - the upper end has a fossa; - the lower end it is situated above of glosoepiglotical plica (2 cm); !!!! the external surface of tonsillar fossa is limited by parapharingian space; this space contains: - conjunctive tissue; - styloglossus muscle and stylohyoidian muscle; - palatine artery, facial artery, external and internal carotid arteries; - internal jugular vein; - nerves: glosopharingian, vagus, accesory, hypoglossal. VASCULARIZATION - arteries from lingual artery, pharyngian artery, facial artery; - veins collects the blood into pharyngian veins; - lymph is collected into submandibular and cervical lymphatic nodes. INNERVATION - there are fibers from lingual nerve and glosopharyngian nerve. 9 THE TEETH - the teeth are thick organs implanted in alveolar cavities at mandible and maxillas; functions – in deglutition and articulated speaking; they are placed in 2 rows called dental arches; The first dentition at human body is formed by 20 teeth: 8 incisors, 4 canines, 8 molars. They appears between 6 months and 36 months, in following order: first - medial incisors, next lateral incisors, next - first molars, next – canines and the last – the second molars. This dentition is a temporary dentition and it is changed from 6 years to 14 years. The adult dentition is formed by 32 teeth: 8 incisors, 4 canines, 8 premolars and 12 molars. The third molar on each side of each alveolar arch appears at 19-30 years. Dental formula is: 18 17 16 15 14 13 12 11 48 47 46 45 44 43 42 41 21 22 23 24 25 26 27 28 31 32 33 34 35 36 37 38 The general aspect of the teeth: - the tooth presents: - a crown; - a neck; - a root; THE CROWN - is visible part of the tooth; - its color is white; - it has: - an external surface or vestibular surface; - an internal surface or lingual surface; - lateral surfaces; - masticator surface; THE NECK - it connects the crown with the root; - THE ROOT it is represented by the part of the tooth which is situated in alveolar cavity; it can be teeth which have 2 or 3 roots. 10 Particular aspect of the teeth - the incisors – they look like a chisel; - the upper incisors are obliquely in front; - the lower incisors are vertical so that when the jaws are closed the upper incisors are in front of the lower incisors. - the canines – they have a strong crown; - they are a little bulging in front; - the premolars – they have 2 tubercles on masticator surface and these tubercles are separated by a transversal groove; - the root is bifidate; - the molars – they have 3-5 tubercles; - their crown is rhomboidal at the upper molars and cubic and bigger at the lower molars; - the upper molars have 3 roots; - the lower molars have 2 roots; STRUCTURE - the tooth presents : - - - dental cavity which contains red soft conjunctive tissue, with many vessels of blood and many nerves; dental cavity is covered by dentine which is like a bony structure and very strong; on the root, the dentine is covered by cement, a bony tissue connected with the alveolar periost by collagen fibers; on the crown, the dentine is covered by enamel – it is white and it represents the most strongest tissue of the human body. 11 THE SUSTAINER AND FIXER APARATE OF THE TOOTH - it is represented by – periodontus – it is conjunctive tissue situated around of the root of the teeth; it is formed by collagen fibers which can be like a sunrays or obliquely; - the gum; - alveolar processes and dental alveolas; - cementum; VASCULARIZATION - arteries – dental arteries from upper alveolar arteries and lower alveolar arteries; - veins accompanies the arteries; - lymph is collected into submandibular and cervical lymph nodes; INNERVATION - branches from maxillary nerve – for the upper alveolar arch; - branches from mandible nerve – for the lower alveolar arch. SALIVARY GLANDS - numerous salivary glands empty their secretion into the oral cavity. They are divided into 2 groups: - the large salivary glands: - parotid glands; - sublingual glands; - submandibular glands; - the small salivary glands; 12 - - - PAROTIDE GLAND it is a paired gland; it is situated immediately below of the external ear; it is limited by: - in front – the posterior border of the mandible; - behind – the mastoid process; - above – external acoustic meatus - below – a conventional line which continues the inferior border of mandible; this gland is covered by a fascia which has 2 extension (one goes with the canal of the gland to the oral vestibule, and one goes to the pharynx) ; the canal of the gland goes above the maseter muscle, passes through the buccinator muscle and is opened in vestibule, near the second upper molar. VASCULARIZATION - parotid arteries from external carotid artery; - jugular vein; INNERVATION - facial nerve; - auriculotemporal nerve. SUBMANDIBULAR GLAND it is a paired gland; it is situated in the submandibular region, limited by: - above – mandible; - below and behind – digastric muscle; - the gland presents a part which goes to the sublingual; - the canal of this gland is called Wharton canal; it is opened in oral cavity, beside the frenulum lingual. - VASCULARIZATION - facial and lingual arteries; - internal jugular vein; - lymphatics – submandibular nodes. 