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GI Exam I > Lecture 9: Blood and Nerve Supply > Flashcards

Lecture 9: Blood and Nerve Supply Flashcards

1
Q

What vertebral level does aorta enter the abdomen and where does it divide?

A
  • Enters via aortic hiatus of diaphragm at T12
  • Ends at L4 by dividing into right and left common iliacs
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2
Q

What are the unpaired visceral branches of the aorta, their spinal levels, and which embryologic region does each branch supply?

A
  1. Celiac (T12) - foregut
  2. Superior mesenteric (L1) - midgut
  3. Inferior mesenteric (L3) - hindgut
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3
Q

What are the paired visceral branches of the aorta and spinal levels?

A
  1. Suprarenal (L1)
  2. Renal (L1/L2)
  3. Gonadal (L2)
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4
Q

What are the paired parietal branches off the aorta and vertebral levels?

A
  1. Inferior phrenic (T12)
  2. Subcostal (T12)
  3. Lumbar (L1-L4)
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5
Q

What are the foregut derivatives, major artery supply, innervation, and referred pain region?

A

Organs: Esophagus, stomach, liver and pancreas, biliary apparatus, and proximal duodenum

Innervation: Greater splanchnic (T5-T9)

Artery: Celiac

Referred pain: Epigastrium

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6
Q

What are the midgut derivatives, major artery supply, innervation, and referred pain region?

A

Organs: Small intestine, cecum and appendix, ascending colon, right 1/2 of transverse colon

Innervation: thoracic splanchnic (T8-12)

Artery: Superior mesenteric

Referred pain: Umbilical region

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7
Q

What are the hindgut derivatives, major artery supply, innervation, and referred pain region?

A

Organs: Left 1/2 transverse colon, descending colon, sigmoid colon, rectum, superior anal canal

Innervation: Lumbar splanchnics (L1-L2)

Artery: Inferior mesenteric artery

Referred pain: Hypogastrium

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8
Q

What are the 3 branches off the celiac trunk?

A

1) Left gastric a
2) Splenic a
3) Common hepatic a

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9
Q

What is the blood supply to the liver off the celiac trunk?

A

Common Hepatic artery –> Proper hepatic artery branches into R. and L. Hepatic arteries. The cystic artery will usually branch off the right hepatic artery.

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10
Q

What are 2 vascular variations of the hepatic arteries?

A

1) Accessory or replaced right hepatic artery coming from SMA
2) Accessory or replaced left hepatic artery coming from left gastric a

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11
Q

What are the relationships of the right hepatic artery to the portal vein?

A
  • Commonly right hepatic artery is anterior to portal vein
  • Sometimes, rarely, can be posterior to portal vein
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12
Q

Explain the dual blood supply to the liver and what each supplies?

A

1) Hepatic portal vein (75-80%) - sustains liver parenchyma
2) Hepatic artery (20-25%) - sustains non-parenchymal structures (intrahepatic bile ducts)

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13
Q

What is the cystohepatic triangle (of Calot) made up of; significance?

A
  • Cystic duct, common hepatic duct, and visceral surface of liver
  • Where the Cystic artery is often found
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14
Q

What arteries anastomose at the lesser curvature of the stomach?

A

Left and right gastric arteries

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15
Q

What arteries anastamose at the greater curvature of the stomach?

A

Right and left gastro-omental arteries

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16
Q

What are the anastomses of the stomach formed by the left gastric artery?

A

Left gastric –> Right gastro-omental

Left gastric –> Left gastro-omental

Left gastric –> Right Gastric

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17
Q

Which artery supplying the stomach can be compromised with a posterior rupture from a peptice ulcer?

A

Gastroduodenal a.

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18
Q

What branches does the gastroduodenal artey give off to supply what part of pancreas and duodenum?

A
  • Anterior and posterior superior pancreaticoduodenal arteries
  • Supplies head of pancreas and 1st/2nd part of duodenum
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19
Q

What branches does the SMA give off to supply what part of pancreas and duodenum?

A
  • Anterior and posterior inferior pancreaticoduodenal arteries.
  • Supplies 3rd and 4th part of the duodenum
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20
Q

What arteries do the major blood supply for the tail, body, and neck of the pancreas and where do they arise from?

A

1) Dorsal pancreatic artery
2) Greater pancreatic artery

*Arise from the Splenic a.

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21
Q

What marks the transition from foregut to midgut?

A

The anastomosis between anterior and posterior superior pancreaticoduodenals w/ the anterior and posterior inferior pancreaticoduodenals.

