Abdominopelvic Autonomics and Pain Flashcards
What is the nervous system broken down to?
Sensory (afferent), and Motor (efferent) nervous system
Within the Somatic, what does it split to?
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
What does the Motor (Efferent Nervous System) split into?
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!!)
What does the Visceral Motor Nervous System (Involuntary) supply?
what does it split into?
Smooth Muscle, cardiac muscle, glands
thoracolumbar (sympathetic) nervous system
Craniosacral (parasympathetic) – cranial brainstem or sacral region
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?
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
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?
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
What are the parasympathetic nerves of the Cranial-Sacral division?
Cranial nerves 3,7,9,10
S2-S4 (pelvic splanchnic
Where do the parasympathetics of the Cranial nerves (3,7,9,10) synapse on?
Vagus + pelvic splanchnics?
Ciliary Ganglion
Pterygopalatine Ganglion
Submandibular Ganglion
Otic Ganglion
in the wall of the organ!
What are the neurotransmitters for parasympathetics? where are these at?
receptors?
Acetycholine – for both the pre and post ganglionic fibers..
pre synaptic and post synaptic release Ach!
receptors are nicotinic and muscarinic.
Where are the sympathetic nerves of the thoracolumbar region?
T1-L2
synapse to superior cervical ganglion, sympathetic chain ganglion, or prevertebral ganglion (Celiac, Sup. Mesenteric, Inf. Mesenteric)
What are the neurotransmitters for the sympathetic nerves?
Ach for the presynaptic cell
NE for the post-synaptic cell (alpha and beta receptors)
Explain the preganglionic sympathetics
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.
Explain the head, upper limb, and chest, both parietal structures and visceral structures.
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
Explain the abdominal body wall, both parietal structures and visceral structures:
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
Explain the lower limb wall, both parietal structures and visceral structures
Lower limb: T11-L2(3)
Visceral structures:
Rectum, bladder, uterus, T12-L2(3)
Explain the lower limb wall, both parietal structures and visceral structures
Lower limb: T11-L2(3)
Visceral structures:
Rectum, bladder, uterus, T12-L2(3)
Pathway of the sympathetic neurons (presynaptic)
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.
What are the different types of paravertebral ganglion?
what connects the paravertebral ganglion from these two regions?
what do both of these together make?
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!
Explain the process of what happens once we get into the paravertebral ganglion? (4 options)
- Ascend to a HIGHER LEVEL and synapse
- LOWER LEVEL and synapse
- SYNAPSE at the level of entry
- TRANSVERSE the trunk WITHOUT synapsing to become a abdominopelvic splanchnic nerve and synapse on prevertebral ganglion. (so passes the paravertebral ganglion)
If we ascend and synapse, what is this good for for sympathetics??
what about descending?
getting sympathetics to the head
that’s how we get sympathetics to the reproductive organs.
Explain postsynaptic fibers of the sympathetics?
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.
why are white rami called white?
grey?
they have myelin, which is white!
unmyelinated look more grey!
functions of the sympathetic neurons?
Vasomotion, Sudomotion, Pilomotion
what happens to the sympathetic innervation of the lower limb?
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.
What happens to the sympathetic innervation of the upper limb?
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
What are the different cervical ganglion? (where are they located?)
what synapses here?
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.
If there are sympathetic fibers that come up and synapse on the superior cervical ganglion, what happens?
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)
when you’re interviewing for medical school… what’s happening from your superior cervical ganglion?
you’re sweating more on your face.. your mouth is kind of dry, and you look kind of pale…
What happens to the internal carotid plexus?
what about at the orbit?.. what keeps your eye open and what opens your eye?
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!
Horner syndrome?
what happens?
4 symptoms?
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)
What happens to the sympathetics that enter the cardiopulmonary splanchnics? (lungs, heart, blood vessles)
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.
How does innervation of abdominal viscera work?
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
What are the abdominopelvic splanchnic nerves? how do they get through the diaphragm?
T5-T9, T10+T11, T12
piercing the diaphragm
Where does greater splanchnic synapse on?
Superior mesenteric ganglion?
aorticorenal?
inferior mesenteric?
Celiac ganglia
some lesser and least
a little bit of everybody.
most of the lumbar splanchnics.
the parasympathetics traveling with the vagus end where?
splenic flexure.
inferior mesenteric ganglion, descending to superior hypogastric plexus and coming down as hypogastric nerves are what?
this whole area are postganglionic or postsynaptic sympathetics.
Difference between cardiopulmonary splanchnic nerves and abdominopelvic splanchnic nerves?
CP –> synapse at paravertebral ganglia
Abdominopelvic –> synapse at PREvertebral ganglia
Where are cell bodies found?
where are these things found?
only in paravertebral ganglia or prevertebral ganglia
paravertebral ganglia are found EVERYWHERE except the abdominopelvic viscera.
What happens with the suprarenal glands?
what happens when there’s a synapse on the medulla?
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
Presynaptic neurons of the PNS are carried through what fibers?
Cranial nerves 3, 7, 9, 10
anterior roots of spinal nerves s2-s4
Sympathetics vs parasympathetics and the nerve fibers?
SNS - short presympathetic (myelinated), long post (unmyelinated)
PNS - super long pre (myelinated), intrinsic ganglion found in the organ itself.
Of the outflow (cranial nerves or sacral), which one dominates?
