Esophagus - Liver Flashcards
What are the parts of the esophagus?
How long is each part?
What are their boundaries?
What is their course?
-
pars cervicalis:
- 5 - 8 cm
- cartilago cricoidea C6/7 - T4
- btw vertebral column + trachea
-
pars thoracica:
- 16 cm
- T4 - hiatus oesophagus T11
- parallel to trachea until bifurcatio trachae, then behind left atrium
-
pars abdominalis:
- 1 - 4 cm
- hiatus oesophageus of diaphragm → ostium cardiacum of stomach
- intraperitoneal
At what level are the esophageal constrictions?
They are caused by… ?
constrictio cricoidea
- C6 - behind cricoid cartilage
- caused by circ. fibers of esophageal sphincter m.
constrictio bronchoaorticea
- T4
- caused by aorta laterally on left side
constrictio phrenica
- T10 - hiatus oesophageus
- caused by lig. phrenico-oesophageale
What is the angle of HIS?
The angle of HIS is an acute angle (< 80°) created between the cardia at the entrance to the stomach, and the esophagus by the collar sling fibres.
It forms a valve, preventing reflux of duodenal bile, enzymes and stomach acid from entering the esophagus, where they can cause inflammation.
BUT:
loss of tension → increased angle → reflux of HCl into esophagus
Which vessels supply/drain the esophagus?
Innervation?
supply:
- cervical part: a. thyroidea
- thoracic part: rr. of aorta + aa. intercostales
- abdominal part: a. gastrica sin./a. phrenica inf. sin.
drainage:
- cervical part: v. azygos/v. hemiazygos
- thoracic part: v. thryoidea inf.
- abdominal part: vv. oesophageales (anastomosis w/ v. gastrica sin.)
innervation:
- n. vagus (X)
Where is the stomach located?
What shape does it have?
How much can it store?
- crescent-shape
- behind left dome of diaphragm, partially behind left costal angle, extends until L2/3
- can store up to 1,500 ml
What attaches at the greater and lesser curvature of the stomach?
- curvatura gastrica minor : **omentum minus **(to be precise: lig. hepatogastricum)
- curvatura gastrica major: omentum majus
to be precise:- lig. gastrocolicum
- lig. gastrophrenicum
- lig. gastrosplenicum
Where do the walls of the stomach attach to?
- paries anterior → abdominal wall
- paries posterior → bursa omentalis + pancreas
Which structures in the stomach increase the surface?
- large gastric folds (plicae gastricae) w/ areae gastricae
- gastric pits (foveolae gastricae) w/ gastric glands (visible on histological specimen)
additionally: in curvatura gastrica minor: gastric canal
Which muscles are responsible for vomiting?
diaphragm + abdominal mm.
What happens if there’s a disproportion btw mucous and gastric acid in the stomach?
What is the most common reason for such a disproportion?
can lead to ulcer in the stomach/duodenum,
(in 80% of the cases caused by helicobacter pylori)
1 - 5
1) truncus coeliacus
2) a. hepatica communis
3) a. hepatica propria
4) - r. sinister
5) - r. dexter
6 - 10
6) v. portae hepatis
7) a. gastrica dextra
8) a. gastroduodenalis
9) a. mesenterica sup.
10) a. gastroomentalis dex.
11 - 16
11) a. gastroomentalis sin.
12) a. splenica
13) a. gastrica sin.
14) aa. gastricae breves
15) a. cystica
16) a. prancreaticoduodenalis sup.
A - E
Why is B) im important?
A) esophagus
B) incisura cardiaca → angle of HIS, closes esophagus
C) cardia
D) fundus gastricus
E) corpus gastricum
F - J
F) curvatura gastrica minor
G) curvatura gastrica major
H) incisura angularis
I) antrum pyloricum
J) canalis pyloris + ostium pylorum
K - L
K) duodenum
L) ostium cardiacum
Differentiate btw the pathway of the vv. of the stomach in the greater and lesser curvature.