13 SUBLINGUAL GLAND -it is situated in sublingual region, limited by: - medially - the root of the tongue; - laterally – the internal surface of mandible; - inferiorly – the mylohyoidian muscle; - it is a small gland; - it has 8-12 excretory ducts, which are opened beside the lingual frenulum. VASCULARIZATION - sublingual and mental arteries; - external jugular vein; INNERVATION - lingual nerve; - tympanic chord. THE SMALL SALIVARY GLANDS These glands secrets saliva, serous and mucous and are divided into 3 topographic groups. - the labiojugal group of glands is situated in the layer below the mucous membrane and more numerous around the oral orifice, the vestibule and region around the Stenon’s duct; - the palatine group of glands is situated in a thin layer between the mucous and submucous of the soft palate; - the lingual group of glands is situated in a deep layer between the deep tongue region and behind the lingual rim. 14 PHARYNX = it is a musculo-membranous organ, situated at the crossing of the digestive way (from the mouth to the esophagus) with the way of breathing ( from the nose to the larynx). - it is a conical tube; it has ~ 15 cm; - it is situated in front of vertebral column, from the skull base to the C6; - it communicates – in first third with the nasal cavity; - in the second third with oral cavity; - in last third with larynx. EXTERNAL CONFIGURATION - it presents – 2 lateral surface; - one posterior surface; - an upper end; - a lower end; POSTERIOR SURFACE – it is a plane surface; - it is situated near the: - vertebral column – cervical part; - the body and transvers processes of vertebrae C1-C6; - prevertebral muscles; - prevertebral fascia; - cervical sympathetic trunk; !!! Behind of the pharynx, between the pharynx and prevertebral fascia there is a space called retropharyngian space which contains elastic conjunctive tissue and 2 lymphatic nodes; this space determines the mobility of pharynx and protects it from the vertebral bodies. LATERAL SURFACES - in cephalic part each lateral surface is situated near the parotid gland; - in cervical part it is situated near the sternocleidomastoidian muscle; - cervical region can be divided into 2 parts: - the upper part contains: - the external and internal carotide arteries; - tiroidian artery; - lingual artery; - internal jugular vein; - tireolinguofacial venous trunk; - hypoglossal nerve; - vagus nerves. 15 - the lower part contains : - the common carotid artery; - internal jugular vein; - vagus nerve; - the tyroid gland (posterior part); - hypoglossal nerve; !!! Laterally, there is lateropharyngian space which is divided by a septum into 2 parts: in front is prestylian space and behind is retrostylian space; the septum is formed by conjunctive tissue and stylian muscles with their fascia. Posterior view of pharynx 16 INTERNAL CONFIGURATION - the pharynx is divided in 3 levels : - first is nasopharynx or rynopharynx; - second is the oropharynx; - the third is laryngopharynx; I. - NASOPHARYNX it lies from the base of the skull to the palatine arch; it communicates in front with nasal cavity and below with oropharynx; the walls are formed by: - the upper wall – it is formed by sphenoid bone and basilar part of occipital bone; - this wall contains pharyngian tonsil (lymphatic organ formed by 7-8 irregular nodes separated one to another and which regress after 16 years; the hypertrophy of this organ is called adenoid vegetation); - this wall contains sometimes the pharyngian hypophsis which is formed by an agglomeration of epithelial cells which are the rest of first hypophysis duct ( from this it is developed adenohypophysis ); - inferior wall - it appears only in deglutition time; - posterior wall - is formed by prevertebral plane (in front of atlas and axis). 