Module 5 Flashcards
- Includes oral cavity, teeth, gingiva, tongue, palate, and palatine tonsils
- Food is ingested and prepared for digestion
- Food is chewed by teeth and saliva facilitate formation of manageable food bolus
- Swallowing is initiated (voluntary phase)
- Food is pushed into the pharynx (automatic phase)
ORAL REGION
Subdivisions of the Oral Region
- Oral vestibule - Gingivae, lips, cheek
- Oral cavity proper - Teeth, dental arches, roof of cavity, floor of mouth, tongue, palatoglossal, palatopharyngeal arches
- It is bounded posteriorly by the two sets of upper and lower teeth and anteriorly, by the lips and cheeks.
- is the slit-like space between the teeth and gingivae (gums) and the lips and cheeks.
- communicates with the exterior through the oral fissure (opening)
Oral vestibule
- Duct of the parotid gland (serous secretion – watery characteristic)
- Opposite the 2nd upper molar
Opening of the Stensen’s Duct
The size of the __ is controlled by the circumoral muscles, such as the orbicularis oris (the sphincter of the oral fissure), the buccinators, risorius, and depressors and elevators of the lips (dilators of the fissure).
oral fissure
- Space between upper and lower dental arches
- Limited laterally and anteriorly by maxillary and mandibular alveolar arches
- Roof: Palate
- Communicates posteriorly with oropharynx by an opening termed the faucial isthmus between the palatoglossal arches
- When mouth is closed, oral cavity is occupied by tongue
- Hard and soft palate
- Maxillary and mandibular dental arches
ORAL CAVITY PROPER
FAUCES OF ORAL CAVITY PROPER
Soft palate – superior
Base of the tongue – inferior
Laterally by pillars of fauces (palatoglossal and palatopharyngeal arches)
–Palatoglossal arch demarcates the oral cavity from the oropharynx
Boundaries of Oral Cavity Proper
Anterior: upper and lower teeth
Roof: palatine bone
- Forms arched roof of mouth and floor of the nasal cavities
- Separates oral cavity from the nasal cavity and nasopharynx
- Has an “extravagant arterial supply” (from branches of the maxillary artery) and many sensory nerves (branches of the pterygopalatine ganglion)
- Comprises the hard palate, or anterior 2/3, and soft palate or posterior 1/3
Palate
- Anterior 2/3 palate made of bony skeleton (palatine process of maxilla and horizontal plates of palatine bone) covered by oral musoca
- Concave
- Filled by tongue at rest
- Contains palatine glands that opens into the surface of the __
Hard Palate
3 foramens of the Hard Palate
- Incisive fossa - Behind central incisor for the passage of nasopalatine nerve
- Greater palatine foramen - Medial to the 3rd molar passage of greater palatine nerves and vessels
- Lesser palatine foramen - Passage of lesser palatine nerves and vessels
The __ contains many palatine glands, a median raphe, and transverse palatine folds or rugae.
mucoperiosteum of the hard palate
- Movable posterior third
- Has no bony skeleton
- Attached to the hard palate by the palatine aponeurosis (expanded tendon of the tensor veli palatini)
- Uvula – conical extension posteriorly
- Tenses to squeeze food to back of mouth
- Prevent passage of food to nasal cavity
- Palatine tonsils – on each side of oropharynx
- Forms superior boundary of the fauces
- During swallowing, it initially tenses against the tongue then moves posteroeuperiorly against eh walls pharynx to prevent passage into nasal cavity of food particles
