Anat. GIT Anatomy and Imaging-Witwer (Exam 2) Flashcards
Hepatic artery goes toward the liver–> hepatic proper artery goes ?
*INTO the liver
Ligament of teres=
end result of the involution of the umbilical vein, in the falsiform ligament
artery of Adamkiewicz(AKA)
also known as the great anterior radiculomedullaryartery, is a majorarterythat joins the anterior spinalarteryin the lower one-third of the spinal cord
BELOW the yellow line=
below the yellow line is RETROperitoneal
- vast majority of pancreas is retraperitoneal except for the tail
- And above it is INTRAperitoneal (the line is the peritoneum)
- what level are we: the transpyloric line= the pylorus, the duodenal bulb, the celiac artery, both renal arteries go out to the side, and renal veins come in, body of the pancreas at this line. It’s half way b/w sternal notch and pubic symphysis. Or halfway b/w xiphoid and umbilicus.
- the liver:
Retroperitoneal organs: S:suprarenal (adrenal) gland A:aorta/IVC D:duodenum(second and third part) P:pancreas(except tail) U:ureters C:colon(ascendinganddescending) K:kidneys E:(o)esophagus R:rectum
Fascia surrounding the kidney=
gerota’s fascia around the kidney (PROTECTS the kidney from developing pancreatitis!
Transverse duodenum location
b/w the SMA/SMV and Aorta
FEMALE PELVIC ANATOMY:
list the 3 common imaging techniques for female/male Pelvis
US: useful for imaging the ovaries, uterus. Or imaging the prostate
MRI: useful for imaging uterus and cervix, and prostate
CT: images uterus, broad and round ligament, ovaries, Seminal vesicles, and prostate , BUT not as well as an MRI
Round ligament originates:
from the uterus
-Round ligament is analogous to the spermatic duct (goes out inguinal canal)
Ascites=
ASCITES IS ABNORMAL! THE ASCITES SLIDES ARE FOR THE ANATOMIC RELATIONSHIPS ONLY
Pouch of douglas aka
*the rectrouterine pouch) where pus and tumor end up
Ovaries can develop ____
follicular cysts*
Describe the uterus
Flexion of the uterus is NORMAL variation***
- Endometrium is the inside of the uterus (mostly mucous or vascular fluid)
- Myometrium= muscle of the uterus
- cervix is located INSIDE the uterus
- Sacrum, coccyx and bladder located inferiorly
Cancer of the Prostate is MC in the _____ portion
MC in the posterior portion (75%)– most are accessible by the digital rectal exam
BPH occurs in the _____ zone
central zone
The prostate capsule is best seen with which imaging study?
- TZ=
- PZ=
MRI
(prostate capsule containes the TZ and PZ)
- transitional zone
- peripheral zone
- Seminal vesicles come in through the posterior urethra (prostatic urethra)
T-3 prostate cancer=
tumor extends beyond the capsule to the rectal wall
Chest films can be very valuable in the evaluation of :
- abdominal pain.
- Sometimes lung or pleural disease can manifest as abdominal pain.
(This pain can be referred to the shoulders (C3, C4 C5)
Free air secondary to a perforated abdominal viscus will gravitate under the _____
diaphragm in an upright film
FREE AIR on Chest film indicates–>
perforation in abdominal viscus
Morison’s pouch=
subhepatic recess, it’s intraperitoneal and it’s located on the right side behind the liver (=posterior hepatorenal space)
Which peritoneum is located in front of the liver?
Which peritoneum is located behind the liver?
- parietal peritoneum
- Visceral peritoneum
Messentary=
is made up of the peritoneum folding around the bowel (mesentery- is what the bowel is hanging off of)
Free intraperitoneal air can occur 2/2:
-perforated viscus
Pneumoperitoneum:
-Morison’s pouch=
Posterior Hepato-
Renal Space
Throat swallowing:
- coordinated by?
- initiated by?
- Swallowing Center in medulla and pons - Bulb
- Initiated by touch receptors in Pharynx
THROAT - Swallowing:
-4 phases?
