Abdomen 2 Flashcards by Denisse Tiangco

Intraperitoneal organs

Duodenum, first part
Liver and gallbladder
Pancreas, tail 
Stomach 
Spleen
Jejunum and ileum
Cecum and appendix
Transverse colon
Sigmoid colon

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Retroperitoneal organs

Kidneys
Ureters
Suprarenal glands
Abdominal aorta
Inferior vena cava

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Secondarily retroperitoneal

Duodenum, second part, third and fourth part
Ascending and descending colon
Rectum
Pancreas, head, neck and body

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Contains the greater sac

Lesser/omental sac

Peritoneal cavity

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Peritoneal fluid amount

50 mL

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Connection between the greater and lesser sac

Epiploic foramen of Winslow

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Anterior to the epiploic foramen of Winslow

Hepatoduodenal ligament

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Posterior to epiploic foramen of Winslow

IVC

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Hepatoduodenal ligament contains the

Portal vein
Hepatic artery
Common bile duct

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Aka hepatorenal recess

Morrison pouch

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Most dependent portion of the abdominal cavity in the supine position

Morrison pouch

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Most dependent area in the upright position

Rectouterine pouch of Douglas

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Access to rectouterine pouch

Posterior fornix of vagina

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Scrotum layers

Skin
Dartos - Camper
Colles - Scarpa
External spermatic fascia - EO
Cremasteric muscle - IO 
NO TRANSVERSUS ABDOMINIS
Internal spermatic fascia - Transversalis fascia
Tunica vaginalis - Peritoneum 
Tunica albuginea

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Part of stomach that Secretes mucus

Cardia

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Part of stomach that houses parietal cell
secretes IF and HCl

chief cell - pepsin

Fundus and body

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Part of the stomach that houses G cells secreting gastrin

Pyloric antrum

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At the level of the stomach, the

anterior nerve

posterior nerve

Left vagus

Right vagus

LARP

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Gives rise to hepatic branch

Nerves of Laterjet (Anterior)

Left/Anterior Vagus nerve

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Gives rise to celiac branch

Nerves of Laterjet (posterior)

Right/posterior vagus

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50% of the stomach is innverated by

Criminal nerve of Grassi

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Innervates the fundus and body of stomach

Nerves of Laterjet

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Innervates the antrum

Crow’s foot

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Denervated structure in truncal vagotomy

Hepatic and celiac branch
Fundus and body
Antrum (needs drainage procedure)

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Denervated structure in selective vagotomy

Fundus Body Antrum

HSV/Parietal/Proximal cell vagotomy denervated structures

Fundus | Body

Modified Johnson Classification of PUD | Type I

Along lesser curvature

MJ Type II

One gastric | One duodenal/prepyloric

MJ Type III

Prepyloric ulcer

MJ Type IV

Proximal gastroesophageal

MJ Type V

Anywhere (associated with chronic NSAID use)

Ulcer type associated with increased gastric acid secretion:

Type II and III

Unique features of the colon

Taenia coli (rectosigmoid junction) Appendices epiplocae Haustra

Cecum -> Splenic flexure Blood supply

SMA

Descending colon -> upper rectum

IMA

Meandering mesenteric artery Union of middle colic artery and left colic artery

Marginal artery of Drummond | Arc of Roilan

Immunologic organ Secretes IgA Part of galt associated lymphoid tissue

Appendix

Inflammation of the appendix Most common acute surgical abdomen Most frequent in the 2nd and 3rd decade of life Rare in very young M/F ratio 1:1 prior to puberty 2:1 at puberty

Acute appendicits

Obstruction of the lumen leads to increase intraluminal pressure

Appendicitis

Most common cause of appendicits

Fecalith

Hypertrophy of the lymphoid tissue Inspissated barium Vegetable and fruit seeds Intestinal worms (ascaris)

Appendicits

Closed loop obstruction (primary block) Continuing normal secretion of appendiceal mucosa Rapid distention (stimulation of visceral nerve pain fibers) Rapid bacterial multiplication Capillaries and venules occluded Vascular engorgement and congestion (reflux nasura and vomiting)