Clinical relevance?
vv. parallel to aa., BUT:
* in greater curvature: indirectly into v. portae via v. mesenterica sup./v. splenica (cf. vessel flashcards for more information)
-
in lesser curvature: v. gastrica dextra + v. prepylorica form v. coronaria ventriculi
⇒ directly into v. portae + connection to vv. oesophageales (portocaval anastomosis)
⇒ portal reflux, e.g. in case of liver cirrhosis or thrombosis in v. splenic, can cause esophageal varices
Which nerves innervate the stomach para- / sympathetically?
Effects?
symp. plexus coeliacus
parasymp.: truncus vagalis ant./post. (branches of n. vagus)
- dilated blood vessels → incr. circulation
- increased secretion of gastric juice + HCl
- incr. stomach movements
How heavy is the pancreas?
Where does its body start?
Where does it attach to?
What is its function?
- 40 - 120g, usually 70g
- corpus starts at L1/2
- facies posterior → post. abdominal wall
facies anterior → covered by peritoneum
= most important digestive gland: 1.5 - 2l secretion/d → stored as zymogens (inactive precursors)
1 - 5
1) truncus coeliacus
2) a. gastrica sin.
3) a. splenica
4) a. hepatica communis
5) a. hepatica propria
6 - 10
6) a. gastroduodenalis
7) a. pancreaticoduodenalis sup.
8) a. gastroomentalis dex.
9) a. pancreaticoduodenalis sup. post.
10) a. pancreaticoduodenalis sup. ant.
11 - 15
11) a. pancreaticoduodenalis inf. ant.
12) a. pancreaticoduodenalis inf. post.
13) a. pancreaticoduodenalis inf.
14) a. mesenterica sup.
15) - r. duodenojejunalis
16 - 18
16) a. pancreatica dorsalis
17) a. pancreatica inf.
18) rr. pancreatici
Common features of the 3 parts of the small intestine?
drainage:
- v. mesenterica sup. → v. portae
innervation:
- symph: 3 nn. splanchnici T5-12 via plexus coeliacus/mesentericus sup.
- parasymp: n. vagus (X)
What is the function of the small intestine?
- digestion via enzymes + resorption via bile acids
- endocrine cells regulate secretion ofpancreatic/gall bladder
How long is the duodenum?
List its parts and give their peritoneal relation.
duodenum = 12 finger → 25 - 30 cm
- pars superior: intraperitoneal
- pars descendens: retroperitoneal
- pars horizontalis: retroperitoneal
- pars ascendens: retroperitoneal
1 - 5
1) a. gastrica sin.
2) a. splenica
3) a. hepatica communis
4) a. hepatica propria
5) a. gastroomentalis dex.
6 - 10
6) a. pancreaticoduodenalis sup. ant.
7) a. pancreaticoduodenalis inf.
8) a. + v. mesenterica sup.
9) a. gastroduodenalis
10) pars superior duodeni
11 - 15
11) pars descendens duodeni
12) pars horizontalis duodeni
13) pars ascendens duodeni
14) flexura duodeni superior
15) flexura duodeni inferior
16 - 20
16) flexura duodenojejunalis
17) lig. hepatoduodenale (1 of 3 parts of omentum min.)
18) Treitz-muscle
19) v. portae hepatis
20) a. hepatica propria
21 - 26
Give 2 names for #21, 22, 23, 24/26
21) ductus choledochus (= common bile duct)
22) papilla dudodeni minor (=SANTORINI’s)
23) papilla duodeni major (=VATERI’s)
24+26) ductus pancreaticus (=WIRSUNG’s)
25) ductus pancreaticus accessorius
27 - 28
27) ductus cysticus
28) gall bladder
What can happen in case of an inflammation of the superior part of the duodenum?
adherence to gall ballder → rupture → bilestones/pus into duodenum → can cause a duodenal obstruction
Where does the Treitz-muscle attach?
Why is it clinically relevant?