-Oral Preparatory Phase -
food processed by Mastication (V3) and Salivation (VII) into bolus
-Oral Phase (Buccal) -
bolus moved to back of tongue, anterior tongue lifts to hard palate and retracts posteriorly to force bolus into oropharynx. Posterior tongue lifted by Mylohyoid m, elevating soft palate and sealing the nasopharynx (V, VII, XII)
-Pharyngeal Phase
Bolus advanced from pharynx to esophagus. Soft Palate is elevated to Posterior Nasopharyngeal wall by Levator veli palatini. Superior Constrictors bring Palatopharyngeal folds together. Larynx and Hyoid are elevated and pulled forward to the Epiglottis to relax Cricopharyngeus m. (V, X, XI, XII)
-Esophageal Phase
Bulbar Palsy=
if issues with swallowing due to nerves 9, 10, these go into the bulb–> BULBAR palsy. Disease with bulbar palsy: polio, ALS, ischemia or infarction of the bulb, or tumor in that area. Bulbar paralyisis is paralayisis of the nerves in the jug foramen (9,10,11)
Swallowing - describe the Sensory and Motor Components
Trigeminal Nerve -CN V -
important in Chewing and sensation (pain, temperature, touch) to the mouth and anterior 2/3 of tongue. PSNS to Salivary Glands in Mouth and Parotid Gland.
Facial Nerve -CN VII -
taste on anterior 2/3 of tongue via Chorda Tympani
Glossopharyngeal Nerve - CN IX -
taste and sensation on posterior 1/3 of Tongue, sensation in oropharynx and upper pharynx
Vagus Nerve - CN X -
sensation from mucous membranes of pharynx, larynx, esophagus, and abdominal viscera of foregut and midgut
taste from epiglottis
motor of soft palate, pharynx and larynx and smooth muscle of abdominal viscera.
Important for airway protection.
Spinal Accessory Nerve - CN XI
Assists in the swallowing function
Hypoglossal Nerve - CN XII -
motor nerves to the Tongue
Describe the Proximal Esophageal Sphincter
-Functional, but not anatomical, sections of the esophageal wall that act as a sphincter.
Skeletal muscle, not under conscious control
Triggered by the swallow reflux
Primary muscle is the Cricopharyngeus muscle portion of the Inferior Pharyngeal Constrictor.
Commonly becomes dysfunctional with aging.
Lower Esophageal Sphincter
- At the Gastroesophageal Junction
- ->Normally not seen on Upper GI Series
Killian’s Dehiscence=
Killian dehiscence is a triangular-shaped area of weakness in the muscular wall of the pharynx, between the transverse and oblique bundles of the inferior pharyngeal constrictor
*It represents a potentially weak spot where a pharyngoesophageal diverticulum (Zenker’s diverticulum) is more likely to occur.
Facial nerve comes out;
styloid foramen
Constrictor muscles are roughly _____
horizontal
Pharyngeal muscles are ______
vertical
Zenker’s diverticulum=
= an outpouching that occurs at the junction of the lower part of the throat and the upper portion of the esophagus. The pouch forms because the muscle that divides the throat from the esophagus, the cricopharyngeal (CP) muscle, fails to relax during swallowing.
- Symptoms include difficulty swallowing, feeling swallowed material sticking in the throat, regurgitation, weight loss, bad breath, choking, and coughing. Swallowed material may accumulate in the diverticulum and be regurgitated long after a meal.
Schatzki Ring: the ring is at the ______
Gastroesophageal Junction
Unknown etiology - possibly a stricture
secondary reflux esophagitis
Lower esophageal rings are common
and usually asymptomatic.
If symptomatic with intermittant
dysphagia, termed a Schatzki Ring
tx: You can use Bouginage for these
Sliding Hiatus Hernia
Hernias REMEMBER THIS: Process vaginalis (this goes out and down and internal inguinal ring-> down the canal– out the external ring– and into the scrotum and vas deferens and seminal vesicles, spermatic cord, veins. Testicular arteries begin up high in the aorta and descend down (via the process of vaginalis).
