GI neurovascular Flashcards by Ahmed Radwan

Where does the Aorta enter the abdominal cavity?

It enters through a diaphragm hiatus at T12 and bifurcates into the 2 Common Iliac A.s at L4

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At what branches does the unpaired visceral branches of the Aorta exit?

T12- celiac trunk
L1- SMA
L3-IMA
**CSI

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At what branches does the paired visceral branches of the aorta exit?

L1- Suprarenal A.s and L. Renal A
L2- R. Renal A. and Gonadal A.s
**ARG

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At what branches does the paired parietal branches exit off the aorta ?

T12- inferior Phrenic A.s and Subcostal A.s
L1-L4 Lumbar A.s
**IS L

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At what levels of the Abdominal cavity is the Aorta posterior to abdominal organs ?

@ L1-L2 Aorta is posterior to the L. Renal Vein, Splenic Vein, and the pancreas
@ L3 Aorta is posterior to the 3rd part of the duodenum

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What are the 3 main branches normally exiting the Celiac Trunk?

Left Gastric A. 
Splenic A. 
Common Hepatic A. 
*visualize 
-supplies the spleen, esophagus, stomach, duodenum, pancreas, liver, gallbladder

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What are the branches coming off the Left Gastric A.? what does it supply?

L. Gastric gives off the esophageal A.s and the L. gastric will continue to anastomose with the R. Gastric A. around the lesser curvature of the stomach

so it supplies the esophagus and the stomach

*visualize

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What are the branches coming off the Splenic A. ? what does it supply?

posterior gastric A.
Short gastric A.s
L. Gastric ommental A.
Splenic A.s
pancreatic A.s
- Splenic A. supplies the body and fungus of the stomach and the spleen
- the short grastrics supply the stomach and the superior pole of the spleen
- pancreas
* visualize

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What branches come off the Common Hepatic. A?

what does it supply?

the gastroduodenal A and the proper hepatic A.
-supplies the stomach, duodenum, the liver, pancreas, gallbladder

*visualize

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What branches come off the gastroduodenal A.?

what does it supply ?

anterior and posterior superior pancreatic-duodenal A.s
Right gastric ommental A.

-supplies the pancreas, duodenum, and stomach
*visualize
passes behind the gastro-duodenal jxn at about L1

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What branches come off the Proper Hepatic A. ?

what does it supply?

R. gastric A.
Left and right hepatic A.s
(right Hepatic Branches into the Cystic A.)

supplies the liver, lesser curvature of the stomach, and the gallbladder
visualize

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Which one is more anterior, Right Hepatic A. or Hepatic Portal Vein?

Right Hepatic A 91% of the time

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What is the major blood supply to the liver?

75-80% Hepatic portal vein (parenchyma like hepatocytes)
20-25% Hepatic A.s (non parenchyma like intrahepatic bile duct)

then the IVC drains right, left, and middle hepatic veins

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Where is the cystic A. found that is significant clinically?

The cystohepatic triangle of Calot

-boundaries: cystic duct, common hepatic duct, and the lower border of the liver

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What are the branches of the common bile duct?

The common bile duct travels in the hepatoduodenal L. and splits into the cystic duct and the common hepatic duct.
distally it joins the main pancreatic duct, flows into the ampulla of Vater, into the major papilla of the duodenum

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explain the blood drainage in the liver

The hepatic arteries and the hepatic portal vein drain into sinusoids into the central vein which will drain into Hepatic veins and then into the IVC.
Bile flows in the opposite direction in bile cannuliculi to interlobular biliary ducts then to the hepatic bile duct then to the common bile duct in the portal triad.
deep lymph ducts drain lymph from perisinusoidal spaces of Disse

Pancreatic Blood supple

Anterior and posterior superior pancreatic-duodenal A.s from the gastroduodenal A.
Anterior and posterior inferior pancreatic-duodenal A.s from the SMA
pancreatic A.s from the Splenic A.

What level does the SMA exit the aorta and what are its branches?

Exits aorta at L1
1. A/P inferior pancreatic-duodenal A.s
2. middle colic
3. Right colic.
4. ileocolic ( which branches into the appendicular A.)
5. ileo-jejenual A.s

Common SMA variations

absent middle colic
absent right colic
1 trunk for middle and right colic
1 trunk for ileocolic and right colic

What is Nutcracker syndrome? SMA syndrome?