Cranial
for parasympathetic postsynaptic neurons, what do the ganglia look like in the trunk?
widely scattered and irregularly spaced… located in the organ itself!! (this is the intrinsic or enteric ganglia)
Ciliary, otic, pterygopalatine, submandibular.. which cranial nerves are synapsing where?
3 on ciliary, 9 on otic, 7 on pterygopalatine and submandibular!
Where are ciliary ganglia found?
what do we care about with the pterygopalatine ganglia?
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
what do parasympathetics do in the head?
Constriction of the pupil
accommodation (helps adjust for near vision)
Serous secretions from lacrimal glands (tears)
watery serous secretion from salivary glands.
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)?
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
SNS on:
pupil bronchioles rate of contraction, force of contraction blood vessels on skin and GI peristalsis, sphincters suprarenal glands reproductive system?
dilates
dilates
increase
vasoconstricts (get blood to the skeletal muscle)
decrease, constricts
stimulate release of adrenaline
ejactulation and remission of erection.
PNS on:
pupil
bronchioles
rate of contraction, force of contraction
blood vessels on skin and GI
peristalsis, sphincters
bladder/rectum?
reproductive system?
constrict
constrict
lower
vasodilator
increase, inhibits
contraction of bladder/rectum
genital erection
What is the PNS most active in controlling?
what is it the primary stimulator of?
vision.. especially if you’re trying to read (near vision)
primary stimulator of the GI tract.
Active in elimination
what are splanchnic nerves comprised of?
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!
What is most of the vagus? what about this same metric but for splanchnics?
80% of it is afferents, 20% of fibers in splanchnics are afferent
Homeostasis and different physiological receptors travel with what?
pain travels with what? exceptions?
parasympathetics (vagus / pelvic splanchnics)
Sympathetics, except below the pelvic pain line.
(boundary is the middle of the sigmoid colon)
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?
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
Pain:
above sigmoid colon, travels with what?
below?
sympathetics.
parasympathetics.
What does Acute abdominal pain mean?
chronic abdominal pain?
subacute?
less than 3 days
greater than 3 weeks
in between
Visceral vs somatic pain?
special case for somatic pain?
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)
What is parietal pain?
type of pain?
what can this start out as?
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.
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?
an approximate spinal level
T6-T9… epigastric region
T8-T10… periumbilical region
epigastric region
spleen, stomach, 1st and second part of the duodenum, pancreas?
spleen?
T6-T9
T6-T8
Kidneys?
3rd part of the duodenum, jejunum, ileum?
Cecum, ascending colon? transverse colon? descending colon?
Sigmoid colon? Rectum?
T10-L1
T8-T10
T10, T10, T11, T12-L1
L2(3), S2/S4
What are you going to consider in the right hypochondriac region?
gallstones, cholangitis, hepatitis, liver abscess
What are you going to consider in the epigastric region?
foregut organs..
esophagitis, peptic ulcer, perforated ulcer, pancreatitis
What are you going to consider in the Left Hypochondriac region?
spleen abscess, acute splenomegaly, spleen rupture
What are you going to consider in the right or left flank?
ureteric colic
pyelonephritis
What are you going to consider in the umbilical?
appendicitis (early)
mesenteric adenitis
meckel’s diverticulum
lymphomas
What are you going to consider in the right inguinal region?
left?
appendicitis late chron's disease cecum obstruction ovarian cyst ectopic pregnancy hernias
left same minus ectopic pregnancy and appendicitis
What are you going to consider in the hypogastric region?
testicular torsion, urinary retention, cystitis, placental abruption
Why would appendicitis start out epigastric pain and end up in right inguinal?
starting to irritate the parietal peritoneum, but its a midgut structure so it starts out in the umbilical region
Liver, gallbladder, and duodenum referred pain?
irritate the diaphragm, which is innervated by the phrenic nerve, which sends referred pain to right shoulder pain.
Duodenum, head of the pancreas, and stomach are in what regions of referred pain?
what’s different about the stomach?
epigastric
can project pain to the back
Liver and gallbladder?
appendix?
kidneys and ureters?
right sided flank + back
umbilical and then goes out to the right lower quadrant as it gets worse
flank pains
what happens if a structure is retroperitoneal and referred pain?
pancreas, kidney, aorta
severe back pain.
aortic aneurism presents with back pain as an example
what is colicky pain
what happens if its in the GI?
urinary tract?
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
Gastric Ulcer?
affect what?
when is it worse?
duodenum or stomach.. both are foregut visceral pain…
duodenal = worse 2-5 hours after eating
stomach ulcer = eating makes it worse
Perforated Gastric Ulcer?
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
What is acute cholecystitis?
what happens if it becomes inflamed?
symptoms?
what test do we do?
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
Acute appendicitis
what happens when it gets inflamed?
symptoms?
what happens if it ruptures?
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
adhesive small bowel obstruction?
type of pain?
vomiting?
noises?
symptoms?
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.
Passage of a kidney stone?
symptoms
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.
Obstructing cancer of the descending colon?
symptoms?
older patient unintentional weight loss
hindgut visceral colicky pain
no flatus/feces
distended abdomen..
possible mass (dull percussion)
increased bowel sounds until silent
Ruptured ectopic pregnancy?
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.
Leaking aortic aneurysm
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.