-if it becomes edemetous–>swelling–> increased pressure on the veins–> more edema–> strangulated hernia= dead bowel (incarcerated bowel–> high risk for strangulated hernia (=MEDICAL emergency) classic finding of dead bowel is massive increase in WBCs
Reducible hernia OR Fixed (non reducible) hernia- OR Incarcerated hernia “it’s in jail” cant get out, inflamm. Rxn. OR strangulated
Barrett’s Esophagus=
Work up a PT with long standing GERD with endoscopy due to metaplasia (changes of normal=mucosa to gastric mucosa — increased risk for malignancy) ORDER AN endoscopy to rule out
Distal 1/3 of the esophagus= barret’s esophagus and adenocarcinoma
Middle third= squamous cell carcinoma
Carcinoma of the Esophagus can metastasize to the _______
liver
MC cause of esophageal varices:
-Cirrhosis of the liver causing backflow (centrifugal) (MR Extensive Varices secondary to Portal HTN)
Hep C MC for cirrhosis and ALCOHOLISM
Ulcer with radiating mucosal folds=
gastric ulcer
Something damages the epithelium–> (say stomach epithel. (ie gastric epithelium) Hhydrochloric acid can now leak through becomes inflamed and LOTS of edema eats through the peritoneum ulcer forms inside the GI tract
Body will try to protect the ulcer with scarring
ABSCESS: where will you have them? Infection and an abscess ocurrs when there is infection and blockage of drainage in an infection (tx: cold steel and sunshine)
-they occur in the skin, gallbladder, appendix, diverticulits, INFECTION that cant get out. First thing= Phlegmon (=diffuse inflammatory process with bacteria)–> this will be staph or strep MC! Phlegmon becomes an abscess= inside the abscess is pus. That pus will work its way to the surface- tx: send it for culture/sensitivity (pus), Abx, and drain it
A chronic atrophic gastritis=
a precancerous condition
-Chronic atrophic gastritis= MC with pernicious anemia
Subphrenic abcess post perforation of Duodenal Ulcer
This abscess is beneath the diaphragm—>surgeons will place drains—> Abs–> drains will clear up the abscess
Blood Supply to the Bowel:
Note Coelic artery, Superior Mesenteric Artery, and Inferior Mesenteric Artery distributions and communications
Adynamic ileus pattern with dilated bowel and air fluid levels=
**mesenteric ischemia
Notes:
due to lack of blood flow from the artery, OR obstructed vein
-veins = low pressure system–> so it will be blocked first in the case of a strangulated hernia
-if you have an infarction–> different thing
Dead bowel can be 2/2 venous obstruction (strangulated hernia)–> build up of edema strangulated arteries. This is Much more common in the small bowel! Also common in the proximal bowel!! Since the superior mesenteric artery can become blocked
Block the vein so blood is going to back uo! In the capillaries there will be increased hydrostatic pressure (going out of the capillary)!!!! and decreased oncotic pressure (pressure going into the capillary)(due to decreased albumin) and this causes edema that blocks the flow of the artery (=dead bowel)
“thumbprinting” on imaging indicates:
Thumbprinting indicating bowel wall edema
(seen with mesenteric ischemia)
-can occur w/ Occlusion of SMA just beyond jejunal branches
-Increased
Postprandial response would be blunted in Ischemia
Crohn’s Disease:
-imaging findings?
- thickened small bowel and mesenteric vascular and inflammatory thickening
- small bowel obstruction after ileocolectomy and recurrant disease
Sprue-Celiac Sprue:
- imaging findings?
- Sx?
-Barium Small Bowel Follow Through shows non-specific findings of dilatation
of SB, contrast dilution, increased ileal folds, barium flocculation, and
**jejunization of the ileum-although the findings are non-specific, together
they are very suggestive of Sprue
-PT losing weight and cant figure out why–> THINK celiac sprue
Abnormal Bowel Gas Patterns can be divided into two groups:
- Functional or Adynamic Ileus
- Mechanical Obstruction
**These two conditions may radiographically look similar to one another and the clinical evaluation is most important in differentiating the two.
Functional or Adynamic Ileus=
- Irritation or inflammation has caused a loss of peristalsis causing dilated, non-functioning bowel.
- This bowel is not truly but “functionally” obstructed.
- This can be localized with one or two loops (sentinal loop) or generalized.
- Examples include: pancreatitis LUQ, Cholecystitis RUQ, Diverticulitis LLQ, and Appendicitis RLQ
- Clinically, the abdomen is **“quiet” and may show signs of inflammation or irritation.
- Radiographically, there are dilated loops of bowel that may have air fluid levels
Mechanical Obstruction=
- This is a true obstruction secondary to adhesions, tumor, hernias, intussusception, and inflammatory bowel disease.
- Obstruction may occur in the Small or Large Bowel
- Bowel peristalsis tries to overcome the obstruction with strong contractions causing cramping pain.
- Clinically, the patients have cramping abdominal pain with loud bowel sounds and may have a history of prior surgery (adhesions), malignancy, or hernia
- Radiographically, the appearance is of a prominently dilated bowel with air-fluid levels.
Nine year old with SBO
secondary to adhesions
from a prior appendectomy= what kind of obstruction?
Mechanical (small bowel obstruction–adhesions*)
55 yo female with SBO
secondary to strangulated
Left Inquinal Hernia== what kind of obstruction?
