Abdomen 2 Flashcards
what is Posterior abdominal wall made of?
Lumbar vertebrae
muscle: Iliacus
muscle: Quadratus lumborum
Divisions of the abdominopelvic cavity and within the pelvic cavity, what is the difference between greater and lesser pelvis?
greater = everything up from pelvic inlet to pelvic crest
lesser (true)= everything below pelvic inlet & its where pelvic organs lie ie, uterus, bladder, rectum
Components of peritoneal fluid
WELIA
Water
Electrolytes
Interstitial fluid
Leucocytes
Antibodies
peritoneal cavity in males vs females
Closed in males
Communication with the exterior via the vagina, uterus and uterine tubes in females
Small gap between the fimbriae and ovaries, can be prone to infection which can spread into the peritoneal cavity
definition of peritoneum
a single layer of mesoepithelial cells underlined by a basement membrane that lines the abdominal and pelvic cavities
Parietal peritoneum function and innervation
lines walls of abdominal
inervated by T7 - T11 SOMATIC nerves, so if patient has inflammation, pain will be localised
sensitive to temp, pressure, touch
Visceral peritoneum function and innervation
lines organs
ANS afferent supply to submesothelial tissue (Vagus nerve - parasymp)
REFFERED PAIN
sensitive to distension (over distension leads to sensation of pain in stomach)
what is intraperitoneal?
Organs are completely covered with visceral peritoneum, and organs are motile because of rge mesentry
and so organs are attatched to each other or the abdo wall viia
*Mesentery
*Ligaments
*Omentum
*Organs have greater mobility.
stomach, liver, spleen
what is extraperitoneal?
Organs are partially or entirely devoid of peritoneum.
They lie outside peritoneal cavity.
According to position they can be:
* Retroperitoneal: posterior to peritoneal cavity ie kidney or pancreas - SADPUCKOR - organ is behind
* Sub-peritoneal: inferior to peritoneal cavity ie bladder - RUDDU - organ is below
NO MESENTERY so immobile
is duodenum completely intraperitoneal?
no, has 4 parts: only 1st part is intra
what are the diff organs types (intra, retro etc)
what runs in the peritoneal double folds and whats the function?
*Route of blood vessels, lymphatics, nerves.
*May contain embryological remnants E.g: Falciform ligament of liver: umbilical vein
*Contains varying amounts of fat ie greater omentum (high volume) and lesser omentum (devoid of fat)
*May contain intraperitoneal parts of organs
*Tail of pancreas lies in splenorenal ligament
*Immunity: greater omentum: policeman of abdomen because it encloses infection
*Prevents effects of gravity.
what structure connects mobile parts of intestines to posterior abdo wall?
mesentries
where is the developing foregut suspended from?
anterior - by ventral mesentry/mesogastrium
posterior - by dorsal mesentry/mesogastrium
where does the liver start to develop and what does it do there?
in ventral mesentry and splits it into lesser omentum (liver to stomach and duodenum) and falciform ligament
anterior abdominal wall –> falciform ligament –> liver –> lesser omentum (hepatogastric ligament and hepatoduodenal ligament)
what is peritonitis?
perforation of abdominal peritoneum or burst appendix = release of fecal matter (poo) into peritoneal cavity
what are the ligaments formed by the lesser omentum (omental bursa)?
lesser ommentum connects lesser curvature of stomach to inferior surface of liver
1) Hepatogastric ligament - stomach to liver
2) Hepatoduodenal ligament - liver to duodenum - contains portal triad
what runs in the free edge of the lesser omentum?
Portal triad runs in free edge of lesser
omentum (hepatoduodenal ligament).
1. Common bile duct
2. Proper hepatic artery
3. Hepatic portal vein
how does the stomach rotate
Stomach rotates 90 degree clockwise - anteroposterior axis
- Left side faces anteriorly
- Right side faces posteriorly
*Pyloric part moves to right and upwards
*Cardiac part moves to left and downwards
where does the round ligament (teres hepatis) run? what is it
inside falciform ligament
remnant of umbillical vein
how do lesser and greater sac communicate?
epiploic foramen
what is greater omentum
how is greater omentum formed?
surgical importance of greater omentum
Double fold of peritoneum folded back on its self (four
layers), forming an apron like structure that hangs from the
greater curvature of stomach:
* Policeman of abdomen
* Varying degrees of fat
Formed from a downwards extension of the dorsal mesogastrium.
