Anatomy GI 4 Peritoneum and Peritoneal cavity Flashcards
Objectives
- structure/ function of peritoneum
- nature of innervation of both parietal and visceral organs covered with peritoneium
- Become familiar with potential spaces within the greater and lesser peritoneal cavity
- Understand the clinical implications of intraabdominal fluid “asctes” , peritonitis and intraabdominal abscess
What is the definition of peritoneum
to stretch over
What is the definition of Parietal Peritoneum
Mesothelial lined innermst surface of abdominal wall
What is the definition of Visceral peritoneum
lining of free surfaces of intraperitoneal viscera,
liver gallbladder stomach spleen, small and large bowel, dome of urinary bladder uterus fallopian tubes ovaries
What are the functions of Peritoneum (3)
- allows for frictionless motion of viscera in abdominal cavity
- In contact with network of vasculature, intercellular gaps allow monocytes and neutrophiles entry to wall-off infections
- Forms fibrin (form of clot) in repsonse to trauma or infection which may eventually become fibrous scar tissue, assits in healing of surgical and traumatic wounds
What does peritoneum lay over?
rests over a layer of fat of variable thickenss called pro or preperitoneal fat
Layer of fat becomees thickened and infiltrated with inflammator fluid when infectino in abdomen is present
What happens to fat around peritoneum when peritoneum becomes inflamed
Adipose tissues become filamed and edamatous (diverticulitis, appendicitis)
Can see fatty layers with CT to help with Dx`
What innervates the Parietal Peritoneum
Innervated by SOMATIC SENSORY NERVES- Intercostal branches , ventral rami;
snesitive to inflammation
detects and relays information about the sense of touch as well as pain and temperature to the brain.
same segmental distribution as abdominal wall
What innervates Visceral Peritoneum (and visera)
Innervated by sensory nerves which follow sympathetic innervation of the organ
WHen you get appendicitis, you feel pain in general stomach area, not just RLQ. what kidn of pain is this?
Inflammatino causes parietal peritoneum pain
What kind of pain is felt when you have an MI, and you feel pain around neck/shoulder
this is Referred Pain ( Visceral pain from ishcemia)
Pain felt in area different from origin
“referred vsiceraal pain
Where would you feel visceral pain of GI
T5 level of stomach
Nerve cells where greater splanghnic nerve is
liens up with epigastrium
What kind of pain do you feel with Biliary colic?
sense it in teh midline/gastrin, back
REFERRED PAIN
What is the pathway of VISCERAL ABDOMINAL PAIN
Afferent nerves that travel in same path as sympathetic nerves of prmordial gut segment and overying peritoneum,
cell bodies of nerve located in dorsal root ganglia at level of splanchnic nerves
(cell bodies where viscera arose in embryo, follow sympathetics up to spinal cord-
What is the pathway of Somatic Abdominal Pain
Afferent somatic sensory nerve branches iwtih enrve endigns in abdominal wall and parietal peritoneu,
cell bodies of nerve located in DRG of abdominal wall dermatome
-follow dermatomes)
What is somatic pain?
Somatic pain is caused by the activation of pain receptors in either the body surface or musculoskeletal tissues. A common cause of somatic pain in SCI persons is postsurgical pain from the surgical incision. It is usually described as dull or aching. Somatic pain, that is a complication of SCI, occurs with increased frequency in the shoulder, hip, and hand, although it also occurs in the lower back and buttocks. Somatic pain is probably caused by a combination of factors, such as abnormalities that may have always been there, inflammation, repetitive trauma, excessive activity, vigorous stretching, and contractions due to paralysis, spasticity, flabbiness, disuse and misuse. Generally speaking, somatic pain is usually aggravated by activity and relieved by rest.
What is Visceral pain?
Visceral pain is the pain we feel when our internal organs are damaged or injured and is by far the most common form of pain. Viscera refers to the internal areas of the body that are enclosed in a cavity. Visceral pain is caused by the activation of pain receptors in the chest, abdomen or pelvic areas. Visceral pain is vague and not well localized and is usually described as pressure-like, deep squeezing, dull or diffuse. Visceral pain is caused by problems with internal organs, such as the stomach, kidney, gallbladder, urinary bladder, and intestines. These problems include distension, perforation, inflammation, and impaction or constipation, which can cause associated symptoms, such as nausea, fever, and malaise, and pain. Visceral pain is also caused by problems with abdominal muscles and the abdominal wall, such as spasm.
How do visceral afferent nerves travel to visera?
in association with the sympathetic nerves; which then in turn enters isceral organ along with its arterial blood supply A
Are viseral afferent nerves part of the ANS
NO!
Where are the GI visvereal afferent nerve fibers cell bodies?
will occur if there is pressure in hollow viscera
in DRG concentate at 3 major sits
at embryonic origins of
CELIAC A
SUPERIOR MESENTERIC A
INFERIOR MESENTERIC A
What does Celiac trunk? artery supply
Foregut (esophagus to duodenum)
Esophagus stomach dudodenum liver spleen gallbladder pancreas
What does Superior Mesenteric artery supply
Midgut
Pancreas duodenum jejunum ileum cecum ascending and transverse colon
What does Inferior Mesenteric artery supply
Transverse and descendng colon
sigmoid colon
rectum
anal canal
where s foregut? If pain in foregut, where is it referred?
distal esophagus stomach duodenum biliary pancreas
refers pain to epigastrium T6-8; Greater Splanchnic nerve through Celiac Ganglion (celiac artery)
What consists of the Midgut ? whre is visceral pain in this area felt
Small bowel
Appendix
Proximal colon
Refers to Periumbilical region T9-T10; Lesser Splanchnic nerve from Superior Mesenteric Ganglion (superior mesenteric artery)
What consists of Hindgut. wehre is pain reerred to
distal colon
Rectum
Refers pain to hypogastriu T11-L1, INfereior mesenteric ganglion, lumbar splanchnic nerve (INferior Mesenteric artery)
Where is pain in renal and ureteral sexction felt
Lateralized to flank and groin
T9-L2
What are the three mechanisms of visceral pain
1 .Distension
- Ischemia
- Mesenteric Traction
Is there response to thermal, tactile, or chemcial stimulation …is visceral pain felt for this
no!