Soft Palate (Velum Palatinum)
Muscles of the Soft Palate
- Tensor veli palatini
- Levator veli palatini
- Palatoglossus
- Palatopharyngeus
- Musculus uvulae
Superior Attachment (SA): Medial pterygoid plate, sphenoid, eustachian tube
(Inferior Attachment) IA: Palatine aponeurosis
Nerve (N): Medial pterygoid nerve (br. CN V3)
Action (A): Tenses the soft palate and opens the PT tube
Tensor veli palatini
SA: Cartilage of the PT tube, petrous temporal
IA: Palatine aponeurosis
N: CN XI via the branch of vagus, pharyngeal plexus
A: Elevates soft palate during swallowing and yawning
Levator veli palatini
SA: Palatine aponeurosis
IA: Side of tongue
N: CN XI via the branch of vagus, pharyngeal plexus
A: Elevates posterior tongue
Palatoglossus
SA: Hard palate
IA: Lateral wall pharynx
N: CN XI via the branch of vagus, pharyngeal plexus
A: Tenses SF / pulls pharynx supero-medially, anteriorly
pharyngeus
SA: Palatine aponeurosis
IA: Uvula
A: Shortens / pulls uvula
Musculus uvulae
Blood Supply of the Palate
Greater palatine artery
Lesser palatine artery
Venous Drainage of the Palate
Pterygoid venous plexus
Nerve Supply of the Palat
Greater palatine nerve (gingiva, mucous membrane, glands)
Nasopalatine nerve (hard palate)
Lesser palatine nerve (soft palate)
A tissue that attaches your tongue to the floor of the mouth
Lingual frenulum
Opening of Wharton’s duct (submandibular gland)
Sublingual papillae
Openings of the duct of Rivinus (sublingual gland)
Sublingual fold
- Mobile muscular organ
- Partly in oral cavity and pharynx
- At rest, occupies oral cavity proper
- Inferior surface is connected to the floor of the mouth by a median fold of mucous membrane, the frenulum
Tongue
Main functions of the Tongue
- Forming words
- Squeezing food into the pharynx when swallowing
Parts of the Tongue
- Body – anterior 2/3
- Root – posterior third
- Apex – pointed anterior
- Dorsum
o Terminal sulcus – V-shaped groove
o Foramen cecum – small pit
o Lingual papilla – rough anterior mucous membrane
Types of Lingual Papillae
- Vallete - Large and flat topped; Anterior to terminal sulcus
- Foliate - Small lateral folds; Poorly developed
- Filiform - Long and numerous; Contain afferent nerve ending; Sensitive to touch; V-shaped row parallel to terminal sulcus
- Fungiform - Mushrooom-shaped; Apex and sides
DISTRUBUTION OF TASTE SENSATION
Sweetness – tip of the tongue
Saltiness – antero-lateral margins
Sourness – lateral margins
Bitterness – posterior part/ base of the tongue
MUSCLES OF THE TONGUE
- Extrinsic muscle
o Origin is outside the tongue
o Main action: to move the tongue genioglossus, styloglossus, hyoglossus, palatoglossus - Intrinsic muscle
o Superior and inferior longitudinal, transverse, and vertical muscles - Almost all muscles are supplied by Hypoglossal nerve (CN XII) except palatoglossus (CN XI pharyngeal plexus)
Nerve Supply of the Tongue
- Special Sensory
Anterior 2/3: chorda tympani branch of CN VII
Posterior 1/3 and vallate papilla: lingual branch of CN IX - General Sensory
Anterior 2/3: lingual nerve of CN V3
Posterior 1/3: lingual branch of CN IX
- Form the lateral movable walls of the oral cavity
- Buccinator = principal muscle of the cheek
- Pushes food from vestibule into mouth proper
- Blood supply: Buccal branch of maxillary artery
- Nerve supply: Buccal branch of mandibular nerve
CHEEKS
The prominence of the cheek occurs at the junction of the __ regions.