Give other names, too.
= m. suspensorius duodeni, sometimes also called suspensory lig. of the duodenum (but actually additional coll. fibers that are clearly differentiable from Treitz-muscle itself)
- from pars ascendens → aortic origin of a. mesenterica sup.
- defines clinically border btw upper/lower gastrointestinal bleeding
Which aa. supply the duodenum?
a. pancreaticoduodenalis sup./inf. ant./post.
→ anastomosis btw truncus coeliacus & a. mesenterica sup.
Where do the jejunum and ileum start and end?
Peritoneal relation?
- lie in pars infracolica
- flexura duodenojejunalis (L2) → valva ileocaecalis (Bauhin-valve): first 2/5 jejunum, last 3/5 ileum
- intraperitoneal
What is a Meckel’s diverticulum?
Why can it be clinically relevant?
= remnant of vitelline duct in 3% of population, approx. 50 - 120 cm above Bauhin-valve
⇒ if inflammed often mistaken with appendicitis
How do you call a mirrored arrangement of the abdominal viscera?
situs inversus
Which aa. supply jejunum + ileum?
What do they form?
a. mesenterica superior
- 4-5 aa. jejunales
- 12 aa. ileales
⇒ form arterial arcades
What are the parts of the large intestine?
Peritoneal relations?
What is its overall lengh?
- 1.5 m
intraperitoneal: (~ all horizontal parts)
- cecum + appendix
- colon transversum
- colon sigmoideum
sec. retroperitoneal: (~ all vertical parts)
- colon ascendens
- colon descendens
- rectum
subperitoneal
- canalis analis
What is the function of the large intestine?
- reabsorption (~ 1.5l/d) of H20 from chymus
- indeg. contents broken down by bacteria
In what way is the colon different from the previous segments of the gastrointestinal tract?
- taeniae
- haustrae/plicea semilunares (produced by muscular contractions)
- appendices epiploicae (fatty appendages)
What are the different taeniae of the colon?
- taenia libera = visible
- taenia omentalis = inserts in omentum majus
- taenia mesocolica = inserts in mesocolon
Where is the cecum located?
How big is it?
Where does it start and end?
- 6 - 8 cm in fossa iliaca dextra
- Bauhin-valve → appendix vermiformis
Explain the variations of cecum’s peritoneal relation.
- caecum mobile: completely covered by peritoneum (→ intraperitoneal)
- caecum liberum: own mesocaecum (→ intraperitoneal)
- caecum fixum: fixed to post. abdominal wall (→ sec. retroperitoneal)
⇒ most commonly intraperitoneal
What is the function of the appendix?
How big is it (also diameter)?
Where is it located (most common variations)?
What is its peritoneal relation?
- part of immune system (abundant lymph follicles)
- 8 - 10 cm long, 6 mm diameter
- 65% retrocecal
31% subcecal - intraperitoneal, sometimes own mesoappendix
1 - 4
Where is #3 and #4. Why are they clinically important?
1) colon ascendens
2) cecum
3) McBurney point:
→ opening to appendix, right 1/3 on line btw navel and r. S.I.A.S. ⇒ physical examination of appendicitis
4) Lanz point:
→ projection of tip of appendix if subcecal variation, right 1/3 on line btw 2 S.I.A.S.
1 - 5
1) a. ileocolica
2) - r. colicus
3) - r. ilealis
4) a. caecalis ant.
5) a. ceacalis post.
6 - 10
Another name for #10.
6) a. appendicularis
7) colon ascendens
8) cecum
9) ostium appendicis vermiformis
10) valva ileocaecalis (=Bauhin-valve)
11 - 15
11) papilla ilealis
12) labium ileocolicum
13) labium ileocaecale
14) frenulum ostii ilealis
15) appendix vermiformis
What are the parts of the colon?
What are their peritoneal relations?
Where do they start and end?