Nutrcracker

when the Left Renal Vein is compressed by the Aorta and the SMA at L1
Signs: proteinuria, hematouria, varices in Left. scrotum, left flank pain

SMA Syndrome

when the 3rd part of the duodenum is compressed by the SMA and Aorta
nausea, bilious vommitting

*both caused by a loss of mesenteric fat pad

When does the IMA exit the aorta? what are its branches ?

Exits at L3
left colic
sigmoid A.s
superior rectal A.s

What makes the Marginal A of Drummond

a large anastomose between right, left, middle, and ileocolic A. s

what are the arteries that supply the rectum?

superior rectal A. from the IMA
middle rectal A. from from internal Iliac A.s
inferior rectal A. from internal pudendal A.

*they all anastomose around the rectum

What levels does the IVC appear in the abdominal cavity? where does it sit in relation to the Aorta?

exits the diagram hiatus at T5 and splits into the common iliac veins at L5
sits to the right of the aorta, 2.5cm from midline

What are the branches off the IVC? and what levels do they exit?

T5- Right, middle and Left hepatic veins - inferior phrenic veins - suprarenal veins - Left renal vein --> Left gonadal vein - Right Renal vein - Right gonadal A. - Lumbar Veins * HIS Right Gonad is Lower

Describe the venous drainage from the rectum

Rectal Venous Plexus--> Superior rectal vein -->IMV--> (Portal system )--> hepatic portal vein --(liver)--> IVC Rectal venous Plexus--> inferior or middle rectal vein ---(Caval system)--> IVC

Internal vs external hemorrhoids

internal - contains the internal venous plexus - bright red blood - NOT painful - above pectinate line external - contains clots of external venous plexus - covered by skin - PAINful - below pectinate line

What comes together to make the Portal Vein

The SMV and the splenic V. come together to make the Portal vein. The IMV drains into the splenic V. before it meets the SMV

What drains into the IMV

superior rectal V. and Colic V.

Name the portal-canal anastomoses and what veins come together in them

1. esophageal - Left gastric V. and Azygous V. 2. paraumbilical - Paraumbilical V. and epigastric V. 3. Rectal - superior rectal V. and middle of inferior rectal V. 4. Retroperitoneal - colic V.s and systemic retroperitoneal V.s (lumbar veins)

Name the pathologies that can occur in the canal-portal anatamoses if there is Portal Hypertension

1. esophageal - varices (can rupture and hemorrhage) 2. Paraumbilical - Caput Medusae or umbilical varices 3. Rectal- hemorrhoids

What are the parasympathetic nerves for abdominal innervation

Presynaptic - vagus N. (R and L vagal trunks) *enter at esophageal hiatus - Pelvic Splanchnic N . (S2-S4) Plexus - Vagus -->Abdominal aortic plexus and periarterial plexus - Pelvic Splanchnic--> inferior hypogastric Plexus Postsynaptic -Enteric (intrinsic) parasympathetic ganglion (ENS)

What are the sympathetic nerves for abdominal innervation

``` Splanchnic: Greater: T5-T9 Lesser: T10-T11 Least: T12 Lumbar: L1-L2 *greater, lesser, and least pierce the diaprahgm ```

Name the sympathetic prevertebral Ganglion and what nerves are most associated with them

``` Greater Splanchnic--> Celiac Ganglion Lumbar--> inferior mesenteric ganglion Lesser/least--> aorticorenal Ganglion and superior mesenteric ganglion *all are abdominal aortic and periarterial plexus ```

Is superior hypogastric plexus SNS or PNS

SNS

does pain visceral afferents travel with PNS or SNS

SNS | *exception is pelvic pain line

Describe SNS and PNS innervation of the rectum

SNS above Pectinate line -lumbar splanchnics-->peri-aortic plexus--> superior hypogastric plexus--> inferior hypogastric plexus PNS above pectinate line -pelvic splanchnic Somatic below pectinate line -pudendal afferents with Pudendal N.

Describe the pelvic pain line and its relation to the SNS and PNS

pelvic pain line corresponds to the inferior limit of the peritoneum for pelvic organs (middle of the sigmoid colon) - SNS travels above the Pain Line - pain visceral afferents travel with PNS below pain line

does visceral reflex afferent travel with PNS or SNS

PNS always