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GI2 > Abdominopelvic Autonomics and Pain > Flashcards

Abdominopelvic Autonomics and Pain Flashcards

1
Q

What is the nervous system broken down to?

A

Sensory (afferent), and Motor (efferent) nervous system

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2
Q

Within the Somatic, what does it split to?

A

Somatic (touch, pain, temp, proprioception up to the brain to process)
super well localized

Visceral - doesn’t respond to pain and touch, but responds to ischemia and stretch.
diffuse pain, NOT localized

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3
Q

What does the Motor (Efferent Nervous System) split into?

A

Somatic (Voluntary) motor system – Have to think about it

Visceral (Involuntary) Motor System – don’t have to think about it (This is the enteric nervous system!!)

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4
Q

What does the Visceral Motor Nervous System (Involuntary) supply?

what does it split into?

A

Smooth Muscle, cardiac muscle, glands

thoracolumbar (sympathetic) nervous system

Craniosacral (parasympathetic) – cranial brainstem or sacral region

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5
Q

SNS

Voluntary or Involuntary?

What type of neuron pathway?

ganglia?

Where does sensory input come from? motor output?

What excites it?

What kind of axons are they?

A

voluntary

single neuron pathway (the nerves in the femoral nerve for example, there’s one nerve that takes info from the spinal cord to the muscle)

no ganglia

general and sensory senses.. skeletal muscle

ACh

thick and myelinated - fast conducting

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6
Q

ANS

Voluntary or Involuntary?

What type of neuron pathway?

ganglia?

Where does sensory input come from? motor output?

What excites it?

What kind of axons are they?

A

Involuntary

2 neuron pathway (presynaptic and postsynaptic neuron)

ganglia are involved

sensory = general and visceral senses, motor = cardiac, smooth muscle, glands

Ach/NE can either excite or inhibit

Axons are thin, preganglionic are lightly myelinated… postganglionic are unmyelinated = slowly conducting

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7
Q

What are the parasympathetic nerves of the Cranial-Sacral division?

A

Cranial nerves 3,7,9,10

S2-S4 (pelvic splanchnic

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8
Q

Where do the parasympathetics of the Cranial nerves (3,7,9,10) synapse on?

Vagus + pelvic splanchnics?

A

Ciliary Ganglion
Pterygopalatine Ganglion
Submandibular Ganglion
Otic Ganglion

in the wall of the organ!

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9
Q

What are the neurotransmitters for parasympathetics? where are these at?

receptors?

A

Acetycholine – for both the pre and post ganglionic fibers..

pre synaptic and post synaptic release Ach!

receptors are nicotinic and muscarinic.

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10
Q

Where are the sympathetic nerves of the thoracolumbar region?

A

T1-L2

synapse to superior cervical ganglion, sympathetic chain ganglion, or prevertebral ganglion (Celiac, Sup. Mesenteric, Inf. Mesenteric)

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11
Q

What are the neurotransmitters for the sympathetic nerves?

A

Ach for the presynaptic cell

NE for the post-synaptic cell (alpha and beta receptors)

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12
Q

Explain the preganglionic sympathetics

A

you have the cell bodies for the presynaptic neurons located in the lateral horns of the spinal cord.

the cell bodies in the lateral horns are called the “intermediolateral cell columns”.. this is where you find the cell bodies.

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13
Q

Explain the head, upper limb, and chest, both parietal structures and visceral structures.

A

Parietal: Head, upper limb, chest @ T1-T6

Visceral structures (T1-T6)

Head, salivary glands = T1-T3/T4

Eye = T1/T2

Heart, Lungs, Esophagus = T4-T6

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14
Q

Explain the abdominal body wall, both parietal structures and visceral structures:

A

Parietal: abdominal body wall T7-T11

Visceral structures (T6/T7-T11):

Stomach, Liver, GB, pancreas = T6-T9
Appendix, colon = T10-T11
Small Bowel: T7-T10
Kidney: T10-L1
Suprarenal gland = T6-L2
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15
Q

Explain the lower limb wall, both parietal structures and visceral structures

A

Lower limb: T11-L2(3)

Visceral structures:

Rectum, bladder, uterus, T12-L2(3)

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16
Q

Explain the lower limb wall, both parietal structures and visceral structures

A

Lower limb: T11-L2(3)

Visceral structures:

Rectum, bladder, uterus, T12-L2(3)

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17
Q

Pathway of the sympathetic neurons (presynaptic)

A

ALL THE PRESYNAPTIC NERVES ARE THE SAME PROCESS BELOW (FROM T1-L2)

Presynaptic neurons leave the anterior/ventral root, go to where the nerve is a mixed spinal nerve, and continue on the anterior (ventral ramus) of a spinal nerve.

it’ll then enter the white ramus communicantes and go into the paravertebral ganglion.