Appendicitis

Inflammatory process involve serosa of the appendix (stimulation of somatic nerve) RUQ pain Absorption of necrotic tissue and bacterial toxin (fever, tachycardia and leukocytosis) Progressive distention Infarction (compromise blood supply) Perforation

Appendicitis

Prime symptom of appendicits

R LQ pain

Constant symptom in diagnosis

Anorexia

75% of patients with Acute Appendicits will present with

Vomiting

Sequence of symptoms in Acute Appendicitis

Anorexia 95% Abdominal pain Vomiting

Classic sign of acute appendicits

Direct tenderness at McBurney’s point (lateral 1/3 from ASIS to umbilicus)

Pain at RLQ when palpatory pressure exerted at LLQ

Rovsing’s sign

Area supplied by spinal nerves on the R T10, T11 and T12

Cutaneous hyperesthesia

Patient lies on the left side, examiner then slowly extends the right thigh, stretching the iliopsoas muscle (+) if extension produces pain

Psoas sign

Hypogastric pain on stretching the obturator internus muscle; performed by passive internal rotation of the flexed thigh with the patient in supine position

Obturator sign

Lab finding in acute appendicits

WBC Moderate leukocytosis (10,000-18,000) uncomplicated | >18,000 complicated

``` ALVARADO SCORE Migratory right iliac fossa pain Anorexia Nausea or Vomiting Rebound tenderness right iliac fossa Fever >/= 36.3 Shift to the left of neutrophils ``` All receive a score of

ALVARADO SCORE | that receives a score of 2

Tenderness: right iliac fossa | Leukocytosis >/= 10 x 10^9 cells/L

An ALVARADO score of <3

Low likelihood of appendicitis

An ALVARADO score of 4-6

Consider further imaging

An ALVARADO score of >/= 7

High likelihood of appendicits

Components of appendicits inflammatory response score

Vomiting 1 Pain in the right inferior fossa 1 Rebound tenderness or muscular defense: light 1, medium 2, strong 3 Body temperature >/= 38.5 1 PMN 70-84% 1, >/=85 2 WBC 10-14.9 1, >15 2 C-RP concentration 10-48 g/L 1, >/= 50 g/L 2

Appendicits inflammatory response score interpretation 0-4 5-8 9-12

0-4 low probability, outpatient follow-up 5-8 indeterminate group, active observation or diagnostic laparoscopy 9-12 high probability, surgical exploration

Imaging studies for acute appendicits Inexpensive Does not require contrast Applicability among pregnants Sign: wall thickening, peri-appendiceal fluid

Grade compression US

Imagig studies for acute appendicits More sensitive and specific

CT Scan

Sign of acute appendicits in CT Thickened cecum that funnels contrast into appendiceal orifice

Arrowhead sign

Accuracy of pre-operative diagnosis in acute appendicits should be >

>85%

Rupture of acute appendicits is higher in the

pediatric and geriatric age groups

Differential diagnosis for acute appendicits

Acute abdomen ``` Acute mesenteric lymphadenitis No organic pathologic condition Acute PID Twisted ovarian cyst or ruptured Graafian follicle AGE ```

``` Gangrene & rupture occur earlier during the course of acute appendicits Inability to give accurate history Diagnostic delays High frequency of GI distress Underdeveloped greater omentum ``` Children <5 years of age Negative appendectomy rate = 25% Perforation rate = 45%

Appendicits in the Young

Most common extrauterine surgical emergency Rare in third trimester Incidence = 1:766 Negative appendectomy rate = 25% (2nd trimester) Consider when there is new onset abdominal pain Laboratory evaluation is not helpful Imaging: US or MRI Incidence of fetal loss = 4% Risk of early delivery = 7% Pregnancy does not alter the location of the appendiceal base more than 2cms from McBurney’s point

Appendicits in Pregnancy

Urgent 12-24h Emergent <12h No significant difference Number of complicated appendices Rate of SSI, intra-abdominal abscess formation Operative time Conversion to open procedure in case of laparoscopy Surgeon and institution dependent