17 - lateral wall – presents the pharyngian orifice of auditiv tuba which permits the communication of the pharynx with medial ear; this orifice presents a prominence from which starts a fold which contains salpingopharyngian muscle - behind of this fold there is a depression called Rosenmuller fossa or pharyngian recesus; - around of tubar orifice there is a lymphoid mass called tubar tonsil or Gerlach tonsil. !!!!! – lingual tonsil - pharyngyan tonsil - tubar tonsil - palatine tonsil they all forms Waldeyer ring. 18 II. - - III. OROPHARYNX it is situated between palatine arch and an horizontal plane which passes through the hyoid bone; it communicates in front with the mouth through the oropharyingian istmus determined by glossopalatine arch – above and the tongue – below. LARYNGOPHARYNX - it is situated between the plane which passes through the hyoid bone and the lower limit of the pharynx which is cricoid cartilage of larynx; - in front there are: - epiglottis; - the root of the tongue; - lingual tonsil; - glossoepiglotical folds; - the enter of larynx = laryngyan aditus. STRUCTURE - mucous – nasopharynx has a respiratory type, but the others parts have digestive type; this plane has glands – mixted in the upper part of pharynx and mucous glands in rest; - conjunctive tissue – it forms a compact fibrous band = pharyngyan aponeurosis; in the upper part this formation is stronger than the lower part and it forms a fascia which sustains the pharynx; - the muscle – are divided into two groups: - constrictors muscles; - levator muscles; - pharyngyan adventice – it is formed by conjunctive tissue. 1. Constrictors muscles - are 3 in number, they are flat muscles; - are situated inverse like the tiles (the upper constrictor is covered a little by the middle constrictor which is covered by the lower constrictor muscle); at the posterior surface the constrictors muscles are crossing with the opposite muscles and forms pharyngian rapheus. The upper constrictor - origin - on the pterigoidian process of sphenoid bone; - pterigomandibular ligament; - milohyoidian line; - the root of the tongue; - it is inserted on the pharyngian rapheus; - action – it shuts the nasopharinx in deglutition time. 19 The middle constrictor - origin on the hyoid bone; - the same insertion with the upper constrictor but in the middle part; The lower constrictor - origin – on the tyroid cartilage; - cricoid cartilage; - first tracheal ring; - insertion – along of the pharyngyan rapheus; - amigdaloglossus – is an inconstant muscle. !!!! all the constrictors muscles determine the progress of the food from the mouth to the esophagus. 2. The levator muscles - these muscles have longitudinally disposition; Stylopharingian muscle - origin is on the styloid process of temporal bone; - insertion is on tyroid cartilage; Palatopharyngian muscle - origin is on the dorsal surface of the pharynx; - insertion is on the palatine aponeurosis; Salpingopharyngian muscle - origin is on the auditive tubar cartilage; - insertion is on lateral wall of the pharynx; !!! all levator of pharynx – levate the pharynx in deglutition time. VASCULARIZATION - pharyngyan artery from external carotid artery; - arterial branches from palatine artery and sphenopalatin artery; - veins – are in conjunctive planes and go to the internal jugular vein; - lymph is collected in retropharyngyan and cervical nodes; INNERVATION - nervous plexus formed by branches from glossopharyngyan nerve and vagus; - vegetative fibers from cervical sympathetic trunk. 20 21 ESOPHAGUS - I. - - it is a musculo-membranous organ situated between the pharynx and the stomach; it has 3 parts: - cervical part; - thoracic part; - abdominal part; CERVICAL ESOPHAGUS it has ~ 5-6 cm; it is situated inside of the neck, from the lower end of pharynx (horizontal line which passes through the crycoid cartilage of larynx) to the limit between the neck and thorax = a conventional line which cross through the sternal manubrium; it has a vertical direction but a little inclined to the left; it has relations with: - in front – trachea; - thyroid artery; - thyroid veins; - the left recurrent nerve (laryngian nerve); - the left lobe of thyroid gland. ; 22 - behind: - cervical column, prevertebral muscles and their fascia; laterally – in the right side it is covered by trachea and it has relations with - common carotid artery; - internal jugular vein; - vagus nerves; - sympathetic cervical trunk; VASCULARIZATION - esophagus branches from the lower tiroidian artery; - esophagus veins which go to the tiroidian veins; - lymph is collected in cervical lymph nodes; INNERVATION - vagus nerve; - glossopharyngian nerve; - fibers from sympathetic cervical trunk; II. - - THORACIC ESOPHAGUS it is limited in the upper part by the limit between neck and thorax and in the lower part by the diaphragm muscle which represents the limit between thorax and abdomen. in thorax esophagus passes behind of aortic arch and descends in mediastinum along the trachea; it presents some narrowing : - at the “mouth of esophagus”; - at the aortic arch; - at the left bronchus; - at cardia ( it is the entrance into the stomach ); - sometime at diaphragm muscle; The relations of thoracic esophagus are: - trachea in the right