zygomatic and buccal
- Mobile, musculofibrous folds surrounding the mouth
- Connected to the gums by superior and inferior frenula
- Contain the orbicularis oris, superior and inferior labial muscles, blood vessels, and nerves
- Covered by skin (outside) and mucous membrane (inside)
- Function: grasping food, sucking liquids, forming speech, kissing
Lips
- Between nose and opening of oral cavity
- Vermillion border (Indicates abrupt start of transitional zone)
- Nasolabial grooves (Between nose and angle of mouth; Prominent when smiling)
- Philtrum (Intranasal depression (median part of the upper lip))
UPPER LIPS
- Between mouth and labiomental groove
- Labiomental groove (Separates lower lip from chin)
- Labial frenula (Free edged folds of mucous membrane in the midline; Extends from vestibular gingival to mucosa of upper and lower lip)
LOWER LIPS
Upper Lip
Blood Supply: Superior labial branch of facial artery; Infraorbital artery
Nerve Supply: Superior labial branch of infraorbital nerves (of CN V2)
Lymphatic Drainage: Submandibular lymph node
Lower Lip
Blood Supply: Inferior labial branch of facial artery; Mental artery
Nerve Supply: Inferior labial branch of mental nerves (of CN V3)
Lymphatic Drainage: Submental lymph node
Composed of fibrous tissue covered with mucous membrane
Gingiva
Gingiva
- Attached gingiva (gingiva proper) - Firmly attached to alveolar process of jaws and necks of teeth; Pink, stippled, and keratinizing
- Loose gingiva (alveolar mucosa) - Shiny red and non-keratinizing
- Lingual gingiva - Related to tongue
- Hard conical structures
- In alveoli of upper and lower jaws
- Mastication; assisting articulation
TEETH
Chief functions of the teeth are to:
- Incise, reduce, and mix food material with saliva during mastication (chewing)
- Help sustain themselves in the tooth sockets by assisting the development and protection of the tissues that support them
- Participate in articulation (distinct connected speech)
TYPES OF TEETH
- Primary Milk Teeth (Deciduous)
- In children
- 20 in all
- In each side of jaw: 1 medial incisor, 1 lateral incisor, 1 canine, 2 molars - Secondary Teeth (Permanent)
- In adults
- 32 in all
- In each side: 1 medial incisor, 1 lateral incisor, 1 canine, 2 premolars, 3 molars
CHARACTERISTIC TYPE OF TEETH
Incisors – thin flat cutting edge, incise food
Canines – pointed, shearing food, single prominent cones
Premolars – 2 cusps, broader surface, chewing food
Molars – 3 or more cusps, grinding food
PARTS OF THE TEETH
Crown – projects from gingiva
Neck – between crown and root
Root – fixed in the alveolus by periodontium
contains connective tissue, blood vessels, and nerves
Pulp cavity
transmits the nerves and vessels to and from the pulp cavity through the apical foramen
Root canal (pulp canal)
- in the alveolar processes of the maxillae and mandible; the skeletal features that display the greatest change during a lifetime; separated by interalveolar septa
Tooth sockets
The roots of the teeth are connected to the bone of the alveolus by a springy suspension forming a special type of fibrous joint called __
dento-alveolar syndesmosis or gomphosis
- Straight muscular tube
- 23-25 cm long (the length is relative to height of the person)
- Extends from pharynx to stomach
- Propels swallowed food to stomach
- Contains mucous glands for lubrication
- Follows the curve of the vertebral column as it descends
through the neck and posterior mediastinum - Enters stomach at cardia
ESOPHAGUS
Border of Esophagus
Right border – continuous with lesser curvature of stomach
Left border – separated from the fundus of stomach by the
cardiac notch (greater curvature)
Esophagus passes through the elliptical esophageal hiatus in the muscular right crus of the diaphragm, just to the left of the median plane at the level of the __.
T10 vertebra
Esophagus terminates by entering the stomach at the cardial orifice of the stomach to the left of the midline at the level of the __.
7th left costal cartilage and T11 vertebra
Esophagus is attached to the margins of the esophageal hiatus in the diaphragm by the __, an extension of the inferior diaphragmatic fascia. This ligament permits independent movement of the diaphragm and esophagus during respiration and swallowing.
phrenicoesopahgeal ligament
- Located at inferior end of esophagus
- Within esophagogastric junction
- Contracts and relaxes
- When one is not eating, esophageal sphincter is closed to
prevent reflux of food or stomach juices to esophagus - Food momentarily stops here before entering stomach
- Approximately 9 secs – time from swallowing to stomach
ESOPHAGEAL SPHINCTER
- Lies to the left of T11 vertebra on the horizontal plane
that passes through the tip of the xiphoid process - Z line – a jagged line where the mucosa abruptly changes
from esophageal to gastric mucosa
Esophagogastric Junction
SEGMENTS OF ESOPHAGUS
- CERVICAL
- Begins at the lower end of pharynx and extends to the thoracic inlet
- From the level of C6 vertebra to the suprasternal notch 18 cm from incisors; 5 cm long - THORACIC
- The longest part
- Divided into 3: upper, middle, lower
3.ABDOMINAL
- Trumpet shaped
- Passes from the esophagus hiatus in the right crus of the
diaphragm to the cardial / cardiac orifice of the stomach
- The shortest esophageal segment (Only 1.25 cm long)
- Its anterior surface is covered with peritoneum of the greater sac, continuous with that covering the anterior surface of the stomach.
