Module 02A - Abdomen Flashcards
Cheryl, 37, had her 3rd and last child 1 year ago. She has been experiencing some lower back pain for the past year since her pregnancy and thought it was due to the extra weight she was carrying in her abdomen. She decided to undergo liposuction to remove the extra weight in her abdomen. It is now 1 most post-surgery and despite the liposuction procedure and taking on a part-time dog walking job, she still has an expanded abdomen as well as back pain
What are some likely diagnoses and which one is most likely?
Complications from liposuction can cause bruising, swelling, and damage to the other layers
Where is the epigastric region of the anterior abdomen?
Superior most and Medial
(top and center)
Epi means above
Where is the hypogastric region of the anterior abdomen?
Inferior most and medial
(bottom and center)
hypo means below
Where is the right inguinal region?
Inferior right
Where is the left lumbar region?
Left of center and middle horizontally
Where is the umbilical region?
in the middle
Where is the left hypochondriac region?
Left superior
What are the 9 layers from surface to deep of the abdominal wall?
Skin Superficial Fascia Investing Fascia External Oblique Internal Oblique Transversus Abdominis Transversalis Fascia Extraperitonel Fat Parietal Peritoneum
Which Layer of the abdominal wall would have been targeted during Cheryl’s liposuction surgery?
Camper’s layer of the Superficial Fascia
Describe the Superficial fascia
It is composed of a fatty layer, Camper’s layer, and a membranous layer, Scarpa’s fascia
What is the rectus Sheath?
layer of fascia that envelopes the rectus abdominis muscle
The internal oblique, external oblique and transversus abdominis become aponeuroti, forming the strong tendinous rectus sheath that encloses the rectus abdominis muscles
Where is the linea alba?
Midline of the rectus sheath
What is the function of the rectus sheath?
Protective layer within the anterior abdominal that supports and protects the contents of the abdomen
What is rectus abdominis diastasis?
Condition where the rectus abdominis muscles become separated due to thinning of the linea alba. Result in protrusion of the abdominal contents
What are the 2 main arteries that supply the anterior abdominal wall
Superior epigastric artery
Inferior epigastric artery
Describe the origin and the path of the superior epigastric artery
It is a terminal branch of the internal thoracic (mammary) artery.
It enters the rectus sheath posteriorly and anastomoses with the inferior epigastric arter
Where does the inferior epigastric artery originate?
External iliac artery
What is a rectus sheath hematoma?
Results from bleeding into the rectus sheath from damage to the superior and/or inferior epigastric arteries and/or their branches
can result from a direct tear of the rectus sheath of of the abdominal wall
What are the 2 groups of lymph nodes responsible for the superficial lymphatic drainage of abdomen?
Axillary lymph nodes
Inguinal lymph nodes
What are the 3 groups of lymph nodes responsible for the deep lymphatic drainage of the abdomen?
Lumbar lymph nodes
Common iliac lymph nodes
external iliac lymph nodes
What is the inguinal canal?
A clinically important passageway approx 4-6 cm in length, located in the lower anterior abdominal wall.
Important passageway for structure between the abdominal region and the pelvic region
What are the 2 ends of the inguinal canal called?
Superficial inguinal ring
Deep inguinal ring
What structures passes through the inguinal canal only in females?
round ligament of the uterus
What structures passes through the inguinal canal only in males?
spermatic cord
What are structures that pass through the inguinal canal in both sexes?
ilioinguinal nerve
What does the ilioinguinal nerve supply?
upper thigh in both males and females
females: skin of upper labia majora and mons pubis
males: supplies the skin of the upper scrotum and root of the penis
What is an inguinal hernia?
When contents of the abdominal cavity protrude into the inguinal canal
What is the inguinal canal weak spot in females?
Where connective tissue from the uterus attaches to the tissue surrounding the pubic bone
generalized pain in anterior abdominal wall, and can thus be difficult to diagnose
Bruising, bulging and pain especially when bending over
What is the inguinal canal weak spot in males?
Where the spermatic cord enters the scrotum
What are the borders of the posterior abdominal wall?