Uncomplicated appendicits

Management for complicated appendicitis

Perforated appendicits commonly associated with abscess or phlegmon 2/10000 per year Standard treatment -immediate appendectomy Non operative management - confined abscess/phlegmon - limited peritonitis Tx - antibiotics, fluids, bowel rest, percutaneous drainage

If appendicits is not found

Cecum and mesentery should be inspected Retrograde evaluation of the small bowel Look for Crohn’s or Meckel’s diverticulitis Inspect reproductive organs (females) Extend the incision if pus or bilious fluid is encountered

Clinical syndrome of the right lower quadrant or right iliac fossa pain secondary to a perforated peptic ulcer

Valentino syndrome | Valentino appendix

Incidental appendectomy | Indications

Children about to undergo chemotherapy Disabled individuals Crohn’s disease (cecum must be healthy) Individuals about to travel to remote places Routinely performed in Ladd’s procedure

Most common site of GI carcinoid

Appendix

Usually small, firm circumscribed, yellow brown tumor Usually located at the tip

Carcinoid tumor with best prognosis Malignant potential related to size

Adenocarcinoma of appendix kinds:

Mucinous adenocarcinoma | Signet ring carcinoma (rarest, lowest survival)

Adenocarcinoma of appendix tx:

Right hemicolectomy

Cystic dilatation of the appendix containing mucoid material

Mucocoele

From non-inflammatory occlusion of the proximal lumen of the appendix

Benign Mucocele

Malignant mucocoele

Cystadenocarcinoma

Mucocoele tx:

Appendectomy Wide resection of the mesoappendix and all appendiceal lymph nodes Collection and cytologic examination of intraperitoneal mucus Right hemicolectomy + tumor at the base + periappendiceal lymph nodes

Diffuse collection of gelatinous fluid and mucinous implants on peritoneal surfaces and omentum (peritoneal surface of bowel spared) More common in women Abdominal pain, distention, mass CT scan (preferred) Tx: thorough surgical debulking appendectomy, omentectomy, TAHBSO

Pseudomyxoma peritonei

Extremely uncommon tumor of the appendix Presents as appendicits CT scan findings Appendiceal diameter >2.5cms surrounding soft tissue thickening Treatment: Appendectomy: confined to appendix Right hemicolectomy: cecal and mesosppendix involvement

Lymphoma of appendix

Anatomical division of the liver is by

Falciform ligament

Physiologic division of liver is by

Cantlie line

Connects the fundus of the gallbladder with the center of the inferior vena cava Divided according to the portal division of blood supply

Cantlie line

Cantlie’s line runs between the medial borders of segment

IV and V/VIII

Blood supply of liver

Hepatic artery 25% | Portal vein 75%

Valves of Heisted

Cystic duct

The biliary tree is made up of the

Cystic duct Right and left hepatic ducts CBD Ampulla of Vater

Biliary tree drains at

posteromedial wall of the 2nd part of the duodenum

Ventral pancreas

Head, inferior Uncinate process Main/major pancreatic duct

Dorsal pancreas

``` Head, superior Neck Body Tail Accesorry/minor pancreatic duct ```

Most common congenital anomaly of pancreas

Pancreas divisum

Failure of fusion of dorsal and ventral pancreatic primordia Bulk of the pancreas drains through the dorsal pancreatic duct and fhe small caliber minor papilla Predisposes to chronic pancreatitis

Pancreas divisum

Bulk of pancreas drains through the

dorsal pancreatic duct | small-caliber minor papilla

Band-like ring of normal pancreatic tissue that encircles 2nd portion of duodenum Assoc with other congenital anomalies Presents as duodenal obstruction (gastric distention, vomiting)

Annular pancreas

Aberrantly situated pancreatic tissue

Ectopic pancreas

Favored sites of ectopic pancreas