- The posterior part is covered with peritoneum of the omental bursa, continuous with that covering the posterior surface of the stomach.
Thoracic Part of the Esophagus
- UPPER THORACIC - From thoracic inlet to tracheal bifurcation; 18-23 cm from the incisors
- MIDDLE THORACIC - From tracheal bifurcation midway to gastroesophageal junction; 24-32 cm from the incisors
- LOWER THORACIC -From midway between tracheal bifurcation and gastroesophageal junction to GE junction, including abdominal esophagus; 32-40 cm from the incisors
- Aka: Cricopharyngeal constriction or upper esophageal
constriction - It is approximately 15 cm from the incisor teeth.
- Narrowest of the 3 constrictions; 1.5 cm narrow
- The food will most likely lodge here
- At the pharyngoesophageal junction
- Caused by the cricopharyngeus muscle
Cervical constriction
- is also known as broncho-aortic constriction. It is 22.5 cm from the incisor teeth where it is first crossed by the arch of the aorta. It is 27.5 cm from the incisor teeth where it is crossed by the left main bronchus
- Caused by the arch of the aorta and left main bronchus
Thoracic constriction
- is approximately 40 cm from the incisor teeth
- Where it passes through the esophageal hiatus of the diaphragm
Diaphragmatic constriction
Blood Supply (BS): Inferior thyroid artery Venous Drainage (VD): Inferior thyroid vein Lymphatic Drainage (LD): Deep cervical lymph nodes Nerve Supply (NS): Vagal trunks
Upper third of the Esophagus
BS: Descending thoracic aorta branches
VD: Azygos veins
LD: Superior and posterior mediastinal lymph nodes
NS: Thoracic SNS trunks
Mid third of the Esophagus
BS: Left gastric artery branches
VD: Left gastric vein (a tributary of the portal vein)
LD: Left gastric lymph nodes; Celiac lymph nodes
NS: Greater and lesser splanchnic nerves
Lower third of the Esophagus
- Thin transparent serous membrane
- is a continuous, glistening, and slippery transperent serous membrane. It lines the abdominopelvic cavity
- 2 layers:
o Parietal – lining of abdominal wall
o Visceral – covers the viscera
PERITONEUM
- Lines the internal surface of abdominopelvic wall
- Irritation here is often referred to the C3-C5 dermatomes over the shoulder
- Sensitive to pressure, pain, heat, and cold
Parietal peritoneum
- Invests viscera such as stomach and intestines
- Insensitive to touch, heat, cold, and laceration
- Stimulated primarily by stretching and chemical irritation
- The pain produced is poorly localized
Visceral peritoneum
Although intraperitoneal organs may be almost entirely covered with visceral peritoneum, every organ must have an area that is not covered to allow the entrance or exit of neurovascular structures. Such areas are called __
bare areas
- Separates parietal and visceral peritoneum
- Normal: 50 ml
- Lubricates peritoneal surfaces
- Enables viscera to move on each other without friction
Peritoneal Fluid
Intraperitoneal Organs vs Extraperitoneal Organs
Intraperitoneal organs – almost completely covered with visceral peritoneum (stomach, spleen)
Extraperitoneal organs – external to the parietal peritoneum
Retroperitoneal organs vs Subperitoneal organs
Retroperitoneal organs – between the parietal peritoneum and posterior abdominal wall; have parietal peritoneum on their anterior surfaces (kidneys)
Subperitoneal organs – has parietal peritoneum only on its superior surface (urinary bladder)
- Double layer of peritoneum which encloses an organ and connects it to abdominal wall
- Contains fat, lymph nodes, blood vessels, nerves going to viscus
MESENTERY
Mesentery (Named after viscus it attaches)
Stomach: mesogastrium Transverse colon: transverse mesocolon Sigmoid colon: mesosigmoid Appendix: mesoappendix Ovary: mesovarium The small intestine mesentery is usually referred to simple as “the mesentery
Most mobile parts of intestine:
Transverse colon
Small intestine
Absent in retroperitoneal viscus
Ascending colon
Kidney
Parts of duodenum
- Double layered sheet or fold of peritoneum
- Attach the stomach to the body wall or to other abdominal organs
OMENTUM
- Four-layered fatty fold of peritoneum
