RCSI Y2 - Superior Mesenteric Vessels, Bowel, and Pancreas PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Superior mesenteric vessels, bowel and pancreas Prof Fabio Quondamatteo 1 [email protected]  Learning Outcomes Describe...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Superior mesenteric vessels, bowel and pancreas Prof Fabio Quondamatteo 1 [email protected]  Learning Outcomes Describe the anatomy of the small and large intestines including parts, blood supply and lymphatics Distinguish the anatomical features of the jejunum, ileum and colon Explain how appendiceal pain is referred Explain the anatomy of the pancreas and pancreatic duct Describe the superior and inferior mesenteric arteries Identify the small intestine, large intestine, pancreas, superior and inferior mesenteric vessels on radiological imaging  The Gastrointestinal System Foregut Midgut Hindgut Oesophagus (distal end) Duodenum (distal half) Transverse colon (distal Stomach Jejunum third) Duodenum (proximal Ileum Splenic flexure half) Cecum Descending colon Liver Appendix Sigmoid colon Gallbladder Ascending colon Rectum Pancreas Hepatic flexure of colon Spleen Transverse colon (proximal two-thirds) Coeliac Trunk Superior Mesenteric Art Inferior Mesenteric Art Splenic Vein Superior Mesenteric Vein Inferior Mesenteric Vein T5 – T10 T9 – T11 L1 & L2 Gastrointestinal System – blood supply Gastrointestinal System – blood supply sec part of dud  Pancreas Lies posterior to stomach J shaped, with 5 parts Head, Neck, Body, Tail, Uncinate process Runs transversely Duodenum to spleen Mostly sec retroperitoneal except tail Tail runs in which ligament? Gland Exocrine (duct) Amylase, trypsin, lipase Endocrine (bloodstream) Islets of Langerhans Insulin, glucagon  Pancreas Lies posterior to stomach J shaped, with 5 parts Head, Neck, Body, Tail, Uncinate process Runs transversely Duodenum to spleen Mostly retroperitoneal except tail Tail runs in which ligament? Gland Exocrine (duct) Amylase, trypsin, lipase Endocrine (bloodstream) Islets of Langerhans Insulin, glucagon https://www.earthslab.com/anatomy/spleen/  Pancreas Common bile duct Minor duodenal papilla PYLORUS Main Pancreatic Duct (Wirsung) Major duodenal papilla DUODENUM Accessory Pancreatic Duct (Santorini)  Pancreas and common bile duct Common bile duct PYLORUS Major duodenal papilla DUODENUM Common bile duct  Pancreas Lesser Omentum Major duodenal Papilla (Vater) Duodenal Ampulla (Vater) Hepatopancreatic Sphincter (Oddi) Variations in the Major duodenal Papilla Pancreas blood supply and drainage Splenic: along the superior Coeliac margin of the pancreas Superior Pancreatico- duodenal greater pancreatic Inferior pancreatic dorsal pancreatic Inferior Pancreatico- Superior mesenteric duodenal Arteries: Branches of coeliac & superior mesenteric artery Pancreas blood supply and drainage Portal vein Splenic (behind the pancreas) Superior mesenteric Veins: Splenic vein & superior mesenteric vein  Pancreas – clinical aspects Pancreatic pain often felt in back posteriorly & abdomen anteriorly Pancreatitis – Pancreatic pseudocyst Cancer of head of pancreas can lead to blockage of common bile duct Congenital abnormalities – Annular pancreas  Jejunum and ileum - mesentery In total approx. 10 feet (3m) Jejunum proximal, Ileum distal Held by mesentery Mesentery base is 6 inches (15cm) long Jejunum has a thicker wall and wider lumen Much more marked inner folding (plica circulares) in jejunum, much less pronounced in the ileum Arcades of vasa recta tall and slender in jeunum, more numerous and smaller in ileum  Jejunum and ileum - mesentery In total approx. 10 feet (3m) Jejunum proximal, Ileum distal Held by mesentery Mesentery base is 6 inches (15cm) long Jejunum has a thicker wall and wider lumen Much more marked inner folding (plica circulares) in jejunum, much less pronounced in the ileum Arcades of vasa recta tall and slender in jeunum, more numerous and smaller in ileum  Jejunum and ileum - mesentery In total approx. 10 feet (3m) Jejunum proximal, Ileum distal Held by mesentery Mesentery base is 6 inches (15cm) long Jejunum Jejunum has a thicker wall and wider lumen Much more marked inner folding (plica circulares) in jejunum, much less pronounced in the ileum Arcades of vasa recta tall and slender Ileum in jeunum, more numerous and smaller in ileum Jejunum and ileum Iliocecal Junction Iliocecal valve  Meckel’s diverticulum Remnant of the embryonic vitello-intestinal (vitelline) duct May contain ectopic gastric mucosa which secretes acid and causes bleeding from intestinal mucosa  Large intestine Caecum (& appendix) – Ileocaecal valve Colon – 4 parts: ascending, transverse, descending, sigmoid – Taenia coli Longitudinal muscle Haustrations – Appendices epiploicae Rectum Large intestine Appendix Appendix: blood supply, mesoappendix Blood Supply: appendicular artery from ileocolic (branch of superior mesenteric) Blood drainage: into superior mesenteric vein Lymph drainage: into superior mesenteric nodes Appendix – Mc Burney’s point McBurney’s point Appendix - Mc Burney’s point Inflammation of appendix in typical location Pain at the pression on the point of Mc Burney Inflammation of retrocecal appendix: pain more intense on the right flank, also irradiated at the inguinal region and right lower limb. Involvement of Ilio-Psoas muscle: Spasm after flexion of the hip. Inflammation of pelvic appendix- the pain is irradiated in lower direction and can simulate urinary infection. Appendiceal pain Colon - variation Colon - variation  Large intestine- diverticular disease Diverticulosis: development of small sacs/out-pouchings in wall of colon (diverticula) Due to increased pressure on weakened spots of intestinal walls e.g. straining during constipation May result in inflammation (diverticulitis)/ rectal bleeding Bowel – blood supply Superior mesenteric artery Superior mesenteric artery Superior mesenteric artery Inferior mesenteric artery Anastomosis SMA - IMA Close to the splenic flexure of Drummond of Drummond  Anastomosis SMA – Celiac trunk Along the second (vertical) part of the duodenum Coeliac Superior Pancreatico- duodenal Inferior Pancreatico- Superior mesenteric duodenal  Portal vein L1