``` Stomach Duodenum Jejunum Meckel diverticula Ileum ```

May cause localized inflammation or mucosal bleeding

Ectopic pancreas

Main pancreatic duct drains to the

Main pancreatic duct of Wirsung drains to the Major duodenal papilla

Accessory pancreatic duct of Santorini drains to the

Minor duodenal papilla

Reversible pancreatic parenchymal injury associated with inflammation Most common etiologies are alcoholism 65% Biliary tract disease 35-60%

Acute Pancreatitis

Causes of acute pancreatitis

Duct obstruction Acinar cell injury Defective intracellular transport

Activated enzymes in acute pancreatitis

Interstitial inflammation and edema Proteolysis (proteases) Fat necrosis (lipase, phospholipase) Hemorrhage (elastase)

Acute Pancreatitis causes

``` Gallstones Ethanol Trauma Steroids Mumps Autoimmune (PAN) Scorpio sting Hyperlipidemia/hypercalcemia ERCP Drugs (sulfa drugs) ```

Proteolytic destruction of pancreatic parenchyma Destruction of blood vessels and subsequent intersitial hemorrhage

Acute Pancreatitis

Ranson Criteria | Admission

``` Glucose >200 AST > 250 LDH > 350 Age > 55 WBC > 16000 ``` GALAW

Ranson Criteria | Initial 48 hours

``` Calcium <8 Hct drop >10% Oxygen <60 BUN >5 Base deficit >4 Sequestration >6L ``` CHOBBS

Necrotizing pancreatitis signs

``` Grey Turner Sign (flank) Cullen sign (umbilicus) ```

What is the most appropriate treatment for acute pancreatitis?

Bowel rest NPO

What is the most appropriate analgesic for patient with acute pancreatitis? Why?

Meperidine | doesn’t cause dysfunction of Sphincter of Oddi

Inflammation of the pancreas with irreversible destruction of exocrine pancreas Most common cause of chronic pancreatitis is long-term alcohol abuse

Chronic pancreatitis

``` Activation of proteolytic enzymes Activation of clotting cascade Inflammation Vascular injury Acinar cell injury Resolution ```

Acute Pancreatitis

Ethanol Oxidative stress Injury Inflammation TGFB TGFB PDGF Collagen secretion ECM remodelling Pancreatic fibrosis Acinar cell loss

Chronic pancreatitis

Parenchymal fibrosis Reduced number and size of acini Dilation of pancreatic ducts

Chronic pancreatitis

Localized collect of necrotic-hemorrhagic material rich in pancreatic enzymes Lack an epithelial lining Usually arise in the following settings: after an episode of acute pancreatitis chronic alcoholic pancreatitis

Pancreatic pseudocyst

Fourth leading cause of cancer death

Pancreatic adenocarcinoma

Strongest environmental influence is cigarette smoking ``` Localization 60% head of the pancreas 15% in the body 5% in the tail 20% diffusely involves the entire gland ```

Pancreatic adenocarcinoma

Spleen size

1 x 3 x 5 inches

Spleen weight

7 oz

Spleen is situated

between ribs 9-11

Splenorenal ligament contents:

Splenic vessels | Tail of pancreas

Gastrosplenic ligament contents:

Short gastric vessels

Compression of the third part of the duodenum

Superior mesenteric artery syndrome

Renal vein entrapment syndrome

Nutcracker syndrome

Most common site of aneurysm

Abdominal aneurysm | Infrarenal

SMV + Splenic vein makes up the

Portal vein

The portal vein is located

behind the neck of the pancreas

Hepatic portal systems drains

Lower 1/3 of esophagus to upper 1/2 of anal canal

Tributaries of the splenic vein

Short gastric vein Left gastroepiploic vein Inferior mesenteric vein Pancreatic vein

Sites of anastomoses between portal and caval systems

Umbilicus Rectum Esophagus Retroperitoneal organs

Paraumbilical veins Superficial veins of the anterior abdominal wall Caput medusae

Umbilicus

Superior rectal vein Middle and inferior rectal veins Internal hemorrhoids

Rectum

Gastric vein Veins of the lower esophagus Esophageal varices

Esophagus

SMV and IMV Veins of the posterior abdominal wall Not clinically relevant

Retroperitoneal organs