side; – in front - the left bronchus; - the pericardial membrane; - diaphragmatic muscle; 23 - behind – vertebral column; - thoracic lymphatic duct; - azygos vein; - laterally – aortic arch; - the left subclavia artery; - the left pleura; - the left recurrent laryngeal nerve; - descending aorta; 24 STRUCTURE - there are 3 coats: - external coat – muscular; - the middle – submucous; - internal coat – mucous, which has longitudinal folds; VASCULARIZATION - branches from –thyroid arteries, bronchus arteries and phrenic arteries; - veins form venous plexus in submucous and go to - the azygos vein in the upper part; - the hepatic portal vein- lower part - lymph – collected in thoracic lymph nodes; INNERVATION - vagus and sympathetic nerve; III. - - ABDOMINAL ESOPHAGUS it has 3 cm; it is limited by diaphragm in the upper part and cardia in the lower part; on the right side it is followed by lesser curvature of the stomach; at the left it forms with the greater curvature of the stomach an angle; it is in relation with: in front: - the abdominal membranes; (peritoneal membrane, lesser epiploon) - liver; behind: - vertebral column; - diaphragm muscle; - the right vagus nerve; VASCULARIZATION - the esophago-cardio-gastric arteries from the left gastric artery; - branches from the diaphragmatic artery; - veins form a venous plexus in submucous and then go to the coronary gastric vein; - lymph is collected in coronary-gastric lymph nodes. INNERVATION - vagus and sympathetic nerve. 25 THE TOPOGRAPHY OF THE ANTERIOR ABDOMINAL WALL The abdomen is situated between the thorax and the pelvis. - the anterior abdominal wall is limited in the upper part by the costal arches and the xiphoidian process and in the lower part the line which connects the inferior limit of the iliac crests. - it is divided into 9 regions by 2 pairs of lines: - vertical lines –medioclavicular lines – connect the middle of clavicle with the inguinal fold (on each side); - horizontal lines – the upper line is called bicostal line because it connects the anterior ends of the tenth ribs; - the lower line is called bicristal line and it connects anterior ends of the iliac crests; - these regions are ( from the right to the left ): - in the first row - the right hypocondrus; - epigastric region; - the left hypocondrus; - in the second row – the right colic region; - the ombilical region; - the left colic region; - in the third row – the right iliac fossa; - hypogastrus; - the left iliac fossa; 26 STOMACH - it is the most dilated organ of digestive tube; it is mobile; it continues the esophagus and it is followed by the duodenum; SITUATION - it is situated in subphrenical space in gastric region, which is limited : - to the left by lien region (spleen); - to the right hepatic region; - above – diaphragm; - below – duodenum; - in front – abdominal wall and the left lobe of the liver; - behind – peritoneal membrane; - it occupy the epygastric region and a part of the left hypochondric region; EXTERNAL CONFIGURATION - the shape and the size of the stomach presents numerous variations, but frequently it is like the letter “J” it has – one vertical part which is formed by: - the fornix or the fundus of the stomach; - the body of the stomach; - one horizontal part which is formed by: - the pyloric antrum; - the pyloric canal. 27 It presents – 2 surfaces – anterior and posterior surface; - 2 borders = curvatures - the greater curvature which is orientated to the left; - the lesser curvature which is orientated to the right; - 2 orifices: – the upper orifice = cardia =the enter to the stomach; - the lower orifice – pylorus = the limit between the stomach and duodenum. INTERNAL CONFIGURATION - the internal surface presents numerous folds of mucous membrane; there are folds along the greater curvature and some vertical, transversal and oblique folds; there are thin grooves which delimitate gastric areas; these formations presents orifices of the gastric glands; cardia presents a cardioesophagian valve; pyloric orifice presents a sphincter and a valve. RELATIONS Anterior surface - it has relations in THORAX through diaphragm muscle with: – the left lung; - the left pleura; - the heart and pericardium; 28 !!!!TRAUBE lunate space = is limited by: - spleen – to the left; - liver – to the right; - heart – above; - costal arch – below; - is important to know about this space because the stomach is in direct contact with the abdominal wall here; - in ABDOMEN the stomach has relations with abdominal wall; the projecton of the stomach here on the abdominal wall is in a triangular area called Labbe triangle; the area is limited by – the inferior border of the liver; - the left costal arch; - transversal colon ; Posterior surface – the stomach has relations with: - in the upper part – diaphragm muscle; - in the middle – the body and the tail of the pancreas; - the left kidney; - the spleen; - in the lower part – duodenojejunal angle and first part of the jejunum. The lesser curvature – the limit between it and the first part of duodenum is represented by pyloroduodenal incisura. The greater curvature – vertical part is united with the diaphragm muscle by gastrophrenic ligament and horizontal part is united with the transversal colon by gastrocolic ligament. STRUCTURE - the stomach presents 4 coats. 