Superiorly by the diaphragm
Inferiorly: 3 major paired muscles: psoas major, iliacus, and quadratus lumborum
What are the origin and insertion of the iliopsoas muscles?
Psoas major originates on the lumbar vertebrae and together with the iliacus merges into the iliopsoas attaching to the lesser trochanter of the femur
What are the origin and insertion of the quadratus lumborum muscles?
Thin flat muscle that originated on the iliac crest and lumbar vertebrae and inserts on rib 12
How can a “tight” quadratus lumborum muscles affect the structures at its origin and insertion?
It can increase the load on a few anatomical structures. Its often asymmetric and can cause pelvic misalignment, it may pull at the ribs, limiting reaching and breathing. When both are tight it may cause compression on the spine, resulting in back pain
What is the lumbar plexus?
Network of nerve fibres responsible for supplying innervation to the skin and musculature of the lower limb
Innervation pattern of these nerves are directly applicable to clinicians as they aid them in locating sources of pain
Where is the lumbar plexus?
Formed in the psoas major muscle by the lumbar spinal nerves 1-4. Branches of the plexus emerges from the psoas major and further divide into several cords
What are the 7 main cords that make up the lumbar plexus?
1- iliohypogastric nerve (spinal nerve L1)
2- Ilioinguinal nerve (spinal nerve L1)
3- genitofemoral nerve (spinal nerve L1 and L2)
4- Lateral femoral cutaneous nerve (spinal nerve L2 and L3)
5- femoral nerve (Spinal nerve L2-L4)
6- Obturator nerve (spinal nerves L2-L4)
7- Lumbosacral trunk (spinal nerves L4 and L5
What does the iliohypogastric (spinal nerve L1) nerve supply?
Skin and muscles of the lower anterior abdominal wall
What does the ilioinguinal (spinal nerve L1) nerve supply?
runs through inguinal canal to supply the upper medial thigh root of penis and anterior scrotum or skin of the mons pubis and labium majus
What does the genitofemoral (spinal nerve L1 and L2) nerve supply?
Divides into 2 branches genital branch and femoral branch
Supplies small area of skin on upper anterior thigh
What does the Lateral femoral cutaneous nerve (spinal nerve L2 and L3) nerve supply?
Skin of the anterolateral thigh
What does the femoral nerve (spinal nerve L2-L4) nerve supply?
muscles of the anterior compartment of the thigh, hip, knee joints and skin of the anterior thigh
What does the obturator nerve (spinal nerve L2-L4) nerve supply?
Muscles of the medial compartment of the thigh, hip, and knee joints and the skin of the medial thigh
What structure foes the lumbosacral trunk join?
Sacral nerves 1-4 ventral rami to form the sacral plexus
What is femoral nerve entrapment?
Pinching of the femoral nerve at some point along its course. Causes pain numbness or weakness along the front of the thigh
Most common cause is disc herniation at L2/3 or L3/4
Where is the lumbar sympathetic trunk located?
Runs down the posterio abdominal wall alteral to the vertebral column
Describe the parasympathetic innervation of the posterior abdominal wall
Branches of the left and right vagus nerves called vagus trunks carry parasympathetic fibres to the aortic plexus.
Spinal nerves S2-4 called pelvic splanchnic nerves carry parasympathetic fibres to the superior hypogastric plexus
What structures are associated with the aortic plexus?
prevertebral ganglia; celiac, superior, inferior mesenteric, and aorticorenal ganglia
What does the aortic plexus innervate?
organs of the abdomen including stomach, small and large intestine and kidneys
What does the superior hypogastric plexus innervate?
organs of the pelvis; uterus, prostate, bladder, rectum, perineum
In an individual experiencing diabetic gastroparesis, which autonomic nerve or autonomic nerve plexus would be implicated?
A) lumbar sympathetic trunk
B) celiac trunk
c) anterior and posterior vagal trunks
C
What is gastroparesis?
Impaired innervation to the abdominal viscera, dysmotility can result. No structural abnormalities within the gut and no inflammation
Symptoms: bloating, abdominal pain, nausea and vomiting
What is the abdominal aorta?