- Hangs down from the greater curvature of the stomach and proximal part of the duodenum
- Connects stomach with diaphragm, spleen, and transverse colon
- Thin as paper in thin persons; Thick and fat laden in obese persons
- Long enough to cover the whole abdomen (looks like an apron)
- “Policeman of the abdomen” because it organizes the bowel - If this is absent, magiging buhol-buhol ang intestines
- This is also important for preventing the spread of infection
Greater Omentum
- Double-layered peritoneal fold
- Connects lesser curvature of stomach and proximal duodenum to liver
2 portions:
o Hepatogastric ligament – connects liver to stomach
o Hepatoduodenal ligament – connects liver to duodenum
Lesser Omentum
Important structure found in hepatoduodenal ligament:
Portal triad (portal vein, bile duct, hepatic artery)
- Double layer of peritoneum that connects an organ with another organ or with abdominal wall
- May contain blood vessels or remnants of blood vessels
Examples:
o Splenocolic ligament – attach spleen to colon
o Gastrosplenic ligament – attach stomach to spleen
PERITONEAL LIGAMENT
- Reflection of peritoneum with sharp borders
- Often formed by peritoneum that covers blood vessels, ducts and obliterated blood vessels
Example: Umbilical folds
PERITONEAL FOLDS
- Peritoneum folds to form a blind pouches (cul de sacs) of tubular cavities that are closed at one end with an opening into the peritoneal cavity
Examples:
o Retrocecal recess – posterior to cecum
o Ileocecal recess – anterior to cecum
PERITONEAL RECESS (FOSSA)
The __ divides the abdominal cavity into a supracolic compartment and an infracolic compartment.
transverse mesocolon
Supracolic and Infracolic Compartment
Supracolic compartment: stomach, liver, spleen
Infracolic compartment: small intestine, ascending and descending colon
- Divides into smaller spaces by falciform ligament
- Subphrenic recess - Right and left; Between diaphragm and liver
- Hepatorenal recess - Between right lobe of liver and right kidney
Supracolic Compartment
- attaches liver to diaphragm; connects the liver to the anterior abdominal wall.
Falciform ligament
- Divided into right and left by mesentery of small intestine
- Paracolic gutters
o Right – associated with ascending colon
o Left – associated with descending colon
o Important in colon surgery - Paravertebral gutter
o On each side of vertebra
o Continuous with kidney, ureter, part of colon
Infracolic Compartment
- Large compartment; an extensive sac-like cavity
- Between stomach and posterior abdominal wall
- Posterior to lesser omentum and stomach
- Extension of the main peritoneal cavity into the invaginated right side of the dorsal mesentery of the stomach
OMENTUM BURSA
Extension of omental bursa:
- Superior recess
- Limited superiorly by diaphragm
- Where you can see the pancreas - Inferior recess (a potential space only)
- The omental bursa communicates with the greater sac through the __, an opening situated posterior to the hepatoduodenal ligament
- can be located by running a finger along the gallbladder to the free edge of the lesser omentum. It usually admits 2 fingers.
omental foramen (epiploic foramen)
Boundaries of Omental Bursa
Posterior - IVC, Right crus of diaphragm
Anterior- Portal triad
Superior - Caudate lobe of liver
Inferior - Superior part of duodenum, portal triad
- Communication of omentum bursa with main peritoneal cavity
- Posterior to lesser omentum
- Admits 2 digits
Foramen of Winslow
- Larger part of abdominopelvic cavity
- Contains viscera
- Located superior to the pelvic inlet
- Lined by parietal peritoneum
PERITONEAL (ABDOMINAL) CAVITY
Boundaries of the Peritoneal Cavity
Posterior - Vertebral column
Anterior - Abdominal wall
Superior - Diaphragm
Inferior - Continuous with pelvic cavity
- Inflammation of peritoneum
- Underlying causes: Inflammed viscus, Abscess in peritoneal cavity, Spillage of intestinal contents into peritoneal cavity, Trauma of abdomen
- Pain in overlying area
- Rebound tenderness
- There is no pain upon direct palpation of the abdomen.
- There is pain upon release of pressure.