Layers can be separated by surgeons to give a passage way into the lesser sac (2)through the ‘inferior recess’ (1).
boundaries of epiploic foramen
Boundaries:
*Superior: Caudate process of liver
*Inferior: 1st part of duodenum
*Posterior: Inferior vena cava and right crus of diaphragm
*Anterior: Portal triad (in free edge of lesser omentum)
CIDP
(Practice) why is lesser sac surgically important?
can access posterior abdominal wall through epiploic foramen
where does spleen form and what is it divided into (ligaments)?
in dorsal mesogastrium
divided into:
- gastrosplenic ligament
and
- lienorenal ligament
what is the transverse mesocolon?
Double fold of peritoneum that connects transverse colon to the posterior abdominal wall.
Anterior layer of transverse mesocolon is attached to the posterior layer of greater omentum.
what is the mesentery of SI and what does it contain?
Fan-shaped double fold of peritoneum that suspends the jejunum and ileum from the posterior abdominal wall.
Contains: Superior mesenteric artery (1) + vein (2)
List some examples of retroperitoneal organs
SADPUCKOR
Suprarenal glands
Aorta and IVC
Pancreas (Head, neck and body)
Ureters
Colon (ascending and descending)
Kidneys
Oesophagus
Rectum (middle 1/3)
What is the median umbilical ligament? what is medial umbilical ligament? and lateral?
Located deep on the anterior abdominal wall
Extends from apex of bladder to umbilicus
Median = Remnant of urachus (Drained the urine from the foetus)
Medial = Remnant of umbilical arteries
Lateral = Only functional ligament, overlies inferior epigastric arteries
Following enormous liver expansion and stomach rotation the dorsal mesogastrium will be split by which organ?
What will it form?
Dorsal mesogastrium is split by the development of the spleen
Form two ligaments
Gastrosplenic ligament = Stomach to spleen
Lienorenal (splenorenal) = Spleen to left kidney
What forms remnants of the dorsal and ventral mesogastrium?
what are the 4 ligaments formed by the developing foregut
Ventral = Falciform ligament and lesser omentum
Dorsal = Gastrosplenic and leinorenal ligament and greater omentum
from ventral mesogastrium
falciform ligament
hepoduodenal - liver to duodenum
hepatogastric - liver to stomach
= in lesser ommentum
from dorsal mesogastrium
lienorenal - spleen to kidney
gastrosplenic - spleen to stomach
label what u can
What is the course of the mesentary?
Where does it start and end?
Oblique course
Starts at: Duodenaljejunal flexure (left L2)
Ends: Ileocaecal junction (near sacroiliac joint)
What is the duodenal-jejunal flexure?
last part of duodenum ascends to the left and terminates at a junction with the jejunum
Located L2
What is the superior and inferior boundary of the oesophagus?
At what level do we find them
Pharyngoesophageal junction (C6)
Cardiac orifice of stomach (T11), NOT DIAPHRAGMMMMM DONT GET THIS MIXED UP. IT LEAVES DIAPHRAGM AT T10 BUT ENTERS CARDIAC ORIFICE OF STOMACH AT T11
what are the two shincters of teh oesophagus and clin rel
- Upper oesophageal sphincter (UES)
* Inferior constrictor muscle - Lower oesophageal sphincter (LES)
* GORD
What are the constrictions of the oesophagus? (ABCD)
A = Arch of the aorta
B = Bronchus (left)
C = Cricoid cartilage (pharyngo-oesophageal junction)
D = Diaphragmatic hiatus (oesophageal hiatus is formed by right crus on diaphragm)
what are the different musculature parts of the oesophagus
1/3rd - skeletal muscle
middle third = skeletal and smooth muscle
distal/ last third = smooth muscle
What is the arterial supply of the oesophagus? (Split into 1/3)
Upper 1/3 = Inferior thyroid artery (from thyrocervical trunk)
Middle 1/3 = Thoracic aorta
Lower = Left gastric artery
Esophageal layers and barrets esophagus syndrome
Reflux in GORD
Causes mucosa in oesophagus change from non keratinized stratified squamous to simple columnar
What is the nerve supply to the oesophagus?