It refers to the portion of the aorta that passes through the abdomen, starting at the abdominal hiatus
Describe the pathway of the aorta through the abdomen and its branching off
Starting at the aortic hiatus the aorta becomes the abdominal aorta, then bifurcates in the to Left and right common iliac arteries. Each iliac artery then bifurcates into an external iliac artery and an internal iliac artery
What can cause weakened i abdominal aorta?
prolonged hypertension
What’s an aortic dissection?
Tearing or rupturing of the aorta, due to its weakening after trauma. People with a history of hypertension are more at risk, because hypertension weakens the walls of the vessels
Abdominal pain, weakness, fainting, death by bleeding out
what are the 3 anterior unpaired visceral branches branching off of the abdominal aorta?
Celiac artery
Superior mesenteric artery
Inferior mesentery artery
Where does the celiac artery orginate?
abdominal aorta
Where does the celiac artery form?
from the abdominal aorta at the level of T12
What branches does the celiac artery give off? (3)
left gastric artery
common hepatic
splenic arteries
What structures do the celiac artery and its branches supply?
foregut (distal esophague to proximal duodenum) structures
where foes the Superior Mesenteric Artery form?
from the abdominal aorta at the level of L1
What are the branches of the Superior Mesenteric Artery? (5)
Inferior pancreaticoduodenal artery jejunal artery ileal artery middle colic artery right colic artery
What does the Superior Mesenteric Artery and its branches supply?
Midgut (distal duodenum, proximal half of transverse colon) gut
What are the branches of the inferior mesenteric artery? (3)
Left colic artery
sigmoidal arteries
superior rectal artery
What structures do the inferior mesenteric artery and its branches supply?
Hindgut (distal third of the transverse colon to the rectum)
What are the 3 lateral paired visceral branches of the aorta?
Suprarenal arteries
Renal Arteries
Gonadal arteries
Where do the left and right suprarenal arteries form?
Abdominal aorta at the level of L1
Where do the left and right renal arteries form?
abdominal aorta at the level between L1 and L2
Where do the left and right gonadal arteries form?
Abdominal aorta at the level of L2
What are the posterior parietal branches?
Right and left inferior phrenic arteries Lumbar Arteries (4 pairs)
Where do the right and left phrenic arteries originate from?
Abdominal aorta
What do the posterior parietal branches supply?
Musculoskeletal structures of the posterior abdominal wall
Where do the right and left inferior phrenic arteries form?
Arise from the abdominal aorta just below the aortic hiatus
What do the right and left inferior phrenic arteries supply?
inferior surface of the diaphragm
How many lumbar arteries are there?
4 pairs so 8
What do the lumbar arteries supply?
posterior abdominal wall
What do the lumbar arteries run in series with?
intercostal arteries
If a pain is felt in the upper left quadrant and the pain is due to an obstructed arter, which affected vessel would most likely cause his pain?
a) splenic artery
b) lumbar artery
c) superior rectal artery
d) right colic artery
A
What are the tributaries of the inferior vena cava?(6)
Right and left renal veins Hepatic veins inferior phrenic lumbar veins left suprarenal right and left gonadal (testicular or ovarian) veins
If the inferior vena cava becomes compressed/obstructed, in which regions of the body would you expect swelling?
The Inferior vena cava drains all tributaries of the lower limbs, therefore patients with IVC obstruction often have edema below the diaphragm especially in the lower limbs
Obstruction can be a blood clot or a tumour
What is the covering of the abdomen called?
peritoneum
What are the 2 layers of the peritoneum?
parietal and visceral
Which layer of the peritoneum lines the inferior surface of the diaphragm, the abdominal and pelvic walls and forms a roof over the pelvic viscera?
parietal
Which layer of the peritoneum covers the organs so when their visceral surfaces are in contact with each other or with the other peritoneum layer, the serous fluid between the peritoneal surface allows free movement?
visceral
What is peritonitis?
inflammation of the peritoneum that is usually caused by a bacterial infection. It is a rapid progressive disease of the abdominal caivty which can be fatal if left untreated
Symptoms: abdominal pain, weight loss, and tenderness of the abdomen
Which sex has incomplete closure of the peritoneal cavity?