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18
Q

What are the different types of paravertebral ganglion?

what connects the paravertebral ganglion from these two regions?

what do both of these together make?

A

3 cervical ganglion: superior, middle and inferior cervical ganglion.

Ganglion Impar

so you have ganglion going from cervical region all the way to coccyx region.

interganglionic connections.

sympathetic trunks!

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19
Q

Explain the process of what happens once we get into the paravertebral ganglion? (4 options)

A
  1. Ascend to a HIGHER LEVEL and synapse
  2. LOWER LEVEL and synapse
  3. SYNAPSE at the level of entry
  4. TRANSVERSE the trunk WITHOUT synapsing to become a abdominopelvic splanchnic nerve and synapse on prevertebral ganglion. (so passes the paravertebral ganglion)
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20
Q

If we ascend and synapse, what is this good for for sympathetics??

what about descending?

A

getting sympathetics to the head

that’s how we get sympathetics to the reproductive organs.

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21
Q

Explain postsynaptic fibers of the sympathetics?

A

exit at the level of the cell body that they synapsed in!

the fibers that go to the parietal structures exit LATERALLY via gray rami communicates

if they’re destined to go to the back they’ll travel through the posterior ramus to go to the back to do sweat glands, blood vessels in the skin, and erector pile muscles that give you goosebumps…

OR

they can go through anterior ramus of the spinal nerves going to the rest of the body.

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22
Q

why are white rami called white?

grey?

A

they have myelin, which is white!

unmyelinated look more grey!

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23
Q

functions of the sympathetic neurons?

A

Vasomotion, Sudomotion, Pilomotion

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24
Q

what happens to the sympathetic innervation of the lower limb?

A

INL to sympathetic chain via the white rami communicates and they’re going to take the descending option, where they synapse on the lower lumbar/sacral portions of sympathetic trunk.. then they jump onto the lumbosacral plexus or create periarterial plexus on the vessels.

from there they go and do vasomotor, sudomotion, pilomotion.

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25
Q

What happens to the sympathetic innervation of the upper limb?

A

upper limb they go the sympathetic chain and go ascending to go to the cervical region… they synapse on the MIDDLE OR INFERIOR CERVICAL GANGLION… then the postganglionic fibers jump onto the nerves of the brachial plexus or make their own periarterial plexus to do the same functions…

vasomotor, sudomotion, pilomotion

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26
Q

What are the different cervical ganglion? (where are they located?)

what synapses here?

A

Superior cervical ganglion which is super close to the bifurcation of the common carotid (which becomes the internal carotid and external carotid)

Middle cervical ganglion at the same level as the thyroid

inferior cervical ganglion

inferior can fuse with the paravertebral ganglion of T1 and become the “stellate ganglion”

if the autonomic ganglion need to go to the head, this is where they go.

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27
Q

If there are sympathetic fibers that come up and synapse on the superior cervical ganglion, what happens?

A

it creates an external carotid plexus and an internal carotid plexus on these arteries..

the external carotid artery gives rise to the vasculature on the superficial face, so the sympathetics here innervate salivary glands (to make mucus), Sweat glands (sweat more), and blood vessels of the face (vasoconstriction)

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28
Q

when you’re interviewing for medical school… what’s happening from your superior cervical ganglion?

A

you’re sweating more on your face.. your mouth is kind of dry, and you look kind of pale…

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29
Q

What happens to the internal carotid plexus?

what about at the orbit?.. what keeps your eye open and what opens your eye?

A

sends fibers to vasoconstriction blood vessels and mucus glands in the nasal/oral cavity

it dilates the pupil, and aids in keeping the eye elevated.