1. the serous coat = visceral peritoneum; !!! it is absent at the fornix (here the stomach is in direct contact with abdominal wall); - this serous forms ligaments between the stomach and the organs from proximity: -gastrocolic ligament; -gastrosplenic ligament; -gastrophrenic ligament; -gastrohepatic ligament; 29 2. the muscular coat – the muscular fibers forms 3 layers: - superficial layer - presents longitudinal fibers; - the middle layer – presents circular fibers; - the profound layer – presents oblique fibers; 3. the submucous coat - it presents numerous vessels for blood and lymph; this coat presents a nervous plexus = the Meissner plexus; 4. the mucous coat – it is formed by epithelium which has mucous glands and fundic glands (these product acidopeptic substance). VASCULARIZATION Arteries: - the stomach presents 2 arterial arches - the lesser curvature arch – it is formed by: - the left gastric artery = coronary artery, which is a branch from celiac trunk; - the right gastric artery = pyloric artery, which is a branch from hepatic artery; - the greater curvature arch – it is formed by: - the left gastroepiploic artery from spleen artery; - the right gastroepiploic artery from gastroduodenal artery. !!!! on anterior surface of the stomach there is a portion which hasn’t vessels = gastrectomy area. 30 Veins : - the veins of the lesser curvature go to the portal vein; - the veins of the greater curvature go to the spleen vein and mesenteric vein; Lymphatics: - the stomach lymphonodes. presents 3 groups of first group – the lymph nodes are situated - along of the lesser curvature; - at the spleen; - retropiloric lymph nodes; - the second group – periaortic lymph nodes; - the third group – supraclavicular lymph node = Wirchof – Troisier. - INNERVATION - nervous fibers from solar plexus; fibers from vagus nerve. 31 DUODENUM - it is the first part of the small intestine; it is the fixed part of the small intestine, the mobile parts of the small intestine are represented by the jejunum and ileum. EXTERNAL CONFIGURATION - its shape is like a horseshoe with the opening upward - it has 4 parts: - first part = duodenal bulb – it lies from duodenopiloric incisura to the gallbladder; - the second part – from the gallbladder to the lower end of the right kidney - this part is descending part of the duodenum; - the third part – from the right kidney to the left border of the vertebral column (this part is transversal part of the duodenum); - the fourth part goes to the upward along of the second lumbar vertebra; - duodenum changes its direction for three times, so that it has: - an upper flexure; - a lower flexure; - duodenojejunal flexure; INTERNAL CONFIGURATION - the mucous membrane forms inside circular folds; it has one vertical fold on descending part determined by coledoc duct; in the lower part of this fold there is a prominence = the greater duodenal papilla which contains the Vater”s ampoule - on which, coledoc duct and pancreatic duct (Wirsung duct) are opened. 32 - - above of this papilla there is another papilla = the lesser duodenal papilla in which accesor pancreatic duct (Santorini duct) is opened; at the distal part of duodenum, it has intestinal villi. STRUCTURE - it has the same 4 coats: - serous membrane; - muscular membrane; - submucous – it presents duodenal glands (Brunner) in the first part of the duodenum; - mucous membrane; RELATIONS - - at the adult, as the result of coalescens process, is formed Treitz fascia and posterior surface of the duodenum unites with posterior parietal peritoneal membrane, so that the second, the third and the fourth parts of duodenum are covered by peritoneum only on the anterior surface. In the fourth part of duodenum, peritoneal membrane forms some lunate folds which are called duodenal fosses: - Superior duodenal fossa; - Inferior duodenal fossa; - Superior or venous paraduodenal fossa; - Inferior or arterial paraduodenal fossa; - Superior duodeno-jejunal fossa; - Superior retroduodenal fossa; 33 - first part of duodenum has relations with: - in front – the liver; - behind – coledoc duct; - portal vein; - gastroduodenal artery; - above – the liver; - below – pancreas; - the second part of duodenum has relations with: - in front – the liver; - gallbladder; - intestinal folds; - behind – the right kidney; - inferior cava vein; - laterally – the liver; - ascending colon; - medially – pancreas; - the third part of duodenum has relations with: - in front – the root of the mezenterum; - mesenteric vessels; - behind – inferior cava vein; - the right ureterus; - aorta; - above – pancreas; - below – intestinal folds; - the fourth part of duodenum has relations with: - above – the stomach; - intestinal folds; - behind – psoas muscle; - the pedicle of the left kidney; - aorta; - laterally – the left kidney; - medially – aorta; 34 VASCULARIZATION - pancreaticoduodenal arteries; the veins go to the portal vein; lymph is collected in hepatic and celiac lymphonodes; INNERVATION - sympathetic and parasympathetic; 35 JEJUNUM AND ILEUM - - - the mobile part of small intestine is represented by jejunum and ileum; situation: - in the inframezocolic space; - from duodenojejunal angle to the ileocecal valve; - from the left side of L1,L2 to the right iliac fossa; the size is variable = ~ 6,5 – 7 m length and 2,5 -3 cm diameter; the shape is cylindrical; they form numerous intestinal folds; above there are jejunal folds which are orientated horizontally and below are ileum folds which are orientated vertically there isn’t a clear limit between jejunum and ileum, but some authors consider that jejunum represents 2/5 from small intestine and ileum represents 3/5; - between jejunum and ileum there are some differences : - jejunum - has more circular folds inside; - its diameter is bigger; - it has more blood vessels; - its muscular fibers are stronger than the ileums’ fibers; - ileum – has Peyer patches (lymphatic formations); 36 RELATIONS - - in front – the greater epiploon; behind – the posterior abdominal wall retroperitoneal space; above – transverse colon and mesocolonum; below – urinary bladder; - rectum; - uterus at women; laterally – ascending and descending colon; !!! Mesenterum = a serous membrane which connects the small intestine with posterior abdominal wall; - it is orientated oblique from the left to the right side and downward; - it has: - 2 surfaces – anterior (the right surface); - posterior (the left surface); - 2 borders – intestinal border (in front); - parietal border (behind); - the root of mesenterum = the first part of mesenterum or parietal part it looks like letter “S” and it has 3 parts which are : - above – oblique; - in the middle – vertical; - below – again oblique downward and to the right; 37 and STRUCTURE - - serous coat = visceral peritoneal membrane; muscular coat – the external layer has longitudinal fibers; - internal layer has circular fibers; - this coat present a nervous plexus – Auerbach plexus; submucous coat – it has Meissner plexus; mucous – unistratified epithelium with glands; - mucous forms numerous circular folds in jejunum and less in ileum; - mucous presents intestinal villi; - it has solitary lymphatic formations and aggregated lymphatic formations = Peyer formations; 38 INTESTINAL VILLI - intestinal villi are some cylindrical formations of mucous membrane and they look like the fingers; they have ~ 0,5 – 1,5 mm height; their function is to increase the intestinal surface (for intestinal absorbtion); they are absent in first part of duodenum and the last part of ileum; structure: at the exterior – epithelium; inside – a central conjunctive vascular ax; 39 THE LARGE INTESTINE - - - - it continues the small intestine; it is situated between ileocecal valve to the rectum region (S3); it has 1,6 m – 1,8 m and its caliber has 78 cm in the proximal part and it decreases to the distal part where it has 3-3,5 cm; it presents following regions: - first part = cecum; - second part – ascending colon; - third part – transversal colon; - fourth part - descending part; - fifth part – sigmoid colon; the large intestine presents some particularities: tenia coli – they are 3 muscular bands which start at the cecum; one of them is visible because it is free ( it hasn’t any insertions) and it is called free tenia; haustrae coli – are some dilatations of intestinal wall delimitated one from another by transversal grooves and which determine inside of the intestine some prominences and look like some lunate folds (!!! in case of the small intestine these folds are determined only by mucous; in case of the large intestine all the coats of the intestinal wall form these folds); Epiploic appendages – they look like yellow tassels and are formed by fat and peritoneum membrane; 40 STRUCTURE - serous coat – peritoneum; muscular coat – external fibers are longitudinal and they are grouped in those 3 taenia and internal fibers are circular; submucous coat – with vessels and nerves; mucous – it has Lieberkuhn glands and many lymphoid formations. 