Females - communication with the exterior by the openings of the fallopian tubes and therefore incomplete closure
– this can lead to spread of infection via the vagina
What are the 2 peritoneal fold
omenta
mesenteries
What is the function of the omenta?
cushion the intestines and act as a protective barrier for infection and trauma of the underlying abdominal organs
Where is the lesser omentum?
between stomach and liver
Where is the greater omentum?
hanging below the stomach
What is the function of the mesenteries?
anchor the abdominal organs to the posterior abdominal wall, helping keep those organs in place while still allowing for some mobility
What are intraperitoneal organs?
organs that are almost completely covered by the peritoneum. The are anchored by the mesentery to the posterior abdominal wall
What are retroperitoneal organs?
found behind the peritoneum and are only covered anteriorly
Name an example of a retroperitoneal organ?
kidney
What is the peritoneal cavity?
space between the parietal and visceral layers of the peritoneum. Analogous to the pericardial and pleural spaces of the heart and lungs.
What are the 2 peritoneal cavities?
lesser sac
greater sac
What is an other name for the lesser sac of the peritoneum?
omental bursa
Where is the omental bursa located?
Lies behind the stomach, extending upward to the diaphragm (superior recess) downward between the layers of greater omentum (inferior recess), as far left as the spleen and to the right where it communicates to the greater sac through the epiploic (omental) foramen (of Winslow)
Where is the greater sac located?
Extends from the diaphragm to the pelvis between the layers of the omentum
What innervates the parietal peritoneum?
network of nerves, including the phrenic nerves, lower intercostal nerves and several others
What innervates the visceral peritoneum?
Visceral sensory nerves that accompany autonomic nerves
How can you qualify the pain felt in the parietal layer of the peritoneum?
Well-localized sensitivity to pain
How can you qualify the pain felt in the visceral layer of the peritoneum?
pain is poorly localized
What is reactive lymphadenopathy?
Lymph nodes become swollen due to an immune response from lymphocytes
Symptoms: tenderness, pain, and warmth upon touch in the region of the affected lymph nodes
What is the location of the pre-aortic lymph node?
Anterior surface of the aorta in close proximity to the major unpaired branches of the aorta
Which nodes drain the foregut, midgut, and hindgut structures?
pre-aortic lymph nodes
Where is the location of the para-aortic lymph nodes?
aka lumbar lymph nodes are located along the length of the aorta on the right and left sides
Which nodes drain lymph from the posterior abdominal wall, kidneys, suprarenal glands, ureters, gonads (ovaries and testes), uterus, and uterine tubes?
para-aortic lymph nodes
The lungs are (???) to the thoracic esophagus?
Lateral
The abdominal esophagus is (???) to the diaphragm?
inferior
The thoracic esophagus is (???) to the trachea?
posterior
Where is the lower esophageal sphincter?
Distal end of the esophagus
What structure prevents the reflux of gastric contents (acid, pepsin, etc…) into the esophagus?
lower esophageal sphincter
What’S gastroesophageal reflux (GERD)
Weak abnormal closure of the LES can result in regurgitation of stomach content into the esophagus is experiences as a burning sensation.
The burning is felt as “heartburn” due to the close proximity of the heart, others symptoms chest pain, nausea and/or vomiting of refluxed content
What are the rugae?
gastric folds
Where is the pyloric orifice/sphincter?
between the distal end of the stomach and proximal end of the duodenum
What structure controls the movement of content from the stomach (chyme) into the duodenum?
pyloric sphincter
What are some anatomical structures that may cause gastroparesis ?
pyloric sphincter and the autonomic nerves innervating the stomach
What is endoscopy?
insertion of a long thin tube directly into the body to observe an internal organ in detail, scuh as the stomach and can be used for imaging and for minor surgeries
What arteries supply the stomach?
right and left gastric arteries which anastomoses at the lesser curvature
Which part of the of the duodenum is not intraperitoneal, but retroperitoneal?
proximal part of the duodenum
What are the 3 parts of the small intestines?
duodenum
jejunum
ileum
Which part of the small instestine is the shortest?
duodenum
What are the 4 parts of the duodenum and describe their anatomy&
Superior (first part)
Only portion of duodenum that is intraperitoneal, bile duct and gastroduodenal artery pass posteriorly to it
Descending (second part)
Runs vertically and passes anteriorly to the hilum of kidney. Contains the major duodenal papilla, which is the site where the hepatopancreatic ampulla (of Vater) drains into
Horizontal (third part)
Passes transversely across IVC and abdominal aorta, just inferior to the origin of the superior mesenteric artery and vein.