CN3 opens your eye, sympathetics keep it open!

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30
Q

Horner syndrome?

what happens?

4 symptoms?

A

lesion at the sympathetic trunk or the superior cervical ganglion..

you inhibit sympathetics going to the head.

causes pupillary constriction (mitosis)

Ptosis (droopy eyelid)

Anhydrosis (no sweat)

Flushing (red in the face)

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31
Q

What happens to the sympathetics that enter the cardiopulmonary splanchnics? (lungs, heart, blood vessles)

A

bronchodilator, vasoconstrictor, inhibits alveolar glands for the lungs

increases heart rate, impulse conduction, force of contraction in the heart.

blood vessels = relaxation of the smooth muscle via beta 2.

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32
Q

How does innervation of abdominal viscera work?

A

pass through paravertebral ganglion without synapsing, choosing to be a abdominopelvic splanchnic nerve… then synapse on prevertebral ganglion (celiac, superior mesenteric, inferior mesenteric, aorticorenal ganglion).

from there they create a periarterial plexuses (celiac, inter mesenteric, superior hypogastric, etc) going to the abdominal organs

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33
Q

What are the abdominopelvic splanchnic nerves? how do they get through the diaphragm?

A

T5-T9, T10+T11, T12

piercing the diaphragm

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34
Q

Where does greater splanchnic synapse on?

Superior mesenteric ganglion?

aorticorenal?

inferior mesenteric?

A

Celiac ganglia

some lesser and least

a little bit of everybody.

most of the lumbar splanchnics.

35
Q

the parasympathetics traveling with the vagus end where?

A

splenic flexure.

36
Q

inferior mesenteric ganglion, descending to superior hypogastric plexus and coming down as hypogastric nerves are what?

A

this whole area are postganglionic or postsynaptic sympathetics.

37
Q

Difference between cardiopulmonary splanchnic nerves and abdominopelvic splanchnic nerves?

A

CP –> synapse at paravertebral ganglia

Abdominopelvic –> synapse at PREvertebral ganglia

38
Q

Where are cell bodies found?

where are these things found?

A

only in paravertebral ganglia or prevertebral ganglia

paravertebral ganglia are found EVERYWHERE except the abdominopelvic viscera.

39
Q

What happens with the suprarenal glands?

what happens when there’s a synapse on the medulla?

A

presynaptic fiber passes through the paravertebral ganglion, AND the prevertebral ganglion, and then it synapses in the medulla of the suprarenal gland…

the cells of the suprarenal medulla actually function as the postsynaptic neurons

NE is released into the blodosteram for a wide-spread response

40
Q

Presynaptic neurons of the PNS are carried through what fibers?

A

Cranial nerves 3, 7, 9, 10

anterior roots of spinal nerves s2-s4

41
Q

Sympathetics vs parasympathetics and the nerve fibers?

A

SNS - short presympathetic (myelinated), long post (unmyelinated)

PNS - super long pre (myelinated), intrinsic ganglion found in the organ itself.

42
Q

Of the outflow (cranial nerves or sacral), which one dominates?

A

Cranial

43
Q

for parasympathetic postsynaptic neurons, what do the ganglia look like in the trunk?

A

widely scattered and irregularly spaced… located in the organ itself!! (this is the intrinsic or enteric ganglia)

44
Q

Ciliary, otic, pterygopalatine, submandibular.. which cranial nerves are synapsing where?

A

3 on ciliary, 9 on otic, 7 on pterygopalatine and submandibular!

45
Q

Where are ciliary ganglia found?

what do we care about with the pterygopalatine ganglia?

A

behind the orbit.

sends nerves into the nasal area and into the palate!

otic ganglion goes to the parotid salivary gland!

submandibular sends parasympathetics to sublingual and submandibular

46
Q

what do parasympathetics do in the head?

A

Constriction of the pupil

accommodation (helps adjust for near vision)

Serous secretions from lacrimal glands (tears)

watery serous secretion from salivary glands.

47
Q

we see sympathetics going into the head, limbs, abdominals.. where do parasympathetics go?

do parasympathetics go to the walls or limbs?

do parasympathetics ever become components of the spinal nerves (or their peripheral branches)?