1. CECUM - it is situated at the end of ileum from ileocecal valve in the right iliac fossa; it is dilated and it is followed by ascending colon; it presents vermiform appendix; there it can be more morphological types of vermiform appendix, but frequently appendix is orientated downward; 41 Relations: - in front abdominal wall; - behind – peritoneum; - fat cellular tissue; - iliac fascia; - psoas muscle; - branches from lombar plexus (femoral nerve and femoral cutaneos nerve); - laterally – iliac fascia; - medially – ileum (last part); - iliac external vessels; - the profound orifice of the inguinal canal; INTERNAL CONFIGURATION - - cecum hasn’t haustrae (it is a single cavity); inside it has ileocecal valve and below of this valve there is vermiform appendix; ileocecal valve – it is horizontally with one upper labium and one lower labium; these labiums are unit at their ends; the small orifice of this valve is orientated to the cecum and the greater opening to the ileum so that it permits to intestinal content to go only to the colon and stops the intestinal content to return to the ileum; vermiform appendices – it is a cylindrical tube – 9 cm – with sinuous direction; it can be orientated descending, lateral, medial or retrocecal; STRUCTURE of cecum and vermiform appendix - serous coat – peritoneum; muscular coat – with longitudinal and circular fibers, but the appendix hasn’t taeniae; submucous; mucous – it has many lymphatic folicles and because of this vermiform appendix is considered a lymphoid organ; VASCULARIZATION ileocolic artery – which is a branch from the upper mesenteric artery; it is divided in some branches: cecal artery anterior, posterior and apendicular artery; ileocolic veins – go to the upper mesenteric vein and then to the portal vein; limphatics – collect the limph in - ileocecal lymphonodes; - mesenteric lymphonodes; - duodenopancreatical lymphonodes; INNERVATION - - the upper mesenteric nervous plexus. 42 2. COLONUM - it is situated between the cecum and rectum; it is divided in following parts: Ascending colon - it extends from the cecum to the lower surface of the liver and here it changes its direction; this place is called the right colic flexure or hepatic angle of the colon; - it occupies the upper part of the right iliac crest and the right lumbar region; - it is covered by peritoneum ; - it has relations with: - in front – peritoneum; - behind – psoas muscle and the right kidney (the lower end); - laterally – the lateral wall of the abdomen; - medially – small intestine; Transverse colon - it extends from the right flexure to the left flexure, which is near the spleen and it can be called spleen angle of the colon; - it presents a long mesous called transverse mesocolon; this determines the mobility of the transverse colon; - mesocolonum – it is inserted transversal on the posterior abdominal wall and it crosses from the right to the left the second part of duodenum and the head of pancreas; the extremities of mesocolonum are situated at the lower end of the right kidney and the upper end of the left kidney; - relations: - in front – anterior abdominal wall; - the greater omentum; - behind – the right kidney; - the second part of duodenum; - pancreas; 43 - above – the lower surface of the liver ; - the greater curvature of the stomach (between them there is gastrocolic ligament); - below – duodenojejunal flexure; - small intestine; Descending colon - it extends from the left flexure to the left iliac crest; it is longer than the ascending colon; - it has relations with: - in front – peritoneum; - small intestine; - behind – lombar quadratus muscle ; - the left kidney; - nerves – iliohypogastric and ilioinguinal; - medially – small intestine; - laterally – peritoneum; 44 Sigmoid colon - it extends from iliac crest until to the rectum, at the third sacral vertebra; it is called ileo-pelvin colon; its haustrae aren’t so well represented; it has only 2 taenia; epiploic appendices are numerous and they are distributed on 2 rows; its mezous is very long and that determines a good mobility of sigmoid colon; - it is divided in 3 parts: - first part – is fixed = “iliac colon “ because it is situated between iliac crest and the internal border of psoas muscle; - the second part – is mobile; - the last part – rectosigmoidian colon ; it forms with the second part – the pelvic colon; - relations : Iliac part – in front – the anterior wall of the abdomen; - small intestine; - the greater omentum; - behind – posterior wall of the abdomen; - iliac fascia; - ilac muscle; - genital vessels (testicular or ovarian); - iliac vessels; 45