- Reflex increase in tone of anterior abdominal wall muscles
- Spasm of anterior abdominal wall muscles
- There is muscle guarding
PERITONITIS
Location of the Stomach
- Lies between the esophagus and intestines (particularly in the duodenum)
- Occupies the epigastric and umbilical regions
Size, Shape and Position of the Stomach
Can vary according to:
- Body type
Thin individuals: it is elongated vertically (J shaped);
may extend to the pelvis
Obese: it tends to be high and transversely arranged
(steer horn stomach)
- Diaphragmatic movement during respiration
- Stomach’s contents (Empty vs. after a heavy meal)
- Position of the person
*Erect position: the stomach moves inferiorly
*Supine position: it commonly lies in the right and left
upper quadrants or epigastric, umbilical, and left
hypochondrium and flank regions
- Gastric mucosa: reddish brown
- It has gastric folds or rugae
- Gastric canal (at the area of lesser curvature)
Interior of the Stomach
- is reddish brown except in the pyloric part which is pink.
Gastric mucosa
- forms temporarily during swallowing between the longitudinal gastric folds of the mucosa along the lesser curvature. It can be observed radiographically and endoscopically.
- forms because of the firm attachment of the gastric mucosa to the muscular layer, which does not have an oblique layer at this site.
Gastric canal
Anatomic Relation of the Stomach
ANTERIOR - Diaphragm; Left liver lobe; Anterior Abdominal Wall
POSTERIOR - Omental bursa; Pancreas
INFERIOR and LATERAL - Transverse colon
- On which the stomach rests in the supine position
- Formed by:
a. Left dome of the diaphragm
b. Spleen
c. Left kidney
d. Suprarenal gland
e. Splenic artery
f. Pancreas
g. Transverse mesocolon
Bed of Stomach
FUNCTIONS OF THE STOMACH
- Enzymatic digestion (chemical action) – primary function
- Acts as a food blender (mechanical action)
- Stores food; can hold 2-3 L of food
PARTS OF THE STOMACH
- Cardia
- Fundus
- Body
- Pylorus
- Dilated superior part
- Lies posterior to the left 6th rib in the plane of the mid-clavicular line
- Related to the left dome of diaphragm
- May be dilated by gas, fluid and food
- Cardial notch lies bet. esophagus and fundus
Fundus
- Major part of the stomach
- Lies between the fundus and pyloric antrum
Body
Pylorus
- Pyloric part - Funnel-shaped outflow region of the stomach
- Pyloric antrum - Wider part; Leads to the pyloric canal
- Pyloric canal - Narrow part; Cavity of the pylorus
- Pyloric sphincter - Distal sphincteric region of the pyloric part; Marked thickening of the circular layer of smooth muscle; Controls the outflow of gastric contents into the duodenum through the pyloric orifice
- the inferior opening or outlet of the stomach
- is 1.25 cm right of the transpyloric plane
Pyloric orifice
- Midway between the jugular notch superiorly and the pubic crest inferiorly
- Transects the 8th costal cartilages and L1 vertebra
Transpyloric plane
- Forms the lower boundary of body of stomach
- From here, draw a vertical line going to the greater curvature to form the antrum
Angular notch or Incisura angularis
- Longer, convex left border
- Passes inferiorly to the left from the junction of the 5th ICS
and MCL, curves to the right and passing to the 9th or 10th
left cartilage - Continues medially to the pyloric antrum
- It is condense and pass from junction of the 5th ICS to the 9th ICS
- Attaches the greater omentum
Greater Curvature
- Shorter, concave right border
- (+) Angular incisures – indicates the junction of the body and pyloric part of the stomach; lies to the left of midline
- Dito makikita ang gastric canal
Lesser Curvature
(Blood Supply of the Stomach)
- Arises from the Hepatic artery at the upper border of the
pylorus - Runs along the lesser curvature
- Supplies: lower right part of stomach
Right Gastric Artery
(Blood Supply of the Stomach)
- Arises from the Celiac artery
- Descends along the lesser curvature
- Supplies: upper part of stomach, lower third of esophagus
Left Gastric Artery
(Blood Supply of the Stomach)