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22
Q

Describe what the SMA does as it enters the middle of the colon, what vertebral level, what are its branches?

A
  • Starts retroperitoneal, but then descends into the mesentery, supplies midgut at level of L1.
  • Branches into:
  • Jejunal as.
  • Ileal as.
  • Middle Colic - transverse colon
  • Right Colic - superior part of ascending colon
  • Ileocolic - lower part of ascending colon
  • Appendicular - appendix
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23
Q

We will need to distinguish the Jejunal arteries from the Ileal arteies, what are the key features that will help us differentiate between the two?

A

Jejunum = long vasa recta w/ few arcades

Ileum = short vasa recta w/ many arcades

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24
Q

What are two of the common variation in the SMA colic arteries?

A

1) Absent middle colic replaced by large branch from left colic
2) Absent right colic artery

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25
Q

What are the Sx’s of renal vein entrapment syndrome?

A
  • Blood and protein in urine
  • Flank pain
  • Nausea and bilious vomiting
  • Left testicular pain
  • Left sided varicocele
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26
Q

What are the branches of the IMA and what spinal level?

A
  • L3
  • Left Colic (ascending and descending branch)
  • Sigmoid arteries
  • Superior rectal as.
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27
Q

What is the anastomotic connection between midgut and hindgut in the colon?

A
  • Middle colic from the SMA anastomses w/ left colic from the IMA = Marginal artery (of Drummond)
28
Q

Which arteries form the Marginal artery (of Drummond)?

A

Ileocolic (SMA), Right colic (SMA), Middle colic (SMA), left colic (IMA), and sigmoid (IMA)

29
Q

What are the 3 rectal arteries and their origins?

A

1) Superior rectal (from IMA)
2) Middle rectal (from internal iliacs)
3) Inferior rectal (from internal pudendal)

30
Q

Describe the path of venous drainage from rectal venous plexus onward; what is this system called?

A

Rectal venous plexus –> Internal pudendal vein —> common iliacs —> IVC —> heart

* The Cavle system*

31
Q

Where does the middle and inferior rectal veins drain into?

A
  • Inferior –> Internal pudendal –> common iliacs –> IVC
  • Middle –> common iliacs –> IVC
32
Q

Where does the superior rectal vein drain?

A

Into the Inferior Mesenteric Vein –> Portal Vein –> Liver

33
Q

Describe internal hemorrhoids

A
  • Prolapse of rectal mucosa that contains normally dilated veins of the internal venous plexus
  • Bleeding is bright red
  • NOT painful because are ABOVE pectinate line
34
Q

Describe external hemorrhoids

A
  • Thromboses or blood clots in veins of the external venous plexus
  • Covered by skin
  • Painful because they are below the pectinate line and are innervated by somatic sensory nerve fiber (inferior anal nerves)
35
Q

Describe the anatomical postion of the IVC in the abdomen

A
  • Begins anterior to L5, 2.5cm to the right of midline, right side of aorta
  • Passes through the caval opening of diaphragm at T8
36
Q

IVC drains blood from which structures in the abdomen?

A
  • Lower limbs and paired visceral structures i.e., kidneys and suprarenal glands
  • Does NOT drain the digestive tube
37
Q

How do the left and right testicular veins differ?

A
  • Left testicular drains into left renal –> IVC
  • Right testicular drains directly into IVC
38
Q

What is an anastomotic connection of the IVC?

A

Ascending lumbar vein anastomoses w/ azygous system (hemiazgous vein in thorax)

39
Q

What is the anatomical position/relationship of the Portal Vein; passes thru which ligament?

A
  • Anterior to the IVC
  • Posterior to the Pancreas
  • Found in hepatoduodenal lig.
40
Q

What 3 veins converge to form portal vein, and what’s the classical route?

A
  • Superior Mesenteric Vein
  • Inferior Mesenteric Vein
  • Splenic vein

*Typically the IMV drains into the Splenic V, which then converges with the SMV to make the Portal Vein

41
Q

What is the role of the Portal vein?

A

Drains the digestive tube

42
Q

What are the 4 Portal-Caval Anastomoses?

A

1) Esophageal - left gastic vein –> Esophageal (azygous system)
2) Rectal - Superior rectal –> middle or inferior rectal Vs.
3) Paraumbilical - Paraumbilical V –> Epigastric V.
4) Retroperitoneal - Colic V –> Systemic retroperitoneal vs.