Mechanical =small bowel obstruction
Small bowel obstruction can occur 2/2 _____
mid gut volvulus (Note jejunum in Right Hypochondrium–> Jejunum SHOULD not be on the right side, should be on the left side of abdomen )
Circulation within the Liver -(describe)
Arterial blood–> stomach and intestines (picks up nutrients)–> hepatic portal vein–> liver–> liver sinusoids—>hepatic vein –> inf vena cava
*Porta Hepatis contains:
Common Hepatic Bile Duct.
Hepatic Artery Proper
Hepatic Portal Vein
**The Coeliac Artery supplies the ____
***Common Hepatic a to the Hepatic Artery Proper to the Right and Left Hepatic aa
Circulation within the Liver
blood from the GIT flows via the Hepatic Portal Vein (Portal Vein) to the Sinusoids which are in contact with the liver cells (hepatocytes) then to the Hepatic Vein to the Inferior Vena Cava
**KNOW: The Portal Triad within the Hepatic lobules contains (3 things)
- Arteriolar branch of the Hepatic artery
- Venule branch of the Portal Vein
- Biliary ductules
Cholelithiasis=
- Note stones and acoustic shadowing
- *US for Dx
- weigh the risks and benefits of cholecystectomy—
Cholecystitis-Cystic Duct Obstruction:
-imaging study?
- HIDA scan–> Abnormal HIDA= Non-filling of GB after 90 minutes
- No filling of the gallbladder= positive test!!! KNOW indicates cystic duct obstruction 2/2 stone or obstruction
**Acalculous Cholecystitisaka Necrotizing Cholecystis
- Usually seen in patients with other coexistant disease processes
- Seen with triad of systemic mediators of inflammatory processes and trauma, biliary stasis, and local or generalized ischemia
- Usually a fulminant course with high rate of complications such as gangrene and perforation
Ampula of Vater contains which sphincter?
ampula of vater (Vater Papilla) - contains a sphincter***** NEED TO KNOW= called the sphincter of oddi –> If stones in the common bile duct they will cut the sphincter of oddi in order to open up the duct and hopefully the stones will pass into the descending duodenum
Hepatic Cirrhosis:
-imaging findings?
-Note nodular liver and ascites
-Note enlarged left lobe and caudate lobes, fibrosis
And shrunken right lobe, and ascites
-Note thickened and edematous large and small bowel walls found in hypoproteinemia and ascites
Ascites: imaging findings?
hazy abdomen and small bowel loops floating
centrally and anteriorly
What is the MC liver tumor?
**Cavernous Hemangioma Liver
- MR Hemangiomas typically bright on T2 Images
- Contrast CT: Note fill in of hemangioma gradually from the periphery over time from the arterial phase to the portal venous phase that shows isodensity with liver
2nd MC liver tumor=
-associated with _____ use
Focal Nodular Hyperplasia
-Hyperplasic process with possible association with *oral contraceptives
-MR T1 Images with early intense contrast enhancement and delayed isointensity with liver
Metastatic Disease to Liver
Diffuse metastatic breast carcinoma to
the liver with resulting portal hypertension
and umbilical vein enlargement
Acute Pancreatitis:
-imaging findings?
- Large, non-enhancing inflammatory mass with surrounding inflammatory changes
- Lipases, amylases and proteases destroying everything around the pancreas (= inflammatory flamon)
- Kidneys are spared due to protective gerota’s fascia
Chronic Pancreatitis:
-imaging findings?
-Shrunken, scarred pancreas with calcifications
OR
-Enlarged, pancreas with calcifications
-+/- Large Pseudocyst in the Head of the Pancreas
**Mass in head of Pancreas encasing and displacing Portal Vein=
=*Adenocarcinoma of Pancreas
-PAINLESS JAUNDICE–> THINK ADENOCARCINOMA OF THE PANCREAS!!!!!
Fat Stranding=
Inflammatory strandy densities in fatty tissues adjacent to an inflammatory process
Appendicitis is an adynamic or dynamic ileus?
Aydynamic ileus
*Intussusception=
A portion of the small bowel (intussusceptum) intussuscepts into
more distal bowel (intussuscipiens)
Pseudomembranous Colitis:
-imaging findings?
-nodular thickening of the
large bowel wall and haustra
-Thumbprinting indicating bowel wall edema
Pseudopolyposis should make you think–>
**ulcerative colitis
-complication of UC= toxic megacolon
Whenever you see a large dilated loop of bowel, think ______
**Volvulus (Cecal Volvulus)
72 YO Female on Diuretics for HTN–> can cause pseudo obstruction 2/2:
- *Hypokalemia
- -Once hypokalemia corrected, PseudoObstruction resolved