-
colon ascendens
cecum → flexura colica dextra
- sec. retroperitoneal -
colon transversum
→ flexura colica sinistra
- intraperitoneal -
colon descendens
→ fossa iliaca sin.
- sec. retroperitoneal -
colon sigmoideum
→ rectum (at L2/3)
intraperitoneal
Which structures attach at the different parts of the colon?
colon transversum
- mesocolon transversum
- lig. hepatocolicum (ext. of lig. hepatoduodenum)
- lig. gastrocolicum
- lig. phrenicocolicum (flexura colica sinistra)
colon sigmoideum
- mesocolon sigmoideum which continues as recessus intersigmoideus
Which structure forms the splenic nest?
lig. phrenicocolicum
flexura coli sinistra → post. abdominal wall
Which aa. supply the different parts of the colon?
a. mesenterica inf.
colon ascendens + transversum
- a. colica dex. (anastomosis w/ r. colicus from a. ileocolica, w/ a. colica med.)
- a. colica med. (anastomosis w/ a. ascendens from a. colica sin. = greater Riolan’s anastomosis)
colon descendens + sigmoideum
- a. colica sin.
- a. sigmoidea (anastomosis w/ a. rectalis sup. = Sudeck’s anastomosis)
- a. rectalis sup. (s.a.)
Which nerves innervate the colon?
Any special features?
symp: plexus mesentericus sup./inf.
parasymp:** **
- n. vagus (X) → Cannon-Böhm point (end of vagus innervation)
- after Cannon-Böhm point: nn. from sacral spinal cord S2-4/5
From where to where does the rectum extend to?
How long is it?
What can you say about its shape?
from colon sigmoideum (S2/3) → canalis analis
∽ 12cm
flexures:
- 1st flexure: flexura sacralis (dorsal)
- 2nd flexure: flexura perinealis (ventral)
- lateral flexures
Which special structures can you find in flexura perinealis?
plicae transversae recti (2 left, 1 right)
→ the right one is the biggest, ∽6-7 cm above anus = Kohlrausch-fold: defines opening to ampulla recti
1 - 5
What is special abt #3?
Are the mm. shown here striated (= voluntary contraction) or smooth (= involuntary contraction)?
1) ampulla recti
2) m. levator ani = striated
3) m. puborectalis = striated (= part of m. levator ani)
4) m. corrugator ani = smooth
5) m. sphincter ani inf. = smooth
6 - 10
What are the parts of #6?
Is it striated (= voluntary contraction) or smooth (= involuntary contraction) muscle?
What is #7 responsible for?
6) m. sphincter ani externus = striated
→ pars profunda, pars superficialis, pars subcutanea
7) corpus cavernosum recti → produces columnae anales
8) plexus venosus rectalis ext.
9) zona cutanea
10) linea anocutanea
11 - 15
Another name for #11. In what way is it different from the overlying structure?
What is special abt #14?
Give 3 names for #15.
11) pecten analis (= zona alba), here: change of simp. colum. to str. squ. non-ker. ep.
12) valvae anales
13) junctio anorectalis
14) sinus anales (origin of gll. anales)
15) columnae anales (columns of Morgagni, zona columnalis)
16 - 18
Another name for #17 and #18.
Why is #18 clinically important?
16) prostate gland
17) linea pectinata (= linea dentata)
18) gll. anales (= proctodeal glands, site for anal fistulas)
What is special abt the blood supply/drainage around the canalis analis?
blood supply differs in 2 areas (zona columnaris, zona alba & cutanea), demarcated by linea dentata
-
blood supply ABOVE linea dentata:
a. mesenterica sup. → a. rectalis sup. → v. rectalis sup. → portal venous system -
blood supply BELOW linea dentata:
a. iliaca int. → a. rectalis inf./med. → v. rectalis inf./med. → systemic circulation
⇒ anastomosis btw portal & caval system
Analogous to the pathway of blood vessels in the rectum there is also a seperation of lymph vessels.
Explain.