-Vagus nerve (CNX) for parasymp and general sensation
- Nerves from cervical and thoracic trunk for sympathetic and pain
what is esophageal achalasia?
oesophagela aperistalsis = impaired relaxationof lower oesophageal sphincter
- barium swallow shows a lack of peristalsis (involuntary control) and shows lower end shows a “bird’s beck”
What is the proximal and distal drainage of the esophageal lymphatics?
Proximal = Upwards to deep cervical lymph nodes (lie by internal jugular vein)
Distal = Juxta-oesophageal lymph nodes (lie anterior to oesophagus in p. mediastinum)
Where is the stomach located?
Intraperitoneal organ
Located in the left hypochondrium and epigastric and
umbililcal region
Located in RUQ and LUQ
Position can vary due to body habitus, contents etc
Identify the following areas on the stomach
Which part of the stomach will appear black on X-rays?
Fundus as it is full of air/gas
Identify the angular incisure on the stomach
Notch of the lesser curvature
Marks the commencement of the pyloric antrum
Identify the cardiac notch, lesser and greater curvature of the stomach
What is the pylorus composed of?
Pyloric antrum
Pyloric canal
Pyloric sphincter
acs
What are the three muscular layers of the stomach?
Inner oblique layer
Middle circular layer
Outer longitudinal layer
What is the purpose of the inner oblique layer, middle circular layer in the stomach and whihc one makes the pyloric sphincter
Inner oblique = Mechanical breakdown of food, will form the ruggae
Middle circular = Thickest at pylorus, will form pyloric sphincter *
Outer longitudinal = Moves bolus to pylorus by muscle shortening
What is a peptic ulcer?
Where can it be located?
What can it be treated by?
Open lesion in mucosa
Can be oesophageal, gastric or duodenal
Caused by NSAIDs, H. Pylori or stress
Treated by Abs and proton pump inhibitors
How is the blood supply to the different gut regions divided?
Foregut - Supplied by the coeliac trunk
Midgut - Supplied by the superior mesenteric artery in mesentery
Hindgut - Supplied by inferior mesenteric artery
What vertebral level does the coeliac trunk arise from?
What are its three branches?
T12
- Common hepatic
- Left gastric
- Splenic artery
Which two arteries anastomose and run along the lesser curvature in lesser omentum?
Where do they come from?
Left gastric (comes from coeliac trunk)
and
Right gastric (comes from hepatic artery proper coming from common hepatic)
Identify the artery on the diagram
Short gastric
Branch of splenic artery
Will pass through gastrosplenic ligament
What branch of the gastroduodenal and splenic artery will anastomosis and run along the greater curvature of the stomach
B. of Gastroduodenal = Right gastro-omental
B. of splenic = Left gastro-omental
What is the sympathetic innervation to the stomach?
What does it do?
The greater splanchnic (T5-T9)
Motor innervation to pyloric sphincter = decreased gastric emptying
How does sympathetic innervation of the stomach lead to referred pain?
Which region is foregut pain referred to?
Pain fibres will hitchhike with splanchnic nerves
Pain from the foregut is referred to the epigastric region
What is the parasympathetic innervation to the stomach?
Left and right vagus nerve form anterior and posterior vagal trunk respectively
Will increase gastric secretion and motor to smooth muscle wall = more digestion
What does the lymphatic drainage of the stomach follow?
Follows blood vessels (see diagram)
Important for cancer spreading
where is the sigmoid colon?
This is the mesentery associated with the sigmoid colon.
The root of this mesentery forms an inverted “V” shape
what are the peritoneal recesses
- Left and right paracolic gutters
The paracolic gutters provide pathways for the flow of ascitic fluid and the spread of
intraperitoneal infections. Similarly, the paracolic gutters provide pathways for the spread of tumour cells - Subphrenic space
Space between the upper surface of the right lobe of the liver and below the diaphragm. - Hepatorenal pouch (of Morrison)
Space between the liver and the right kidney. - Rectovesical pouch in the male pelvis.
Space between rectum and bladder (male) - Uterovesical pouch in the female pelvis.
Space between uterus and bladder (female) - Rectouterine pouch (of Douglas) in the female pelvis
Space between uterus and rectum (female
Where does purulent material (consisting of or containing pus) in the abdomen, which
has been transported along the paracolic gutters, pool when the patient is supine?
Hepatorenal pouch or rectovesical pouch (males) / rectouterine pouch (females)