Ascending (fourth part)
Forms the duodenojejunal flexure, which is anchored to the posterior abdominal wall by the fibromuscular suspensory ligament of the duodenum, the ligament of Treitz
What is the ligament of Treitz
Fibromuscular suspensory ligament that anchors the duodenojejunal flexure to the posterior abdominal wall
What arteries supply the duodenum?
Foregut (1st and 2nd parts) is supplied by the gastroduodenal artery and its branch the superior pancreaticoduodenal artery
Midgut (3rd and 4th parts) os supplied by the inferior pancreaticoduodenal artery, a branch of the superior mesenteric artery
What arteries supply the jejunum and the ileum?
The jejunal and the ileal arteries, branches of the SMA
What are Vasa Recta?
Terminal branches of the series of anastomotic loops that reach the intestinal wall
Describe the network made by the jejunal arteries and vasa recta?
Fewer arcades and longer vasa recta
Describe the network made by the ileal arteries and vasa recta?
Many arcades shorter vasa recta
What is Meckle’s diverticulum?
An outpouching (bulging) of tissue in the distal ileum of the small intestines. This may develop in ulcer resulting in severe sudden abdominal pain accompanied with rectal bleeding. It can obstruct movement of intestinal contents, leading to vomiting or constipation. Pain referred to epigastric and umbilical regions of the abdomen
What are the 3 distinguishing feature of the large intestine?
Teniae coli
Haustra
Epiploic (Omental) Appendages
What are the Teniae Coli?
3 thickened bands of longitudinal muscle
What are the Haustra?
segmented pouches or folds
What are epiploic (omental) appendages?
Fatty tags enclosed by peritoneum
What is hirschsprung disease
Disorder that occurs at birth when motor nervel cells, called the auerbach’s plexus, are absent in the muscles of the colon. It affects motility in the colon making it difficult to pass stool
What type of contractions occur in the colon?
Haustral contractions (non propulsive
What is the ileocecal (iliocolic) valve?
The opening of the ileum into the cecum controlled by the valve
describe the anatomy of the cecum?
blind-ended pouch lying in the right iliac region (lower right quadrant) and is almost completely covered with peritoneum (omentum) but has no mesentery
Which parts of the large intestines are considered intraperitoneal?
cecum
transverse colon
Sigmoid colon
Which parts of the large intestines are consider retroperitoneal?
Ascending colon
Descending Colon
Rectum
Select all the arteries that supply the midgut portion of the large intestines: ileocolic artery superior rectal artery splenic artery right colic artery middle colic artery left colic artery
ileocolic artery (cecum and appendix)
right colic artery (ascending colon)
middle colic artery (transverse colon)
Select all the arteries that supply the midgut portion of the large intestines: ileocolic artery superior rectal artery splenic artery right colic artery sigmoidal arteries middle colic artery left colic artery
Superior rectal artery (rectum and upper anal canal)
Left colic artery (descending colon)
sigmoidal arteries (sigmoid colon)
What is mesenteric artery ischemia?
Condition resulting in the occlusion of the mesenteric arteries. This affects the structures of the midgut (distal duodenum, jejunum, ileum, and colon)
Interruption of blood flow can lead to tissue death, intestines then cant function normally leading to disrupted BM, nausea and vomiting. Abdominal pain is typically abrupt and accompanied by abdominal tenderness
What are the 3 main veins that drain the gastrointestinal viscera?
splenic vein
Superior mesenteric vein
Inferior mesenteric vein
Describe the path of the splenic vein
It leaves the spleen and passes posterior to the pancreas to join the superior mesenteric vein
What does the splenic vein drain?
spleen, lower esophagus, and part of the stomach and pancreas
describe the path of the splenic vein
Ascend through the mesentery of the small intestine to join the splenic vein posterior to the pancreas. As the name suggest, the SMV branches correspond with the branches of the SMA
What is mesenteric ischemia?
occlusion of the superior or inferior mesenteric vein. though rare it can be fatal
describe the path of the inferior mesenteric vein
the IMV ascends on the left to join the splenic vein
what are the inferior mesenteric vein’s tributaries
correponds to those of the IMA
What is the function of the hepatic portal vein?
carries nutrient-rich deoxygenated blood from the digestive tract to the liver.