Why is it clinically relevant?
lymph flow differs in 2 areas (zona columnaris, zona alba & cutanea), demarcated by linea dentata
-
lymph flow ABOVE linea dentata:
→ lnn. rectalis sup. → lnn. mesenterici inf., iliaci int. (in lumbar area) -
lymph flow BELOW linea dentata:
→ lnn. inguinales sup. (in pelvic area)
⇒ metastasis of rectal carcinomas in various directions
→ sup. carcinomas: painless (arise from col. ep.)
→ inf. carcinomas: painful (arise from strat. squ. ep.)
What is a reason for hemorrhoids?
portal hypertension (e.g. in case of liver cirrhosis) → enlargement of rectal portocaval anastomosis in corpus cavernosum of anus (= v. rectalis sup. + med./inf.)
Why is rectal administration of drugs (= suppositories) so effective?
drugs get in rectal portocaval anastomosis via v. rectalis med./inf. (→ v. iliaca int. → v. cava inf.) into systemic circulation
Which structures are part of the organ of continence?
What is the “normal” situation?
organ of continence:
- rectum
- anal sphincter mm.
- corpus cavernosum recti
⇒ sustained tonic contraction of sphincter mm.
⇒ sling formed by m. puborectalis closes anus
⇒ supported by corpus cavernosum recti
What happens in the process of defecation?
- content of colon → increases wall tension of ampulla recti
- reflexive relaxation of m. sphincter ani int. + contraction of rectum/colon sigmoideum
- voluntary relaxation of m. sphincter ani ext. (n. pudendus)
Where is the liver located?
What is its peritoneal relation?
How heavy is it?
How do you call its main surfaces?
- located under right costal dome
-
intraperitoneal, except:
- area nuda (attaches to diaphragm)
- porta hepatis
- fossa vesicae biliaris
- sulcus v. cavae
- 1,200 - 1,800g
- facies visceralis (= back), facies diaphragmatica (= top)
What attaches to the liver and where?
-
lig. hepatoduodenale (part of omentum minus)
on tuber omentale → duodenum -
lig. hepatogastricum
in sulcus lig. venosi → curvatura gastrica minor -
lig. falciforme
front → parietal peritoneum
What are the functions of the liver?
- metabolism: produces proteins for blood clotting, cholesterol, storage of glycogen
- detoxication
- exocrine gland: produces bile
- storage of lipid soluble vitamins (esp. vit A)
- immune defense: produces Kupffer-cells, plasmaproteins
- during fetal period: hematopoiesis
Which structures divide the liver into functional liver parts (= partes hepatis dextra/sinistra)?
Which segments belong to each part?
Why is it segmented?
A - I.
sagittal plane through gall bladder + v. cava inf.
- segments I-IV: left lobe
- segments V-VIII: right lobe
segmented accordingly to pathways of Glisson’s triad (v. portae, a. hepatica, bile ducts + vv. hepaticae)
⇒ important for liver resection to ensure as little blood loss as possible
A = VII<br></br>B = V<br></br>C = III<br></br>D = IVa<br></br>E = VI<br></br>F = VIII<br></br>G = IVb<br></br>H = II<br></br>I = I = lobus caudatus
1 - 5
1) vesica biliaris
2) lobus quadratus
3) lig. teres hepatis
4) incisura lig. teretis
5) fissura lig. teretis
6 - 10
What attaches to #6?
6) margo inf.
7) porta hepatis
8) lobus hepatis sin.
9) impressio gastrica
10) tuber omentale → omentum minus
11 - 15
11) impressio oesophagea
12) appendix fibrosa hepatis
13) lobus caudatus
14) v. cava inferior
15) lig. venae cavae
16 - 20
16) area nuda
17) impressio suprarenalis
18) lig. coronarium
19) v. porta hepatis
20) impressio renalis
21 - 25
21) impressio duodenalis
22) a. cystica
23) impressio colica
24) lobus hepatis dex.
