Gastrointestinal Flashcards
GI embryo - foregut, midgut, hindgut
Foregut - pharynx to duodenum
Midgut - duodenum to proximal 2/3 of transverse colon
Hindgut - distal 1/3 of transverse colon to anal canal above pectinate line
Developmental defects of anterior abdominal wall due to failure of:
Rostral fold closure - sternal defects
Lateral fold closure - omphalocele, gastroschisis
Caudal fold closure - bladder exstrophy
Duodenal atresia
Failure to recanalize (trisomy 21)
Jejunal, ileal, colonic atresia
Due to vascular accident (apple peel atresia)
Midgut development
6th week - midgut herniates through umbilical ring
10th week - returns to abdominal cavity + rotates around superior mesenteric artery (SMA)
Gastroschisis
extrusion of abdominal contents through abdominal folds; not covered by peritoneum
Omphalocele
Persistence of herniation of abdominal contents into umbilical cord, sealed by peritoneum
Tracheoesophageal anomalies
Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common (85%)
Results in drooling, choking, and vomiting with first feeding. TEF allows air to enter stomach (visible on CXR). Cyanosis is secondary to laryngospasm (to avoid reflux-related aspiration). Clinical test: failure to pass nasogastric tube into stomach
In H-type, the fistula resembles the letter H. In pure EA the CXR shows gasless abdomen
Congenital pyloric stenosis
Hypertrophy of the pylorus causes obstruction. Palpable “olive” mass in epigastric region and nonbilious projectile vomiting at about 2-6 weeks old. Occurs in 1/600 live births, more often in firstborn males.
Results in hypokalemic hypochloremic metabolic alkalosis (secondary to vomiting of gastric acid and subsequent volume contraction). Treatment is surgical incision (pyloromyotomy)
Pancreas and spleen embryo
Pancreas - derived from foregut. Ventral pancreatic buds contribute to uncinate process and main pancreatic duct. The dorsal pancreatic bud alone becomes the body, tail, isthmus, and accessory pancreatic duct. Both the ventral and dorsal buds contribute to the pancreatic head.
Annular pancreas - ventral pancreatic bud abnormally encircles 2nd part of duodenum; forms a ring of pancreatic tissue that may cause duodenal narrowing
Pancreatic divisum - ventral and dorsal parts fail to fuse at 8 weeks. Common anomly; mostly asymptomatic, but may cause chronic abdominal pain and/or pancreatitis
Spleen - arises in mesentery of stomach (hence is mesodermal) but is supplied by foregut (celiac artery)
Retroperitoneal structures
Retroperitoneal structures include GI structures that lack a mesentery and non-GI structures. Injuries to retroperitoneal structures can cause blood or gas accumulation in retroperitoneal space
SAD PUCKER
Suprarenal (adrenal) glands Aorta and IVC Duodenum (2nd through 4th parts) Pancreas (except tail) Ureters Colon (descending and ascending) Kidneys Esophagus (thoracic portion) Rectum (partially)
Falciform ligament
Connects liver to anterior abdominal wall
Contains:
Ligamentum teres hepatis (derivate of fetal umbilical vein)
Derivative of ventral mesentery
Hepatoduodenal ligament
Connects liver to duodenum
Contains:
Portal triad - proper hepatic artery, portal vein, common bile duct
Pringle maneuver - ligament may be compressed between thumb and index finger placed in omental foramen to control bleeding
Borders the omental foramen, which connects the greater and lesser sacs
Gastrohepatic ligament
Connects liver to lesser curvature of stomach
Contains:
Gastric arteries
Separates greater and lesser sacs on the right.