- Arises from the Gastroduodenal artery of the hepatic artery
- Supplies: stomach along the lower part of the greater
curvature - It suffices the greater omentum
Right Gastro-omental (Gastroepiploic) Artery
(Blood Supply of the Stomach)
- Arises from the Splenic artery
- Supply: stomach along the upper part of the greater
curvature
Left Gastro-omental (Gastroepiploic) Artery
(Blood Supply of the Stomach)
- Arises from the Splenic artery
- Supplies: fundus of stomach
Short and Posterior Gastric Arteries
Venous Drainage of the Stomach
Right and left gastric veins - Drain to the portal vein
Right gastro-omental vein -Drain to the superior mesenteric vein (SMV)
Left gastro-omental vein; Short gastric vein - Drain to the splenic vein
Prepyloric vein - Ascends over the pylorus to the right gastric vein; Used by surgeons in
identifying the pylorus
(Lymphatic Drainage of the Stomach)
- Lymph from the superior two thirds of stomach
- Along the right and left gastric vessels
Gastric lymph nodes
(Lymphatic Drainage of the Stomach)
- Lymph from the fundus and superior part of body of stomach
- Along the short gastric arteries and left gastro-omental vessels
Pancreaticosplenic lymph nodes
(Lymphatic Drainage of the Stomach)
- Lymph from the right two thirds of the inferior third of stomach
- Along the right gastro-omental vessels
Pyloric lymph nodes
(Lymphatic Drainage of the Stomach)
- Lymph from the left one third of greater curvature
- Along the short gastric and splenic vessels
Pancreaticoduodenal lymph nodes
- derived mainly from the left vagus nerve (CN X) usually enters the abdomen as a single branch that lies on the anterior surface of the esophagus
- runs toward the lesser curvature of the stomach where it gives off hepatic and duodenal branches, which leave the stomach in the hepatoduodenal ligament
anterior vagal trunk
- derived mainly from the right vagus nerve, enters the abdomen on the posterior surface of the esophagus and passes toward the lesser curvature of the stomach
- supplies branches to the anterior and posterior surfaces of the stomach. It gives off a celiac branch, which runs to the celiac plexus, and then continues along the lesser curvature, giving rise to the posterior gastric branches.
posterior vagal trunk
The sympathetic nerve supply of the stomach from the __ passes to the celiac plexus through the greater splanchnic nerve and is distributed through the plexuses around the gastric and gastroomental arteries
T6-T9 segments of the spinal cord
- Protrusion of part of the stomach into the mediastinum
through the esophageal hiatus of the diaphragm - Weakening of the muscular art of the diaphragm and
widening of esophageal hiatus
Hiatal Hernia
- Open lesions of the mucosa of the stomach
- High gastric acid secretion reducing the effectiveness of the mucosal lining
- Present in people with chronic anxiety
- Associated with Helicobacter pylori
- Bacteria erode the protective mucous lining of the stomach making it vulnerable to the effects of gastric acid and digestive enzymes
- Erosion into the gastric arteries can cause bleeding
- A posterior gastric ulcer can erode through the stomach wall into the pancreas with erosion of the splenic artery
Gastric Ulcer
- First and shortest part of the small intestine
- Widest and most fixed part
- C-shaped tube; 25 cm long
- Mucous membrane is thick
- First part is smooth
- Remainder is thrown into numerous circular folds called plicae circulares
Duodenum
Location of Duodenum
- Lies in the epigastric and umbilical regions
- Start: Pylorus
- End: Duodenojejunal flexure
- Partially retroperitoneal
The __ occurs approximately at the level of the L2 vertebra, 2-3 cm to the left of the midline. The junction usually takes the form of an acute angle, the duodenojejunal flexure
duodenal junction
FUNCTION OF DUODENUM
Primary site for absorption of nutrients from ingested
materials
PARTS OF THE DUODENUM
- Superior
- Descending
- Horizontal
- Ascending
- Ascends from the pylorus
- Overlapped by the liver and gallbladder
- Proximal part has the hepatoduodenal ligament
- Short (5 cm.)