43
Q

What are the 3 conditions that can arise from Portal HTN?

A

1) Esophageal varices
2) Rectal - hemorrhoids
3) Paraumbilical - Caput Medusae

44
Q

Describe the type of fibers that the Vagus nerve conveys, supplies what ‘derm structures, and stops where?

A
  • Pre-synaptic parasympathetic and visceral afferent fibers to the abdominal aortic plexuses and the periarterial plexus
  • Supplies foregut and midgut structures, stops at the left colic (splenic) flexure
45
Q

How are the pelvic splanchnic nerves distinct from other splanchnic nerves; supply which ‘derm?

A
  • Have NOTHING to do w/ the sympathetic trunks
  • Convey PREsynaptic PARAsympathetic fibers to the inferior hypogastric (pelvic) plexus
  • Supply hindgut endoderm
46
Q

Describe the path of the cell bodies for sympthathetic innervation

A
  • Pre-synaptic cell body leaves lateral horn via ventral root and joins mixed spinal nerves
  • Leaves ventral ramus via white rami communicantes and passes thru para-vertebral ganglia
  • Synapse on the pre-vertebral ganglia of sympathetic chain
  • Post-synaptic cell now travels on BV’s via periarterial plexus to target organ
47
Q

What passes through the Celiac ganglion/plexus?

A
  • Pre-dominantly Greater Splanchnic (sympathetic), but Vagus (parasympathetic) travels through it
48
Q

What sympathetic nerve synapses on the aorticorenal ganglion?

A
  • Lesser splanchnic (T10-T11)
49
Q

The superior mesenteric plexus gets contributions from?

A
  • Celiac plexus, lesser, least, and sometimes lumbar
  • Parasympathetics travel through here
50
Q

What travels through the intermesenteric plexus and supplies what?

A
  • Mix of sympathetic and parasympathetic
  • Supplies kidneys, gonads, and ureters
51
Q

What travels through the superior hypogastric plexus?

A
  • Purely post-synaptic sympathetics
52
Q

The inferior mesenteric ganglion/plexus gets contributions from?

A
  • Intermesenteric plexus
  • Lumbar splanchnics
53
Q

The right and left hypogastric nerve is made up of what kind of autonomic innervation and contributes to?

A
  • Post-ganglionic sympathetics
  • Contributes sympathetics to the inferior hypogastric plexus
54
Q

What does the inferior hypogastric plexus innervate and what kind of nerves does it contain?

A
  • Sympathetics from the R and L hypogastric nerve
  • Pelvic splanchnics (para-sympathetics) travel through
  • Supplies a lot of pelvic organs
55
Q

Where do parasympathetics synapse?

A

Travel through ganglion to wall of the organ where they synapse in the Myenteric plexus of Auerbach or Submucosal plexus

56
Q

Describe sympathetic innervation of the rectum by the lumbar splanchnics

A
  • Lumbar splanchnics synapse at the IMG, which send post-synaptic fibers to the superior and inferior hypogastric plexuses
  • Innervate anything above pectinate line
57
Q

Describe parasympathetic innervation of the rectum.

A
  • Pelvic splanchnics go through the inferior hypogastric plexus and innervate anything above pectinate line
58
Q

How is the rectum innervated below the pectinate line?

A
  • Somatic innervation via the pudenal nerve
59
Q

Pain travels with which visceral afferents and what’s the exception?

A
  • Travels w/ sympathetics
  • EXCEPTION: Travels w/ parasympathetics below the pelvic pain line
60
Q

What is the pelvic pain line and its significance?

A
  • Corresponds to the middle of the sigmoid colon

- Anything from middle to superiorly, pain will be carried by sympathetics (lumbar plexus)

  • Anything from middle to inferior, pain will be carried by parasympathetics (pelvic splanchnics)
61
Q

Visceral reflexes travel w/ what part of autonomics?

A

Parasympathetics

62
Q

Which vessels travel through the hepatoduodenal lig?

A
  • Portal triad
  • Right Gastric a.
  • Proper Hepatic a.
  • Portal V.
63
Q

Which vessels travel through the splenorenal lig?

A

Splenic a and v

64
Q

Which ligament does the left gastric artery travel through?

A

Hepatogastric lig

65
Q

Which ligament do the short gastric arteries travel through?

A
  • Gastrosplenic lig
66
Q

Which ligament do the left and right gastro-omentals travels through?

A

Gastrocolic lig.

67
Q
A

GI Exam I (14 decks)

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