May be cut during surgery to access liver sac
Gastrocolic ligament
Connects greater curvature and transverse colon
Contains:
Gastroepiploic arteries
Part of grater omentum
Gastrosplenic ligament
Connects greater curvature to spleen
Contains:
Short gastrics
Left gastrorpiploic vessels
Separates greater and lesser sacs on the left
Splenorenal
Connects spleen to posterior abdominal wall
Contains:
Splenic artery and vein
Tail of pancreas
Layers of gut wall
MSMS
Mucosa - epithelium, lamina, propria, muscularis mucosa
Submucosa - includes Submucosal nerve plexus (Meissner), Secretes fluid
Muscularis externa - include Myenteric plexus (Auerbach), Motility
Serosa (when intraperitoneal), adventitia (when retroperitoneal)
Frequencies of basal electric rhythm (slow waves)
Stomach - 3 waves/min
Duodenum - 12 waves/min
Ileum - 8-9 waves/min
Digestive tract histology
Esophagus - Nonkeratinized stratified squamous epithelium
Stomach - gastric glands
Duodenum - Villi and microvilli increase absorptive surface Brunner glands (HCO3 secreting cells of submucosa) and crypts of Lieberkuhn
Jejunum - Plicae circulares and crypts of Lieberkuhn
Ileum - Peyer patches (lymphoid aggregates in lamina propria, submucosa), plicae circulares (proximal ileum), and crypts of Liberkuhn. Largest number of goblet cells in the SI
Colon - Colon has crypts of Lieberkuhn but no villi; abundant goblet cells
Superior mesenteric artery syndrome
When the transverse portion (third part) of duodenum is entrapped between SMA and aorta, causing intestinal obstruction
GI blood supply and innervation
1) Foregut embryologic origin
Celiac Artery Vagus Nerve (parasymp) Vertebral level = T12/L1
Pharynx (Vagus only) and lower esophagus (celiac artery only) to proximal duodenum; liver, gallbladder, pancreas, spleen (mesoderm)
2) Midgut
SMA
Vagus (parasymp)
L1
Distal duodenum to proximal 2/3 of transverse colon
3) Hindgut
IMA
Pelvic (parasymp)
L3
Distal 1/3 of transverse colon to upper portion of rectum; splenic flexure is a watershed region between SMA and IMA
Celiac trunk
Branches of celiac trunk = Common hepatic, splenic, and Left Gastric. These constitute the main blood supply of the stomach
Short gastrics have poor anastomoses if splenic artery is blocked.
Strong anastomoses exist between:
L and R gastroepiploics
L and R gastrics
Portosystemic anastomoses
1) Esophagus - Esophageal varices
L gastric vein and esophageal vein
2) Umbilicus - Caput medusae
Paraumbilical veins - small epigastric veins of the anterior abdominal wall
3) Rectum - Anorectal varices (NOT internal hemorrhoids)
Superior rectal vein - middle and inferior rectal veins
Varices of gut, butt, and caput are commonly seen with portal HTN
Treatment with a transjugular intrahepatic portosystemic shunt (TIPS) between the portal vein and hepatic vein relieves portal HTN by shunting blood to the systemic circulation bypassing the liver
Pectinate (Dentate) line
Formed where endoderm (hindgut) meets ectoderm
1) Above pectinate line - internal hemorrhoids, adenocarcinoma
Arterial supply from superior rectal artery (branch of IMA)
Venous drainage: superior rectal vein - inferior mesenteric vein - portal system
Internal hemorrhoids receive visceral innervation and are therefore NOT PAINFUL
Lymphatic drainage to internal iliac lymph nodes
2) Below pectinate line - external hemorrhoids, anal fissures, squamous cell carcinoma
Arterial supply from inferior rectal artery (branch of internal pudendal artery)
Venous drainage: inferior rectal vein - internal pudendal vein - internal iliac vein - common iliac vein - IVC
External hemorrhoids receives somatic innervation (inferior rectal branch of pudendal nerve) and are therefore PAINFUL if thrombosed
Lymphatic drainage to superficial inguinal nodes
Anal fissure - tear in the anal mucosa below the Pectinate line: Pain while Pooping; blood on “toilet” Paper. Located Posteriorly since this area is Poorly Perfused