Does not respond to touch
like C-section, do not feel’ more feeling distension
Is appendicities visceral or somatic pain
Visceral pain!
Foregut
Greater splanchnic nerve
Celiac Ganglion
Celiac Artery
Midgut
Lesser Splanchnic nerve
superior mesenteric ganglion
superior mesenteric artery
Hindgut
Lumbar Splanchnic nerve
Inferior Mesenteric Ganglion
Inferior Mesenteric Artery
Where are the abdominal dermatomes for Somatic Pain
Central diaphragm?
T6-L1
Central Diaphragm” C 3,4,5- we will feel pain in shoulder/neck
What does thermal, tactile, and chemical irritaiton lead to?
Peritonitits (somatic pain)
what other factors can lead to somatic pain
Acid, Digestive enzymes, blood, bacteria, bile, ruine, feces
What is a Kehr’s sign?
Referred somatic Peritoneal Pain
Pain from phernic irritation
usually from ruptured spleen/ irritated diaphragm
Feel it in shoulder region
What is referred pain?
Pain perceived as coming form site remote form its actual origin
What is an example of somatic referred pain?
Herniated disc- feel pain going down leg
Sciatica!
L4, 5 or L5, S1
Pain sensed b/c of pressure on nerve
Pain is sensed over distributino of nerve
All visceral pain is referred
Certain types of somatic pain is referred
where does lymphatic drainage of parietal peritoneum travel
follows abdominal wall
Where does viseral drainage of peritonum follow
Follows attached viscera
What is Ascites? What kind of diseases does it occur in?
Greek askos = bag
Occurs when production of fluid exceeds absorption as in
cirrhosis,
chronic renal failture,
nephrotic syndrome
Where are the two regions that abdominal wall lympatics / tumors metastasize can travel to?
Axilla and Inguilan region
Definition of MEsentery
Greek- middle
enteron- intesne
Double layer of peritoneum extendign form abdominal wall to enclose any portion of a viscera,
carries blood and lympathic vessels, lymph nodes,
and nerves
What is Peritoneal Ligament? examples?
Double layer of periteoneum that attaches an organ to abdominal wall or anotehr organ
eg falciform, round, or splenic ligament
What is the definition of Omentum
membrane that encloses the bowels
Double layered sheet of fatty tissue attached to greater curvature of stomach (and trasnverse colon)
Coerving anterior aspect of abdominal cavity
What is the peritoneal fold? what does it overly?
raised edge of peritoneum overlying vessels or vestigial embryonic structures (e.g median and medial umbilical folds (and lateral- viable structure that covers inferior epigastrics) often hole vestigial
What is peritoneal recess
Cavity or potential space lined by periteoneu
eg SUBPHRENIC or SUBHEPATIC space
What are teh two potential spaces
Greater sac
Lesser sac
What is the greater sac
main portion of peritoneal cavity
allt he potential open are of abdomen
Enter it once you open abdominal wall
What is the lesser sac?
peritoneal space POSTERIOR to stomach
one opprotunity to feel it,
Put finger through Foramen of Winslow
has superiro and inferior recesses
What srucatures is the omentum connected to?
Both Stoamch (which shares blood supply ) and Tranverse colon
What is the Foramen of Winslow
Site of entrane into lesser sac
Anterio wall= portal triad (portal vein, hepatic artery, and common bile duct)
Posterior wall- inferior vena cava and right crus of diaphragm
Superior wall- caudate lobe of liver
Inferior wall- duodenal bulb
What is the portal triad
Hepatic Artery
Bile Duct
Portal Vein
What is the Pringle Maneuver?
Compression of the hepatoduodenal ligaent occludes both hepatic artery and porteal vein, limitng all blood flow into teh liver
What are the pouches of the peritoneal cavity?
Free fluid in teh peritoneal cavity graivtaeates to most dependene sites
Hepato-renal pouch
Recto-vesical pouch
What is the clinical importance of Peritoneal spaces
Spaces in peritoneal cavity become clinically important when fluid collects from perforated intestine or blood accumulates post-surgery
What are the pouches of the peritoneal cavity?
Free fluid in teh peritoneal cavity graivtaeates to most dependene sites
Hepato-renal pouch
Recto-vesical pouch
What is the clinical importance of Peritoneal spaces
Spaces in peritoneal cavity become clinically important when fluid collects from perforated intestine or blood accumulates post-surgery
What can perforation of gallbladder lead to?
right SUBPHRENIC or SUPHEPATIC ABSCESS
What can perforation of gallbladder lead to?
right SUBPHRENIC or SUPHEPATIC ABSCESS
what can removal of the spleen cause?
accumulation of blood in teh left subphrnic space
what can removal of the spleen cause?
accumulation of blood in teh left subphrnic space
What happens to accumulated blood
its a bacterial culture media and can become infected, thereby creating n intraabdominal abscess
What happens to accumulated blood
its a bacterial culture media and can become infected, thereby creating n intraabdominal abscess
Where is site of abscess loculationw ith performation of appendix and left colon?
Right and left paracolic gutters
Where is site of abscess loculationw ith performation of appendix and left colon?
Right and left paracolic gutters
Where do many abseceses accumulate ?
in most dependent region of peritoneal cavity- the pelvis
Where do many abseceses accumulate ?
in most dependent region of peritoneal cavity- the pelvis