25) lig. venosum
26 - 30
26) fissura lig. venosi
27) fissura venae cavae
28) ductus choledochus
29) proc. caudatus
30) proc. papillaris
What are the 3 hepatic veins?
Variations?
- v. hepatica dex.
- v. hepatica sin.
- v. hepatica intermed.
BUT: in 2/3 v. hepatica sin. + intermed. form truncus hepaticus sin.
What are possible causes for portal hypertension?
Explain the process.
- a) alcoholism → can cause liver cirrhosis
b) hepatitis B/C - scar tissue in liver
- increased resistance to blood flow due to compression of vessels
- portal hypertension
What are possible effects of portal hypertension?
- splenomegaly: 30-50% of all patients
- Cruveillhier-Baumgarten murmur: loud venous murmur audible over upper abdomen
-
dilation of portocaval anastomoses
- caput medusae syndrome: dilated vv. paraumbilicales + reopening of v. umbilicalis
- esophageal varices: most common cause of death (bleeding)
- in rectum
- in stomach
- in retroperitoneum
- in spleen
- in kidneys
Explain the blood flow in the liver.
- a) a. hepatica propria (= vas privatum)
b) v. portae hepatis (= vas publicum) - a) interlobular a.
b) interlobular v. - hepatic sinusoids
- hepatocytes
- central v.
- collecting v.
- vv. hepaticae
Where is the gall bladder located?
Describe its structure (incl. duct).
in fossa vesicae biliaris on liver → 1/2 covered by peritoneum
structure:
- fundus
- corpus
- collum
- ductus cysticus with plica spiralis (= Heister’s), closes duct
How much bile can be stored in the gall bladder?
How does it get filled?
- usually 40 - 70 ml, when dilated up to 200 ml
- gets filled by reflux of bile when papilla is closed
Explain the intrahepatic bile flow.
synthesized by hepatocytes
- bile canaliculi btw hepatocytes
- canals of Hering
- interlobular bile ducts
- unite
- ductus hepaticus dex./sin.
Explain the extrahepatic bile flow.
- ductus hepaticus communis (4 - 6cm)
ductus cysticus - ductus choledochus (6 - 8 cm long, 0.4 - 0.9 cm diameter)
- papilla duodeni major
What are the parts of ductus choledochus?
- pars supraduodenalis (in lig. hepaticoduodenale)
- pars retroduodenalis
- pars pancreatica (in head of pancreas)
- pars intraduodenalis (to duodenum desc.)
Explain the most frequent variation of the structure of papilla duodeni major.
in 60% ampulla hepatopancreatica + 2 sphincter mm.
- m. sphincter ductus pancreatici
- 2nd sphincter has 2 names
- upper part = m. sphincter ductus choledochi
- lower part = m. sphincter ampullae (= Oddi’s)
Explain blood supply/drainage + innervation of the gall bladder.
- blood supply: a. cystica (supplied by r. dex. of a. hepatica propria)
- blood drainage: v. cystica → v. portae
-
innervation:
- symph./parasymph.: plexus hepaticus
- sensory: n. phrenicus dex.
Which structures form trigonum cholecystohepaticum?
Give another name.
Explain its clinical relevance.
= Calot’s triangle: in 75% origin of a. cystica
- ductus cysticus
- ductus hepaticus communis
- liver
⇒ a. cystica/ductus cysticus must be sealed before gall bladder can be removed
What are possible causes for obstructive jaundice?
chronic pancreatitis/pancreas carcinomas can cause reflux of bile (= cholestase) into ductus choledochus → deposit of bile pigments in skin → yellow
BUT: enlargement of ductus choledochus (> 1 cm) can also be caused by bile stones or inflammation
What could be a symptom of an inflammed gall bladder and why?
radiating pain in the right shoulder due to same sensory innervation (n. phrenicus)
What is a possible reason for an acute pancreatitis?
reflux of bile into pancreas due to bile stone stuck in ampulla
(lower risk if ductus choledochus + Wirsung’s duct seperated → no common ampulla)