What is the path of the hepatic portal vein?
Formed posterior to the pancreas by the union of the splenic and superior mesenteric veins. The portal vein ascends before entering the porta hepatis of the liver
What is one use of the hepatic portal vein in the detection of early cirrhosis
pulsatility (rate of blood flow)
What is the largest internal organ of the body?
liver
What is the falciform ligament&
A fold of the peritoneum that divides the 2 lobes of the liver
Why are the spaces and recessus/fossae clinically important?
They allow a passage for infection fluids from different compartments of the abdoment
What are subphrenic recesses?
Superior extension of the peritoneal cavity between the liver and diaphragm. There is a left and right subphrenic recess separated by the falciform ligament
What is the pouch of Morrisson?
Hepatorenal recess
What is the hepatorenal recess
deep recess in the peritoneal cavity on the right side between the liver and the right kidney
To which organ does almost 1/3 of the cardiac output pass through?
liver
What vessels send blood through the liver?
portal vein 80%
hepatic artery proper 20%
What is portal vein thrombosis (PVT?
Blood clot is formed in the portal vein. An occlusion in this vessel interrupts the flow of nutrient right blood from the intestnes to the liver.
Symptoms: upper right abdominal pain, abdominal swelling, and a fever
Describe the location of the gallbladder?
The fundus projects anteriorly from the inferior border of the liver, while the body projects posteriorly and narrow to the neck which is continuous with the cystic duct
Describe the location of the pancreas
lies transversely on the posterior abdominal wall, posterior to the stomach.
What is pancreatitis?
inflammation of the pancreas, a common cause if gall stones.
Structures involved are the pancreas, common bile duct and gallstone
What is the largest lymphatic organ of the body?
spleen
Describe the location of the spleen
Under the left dome of the diaphragm behind the stomach and anterior to ribs 9, 10, 11
It has unique notches and a hilum on its medial surface which can be palpated if swollen
What is splenomegaly?
when the spleen becomes enlarged it may affect other abdominal organ in close proximity to the spleen
Which organ is centrally located within the abdominal cavity and nestles its head into the arms of the duodenum and distally, its tail is playing footsies with the spleen
pancreas
Which structure passes through the duodenum, proximal to the pancreas.
common bile duct
Which structure has a very close relationship with vessels of the superior mesenteric artery and the abdominal aorta. In fact it is “sandwiched” between the 2 at one point
duodenum
Which structure is the largest abdominal organ and is inferior to the diaphragm?
liver
Which kidney is positioned slightly lower in the abdomen and why?
right, because of the position of the liver
What is pyelonephritis
Kidney infection typically caused by a bacterial infection of the bladder
describe the path of the ureters
leaves the hilum of the kidney and descends vertically toward the pelvis. It passes anterior to the psoas muscle and the bifurcation of the common iliac artery and vein
What is a ureter stone?
kidney stone that has moved from the kidney into another part of the urinary tract obstructing the pathway of the urine from the kidney to the bladder
Severe intermittent pain in the flank region,
What arteries supply the adrenal glands
suprarenal artery as well as branches from the inferior phrenic and renal arteries
Whats the difference between the symptoms of a tumour on the adrenal gland and the kidney stones?
The pain associated with the tumour on the adrenal gland would be higher
What arteries supply the kidneys?
renal arteries
accessory renal arteries are quite common and may arise from the aorta above or below the main renal artery and enter the kidney above or below the hilum
What is nut cracker syndrome?
very rare condition that occurs when the left renal vein becomes compressed between the abdominal aorta and the superior mesenteric artery.
symptoms: blood or protein in the urine, flank pain and/or abdominal pain