A

internal glands and glands of head and body cavities.

no, except for the erectile tissue of the external genitalia.

no, except for the initial parts of S2-S4

48
Q

SNS on:

pupil
bronchioles
rate of contraction, force of contraction
blood vessels on skin and GI
peristalsis, sphincters
suprarenal glands
reproductive system?
A

dilates

dilates

increase

vasoconstricts (get blood to the skeletal muscle)

decrease, constricts

stimulate release of adrenaline

ejactulation and remission of erection.

49
Q

PNS on:

pupil

bronchioles

rate of contraction, force of contraction

blood vessels on skin and GI

peristalsis, sphincters

bladder/rectum?

reproductive system?

A

constrict

constrict

lower

vasodilator

increase, inhibits

contraction of bladder/rectum

genital erection

50
Q

What is the PNS most active in controlling?

what is it the primary stimulator of?

A

vision.. especially if you’re trying to read (near vision)

primary stimulator of the GI tract.

Active in elimination

51
Q

what are splanchnic nerves comprised of?

A

both visceral afferents and efferents!

visceral afferents (sensory picking up from organs).. take it from the organ to the Brain to process it.

then we have visceral motor (efferents) to our target gland.. (smooth muscle, glands)

so both of these are in splanchnic!

52
Q

What is most of the vagus? what about this same metric but for splanchnics?

A

80% of it is afferents, 20% of fibers in splanchnics are afferent

53
Q

Homeostasis and different physiological receptors travel with what?

pain travels with what? exceptions?

A

parasympathetics (vagus / pelvic splanchnics)

Sympathetics, except below the pelvic pain line.

(boundary is the middle of the sigmoid colon)

54
Q

Where is the thoracic pain line located?

above that where does pain travel with?

where is the pelvic pain line?

below that where does pain travel with?

between these two lines?

A

sternal angle (T4-T5)

pain travels with parasympathetics (vagus mostly)

plane of lower extent of the peritoneum (top of the uterus, parts of the bladder OR AT THE MIDDLE OF THE SIGMOID COLON)

travel with the parasympathetics.

sympathetics

55
Q

Pain:

above sigmoid colon, travels with what?

below?

A

sympathetics.

parasympathetics.

56
Q

What does Acute abdominal pain mean?

chronic abdominal pain?

subacute?

A

less than 3 days

greater than 3 weeks

in between

57
Q

Visceral vs somatic pain?

special case for somatic pain?

A

visceral = organs.. diffuse, poorly localized… often referred pain to somatic regions

somatic = well localized. caused by injury to skin, muscles, bone, joint, connective tissue.

you can get somatic pain if an organ irritates the parietal peritoneum! (gallbladder, appendix)

58
Q

What is parietal pain?

type of pain?

what can this start out as?

A

irritation of the fibers that innervate the parietal peritoneum.

this is localized

can start as visceral pain and then gives way to parietal pain, causing tenderness and guarding.

59
Q

Visceral pain can be localized to what?

foregut organs in general are what spinal levels? where do they produce pain?

jejunum and ileum, and the midgut organs?

handgun organs?

A

an approximate spinal level

T6-T9… epigastric region

T8-T10… periumbilical region

epigastric region

60
Q

spleen, stomach, 1st and second part of the duodenum, pancreas?

spleen?

A

T6-T9

T6-T8

61
Q

Kidneys?

3rd part of the duodenum, jejunum, ileum?

Cecum, ascending colon? transverse colon? descending colon?

Sigmoid colon? Rectum?

A

T10-L1

T8-T10

T10, T10, T11, T12-L1

L2(3), S2/S4

62
Q

What are you going to consider in the right hypochondriac region?

A

gallstones, cholangitis, hepatitis, liver abscess

63
Q

What are you going to consider in the epigastric region?

A

foregut organs..

esophagitis, peptic ulcer, perforated ulcer, pancreatitis

64
Q

What are you going to consider in the Left Hypochondriac region?

A

spleen abscess, acute splenomegaly, spleen rupture

65
Q

What are you going to consider in the right or left flank?

A

ureteric colic

pyelonephritis

66
Q

What are you going to consider in the umbilical?

A

appendicitis (early)
mesenteric adenitis
meckel’s diverticulum
lymphomas

67
Q

What are you going to consider in the right inguinal region?

left?

A 
appendicitis late
chron's disease
cecum obstruction
ovarian cyst
ectopic pregnancy
hernias

left same minus ectopic pregnancy and appendicitis

68
Q

What are you going to consider in the hypogastric region?

A

testicular torsion, urinary retention, cystitis, placental abruption

69
Q

Why would appendicitis start out epigastric pain and end up in right inguinal?

A

starting to irritate the parietal peritoneum, but its a midgut structure so it starts out in the umbilical region

70
Q

Liver, gallbladder, and duodenum referred pain?

A

irritate the diaphragm, which is innervated by the phrenic nerve, which sends referred pain to right shoulder pain.

71
Q

Duodenum, head of the pancreas, and stomach are in what regions of referred pain?

what’s different about the stomach?

A

epigastric

can project pain to the back

72
Q

Liver and gallbladder?

appendix?

kidneys and ureters?

A

right sided flank + back

umbilical and then goes out to the right lower quadrant as it gets worse

flank pains

73
Q

what happens if a structure is retroperitoneal and referred pain?

A

pancreas, kidney, aorta

severe back pain.

aortic aneurism presents with back pain as an example

74
Q

what is colicky pain

what happens if its in the GI?

urinary tract?

A

cramp-like pain intermittently

usually caused by an obstruction of hollow muscular structures..

bowel obstruction, stone in ureter, or stone in neck of gall.

in the foregut, midgut, or hindgut will go either to epigastric, umbilical, or hypogastric.

loin to groin

75
Q

Gastric Ulcer?

affect what?

when is it worse?

A

duodenum or stomach.. both are foregut visceral pain…

duodenal = worse 2-5 hours after eating

stomach ulcer = eating makes it worse

76
Q

Perforated Gastric Ulcer?

A

posterior perforation goes into lesser sac.. anterior = greater sac.

foregut chronic visceral pain.

once this happens you have a sudden severe pain spreading all over abdomen.

you’ll get signs of general peritonitis

77
Q

What is acute cholecystitis?

what happens if it becomes inflamed?

symptoms?

what test do we do?

A

gallbladder so foregut visceral pain

if it becomes inflamed we get somatic pain in right upper quadrant specifically under the 9th rib.

if the gallbladder irritates the diaphragm –> referred pain to right shoulder

N/V, Tenderness right upper quad, fever

positive Murphys sign
positive psoas sign

78
Q

Acute appendicitis

what happens when it gets inflamed?

symptoms?

what happens if it ruptures?

A

midgut structure = umbilical region

as it becomes inflamed, we get somatic pain in right lower quadrant.

n/v, fever, tenderness.

peritonitis in right lower quadrant if it ruptures

79
Q

adhesive small bowel obstruction?

type of pain?

vomiting?

noises?

symptoms?

A

adhesive shows signs of previous abdominal surgery

midgut hollow structure so colicky cramp like pain…

if higher in the ileum, vomiting more.. lower, might not

no flatus or bowel action below the obstruction because you’ve defecated everything you could.

dehydrated.

distended, non tender

increased bowel sounds that eventually become silent once filled up.

80
Q

Passage of a kidney stone?

symptoms

A

loin to groin pain

severe colicky pain.

severe back pain since retroperitoneal

can’t get comfortable, blood in the urine.. no fever.. soft abdomen..

tender renal angle.

81
Q

Obstructing cancer of the descending colon?

symptoms?

A

older patient unintentional weight loss

hindgut visceral colicky pain

no flatus/feces

distended abdomen..

possible mass (dull percussion)

increased bowel sounds until silent

82
Q

Ruptured ectopic pregnancy?

A

missed last menstrual period

sudden acute severe hypogastrium pain radiating to sacral area.

no fever.

peritonitis in s uprapubic area.

tenderness in rectouterine pouch on DRE or vaginal examination.

83
Q

Leaking aortic aneurysm

A

men more likely to get it.. history of atherosclerosis or cardiac disease.

sudden onset of SEVERE BACK PAIN

pale, shocked, hypotensive (losing blood)

tender epigastrium (palpate the aorta in those region)

impulse from aneurysm in epigastrium.

GI2 (20 decks)

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