- First 2 cm. has a mesentery and is mobile (duodenal cap)
- Distal 3 cm has no mesentery and is immobile
- Peritoneum covers its anterior aspect
- Bare of peritoneum posteriorly except the ampulla
Superior Part
- 7-10 cm. long
- Curves around the head of pancreas
- Lies to the right and parallel to the IVC
- Descends along the right side of L1 to L3 vertebrae
- Retroperitoneal
- Bile and main pancreatic ducts enter its posteromedial wall
o These ducts unite to form the hepatopancreatic ampulla,
which opens on an eminence called the major duodenal
papilla located posteromedially - Accessory pancreatic duct opens into the minor duodenal
papilla, which is 1.9 cm above the major duodenal papilla
Descending Part
REMEMBER (Duodenum)
Descending Part
MINOR duodenal papilla is SUPERIOR to the MAJOR duodenal papilla.
Horizontal Part
IVC, aorta – posterior to horizontal part of duodenum
SMA, SMV, mesentery – anterior to the horizontal part
- 6-8 cm long
- Runs transversely to the left passing over the IVC, aorta, and L3 vertebra
- Crossed over by the superior mesenteric vessels and
roots of the mesentery of jejunum and ileum - Anterior surface: covered with peritoneum except where it is crossed by the superior mesenteric vessels and the root
of the mesentery
Horizontal Part
- 5 cm long
- Runs superiorly along the left side of the aorta
- Curve anteriorly to join the jejunum at the duodenojejunal
flexure which is supported by the suspensory muscle of
duodenum (ligament of Treitz)
Ascending Part
- suspensory muscle of the duodenum. This muscle is composed of a slip of skeletal muscle from the diaphragm and a fibromuscular band of smooth muscle from the third
and fourth parts of duodenum. Contraction of this muscle widens the angle of the duodenojejunal flexure, facilitating movement of the intestinal contents.
Ligament of Treitz
(Blood Supply of the Duodenum)
- Arises from the Gastroduodenal artery
- Supplies: duodenum proximal to the entery of bile duct in
the descending part
Superior Pancreaticoduodenal Artery
(Blood Supply of the Duodenum)
- Arises from the Superior mesenteric artery
- Supplies: duodenum distal to the bile duct
Inferior Pancreaticoduodenal Artery
VEINS of the Duodenum
Superior pancreaticoduodenal vein»_space; Portal vein
Inferior pancreaticoduodenal vein»_space; superior mesenteric vein
Nerve Supple of the Duodenum
Vagus nerve (CN X) Greater and lesser splanchnic nerves
Lymphatic Drainage of the Duodenum
Anterior Lymphatic Vessels
- Drain into the prancreaticoduodenal lymph node then into the pyloric lymph node
Posterior Lymphatic Vessels
- Drain into the superior mesenteric lymph nodes
- Inflammatory erosion of duodenal mucosa
- 65% occur in posterior wall of superior part of duodenum,
within 3 cm of the pylorus - Ulcer penetration of the duodenal wall may cause peritonitis
- Erosion of gastroduodenal artery results in severe
hemorrhage
Duodenal Ulcer
JEJUNUM AND ILEUM
- Jejunum – starts at duodenojejunal flexure
- 6-7 m long
- 2/5 – jejunum, 3/5 – ileum
- Coiled
- Covered by greater omentum
- No clear line of demarcation between these two
- Localization is of surgical importance
o There is no clear line of distinction between the two arts but it is important to recognize either segment, especially in performing gastrojejunostomy or tube jejunostomy for feeding.
- Latin jejunus – means empty
- Often empty
- Thicker and more vascular (redder)
- Lies in umbilical region
- Circular folds (Plicae circulares or Valves of Kerckring) of mucous membrane are large and well-developed
JEJUNUM
- Thin and less vascular (less red)
- Lies in hypogastric and right inguinal regions
- Plicae circulares are small in superior ileum and absent in terminal ileum
- Lymph follicles are aggregated as Peyer’s patches located at the anti-mesenteric side
- Site of an outpouching called Meckel’s diverticulum
- Ends at ileocecal junction
ILEUM
- Most common malformation of GIT
- In 1-2% of population
- Finger-like pouch
- Remnant of embryonic yolk stalk
- Same layers as wall of ileum
- May contain gastric epithelium and secrete acid causing ulcer
- 3-6 cm long
- From anti-mesenteric border of ileum
- Within 50 cm of ileocecal junction
- When inflamed, mimics acute appendicitis
MECKEL’S DIVERTICULUM
- Double layer of peritoneum which enclose an organ and connects it to abdominal wall
- Contains fat, lymph nodes, blood vessels, nerves going to viscus
- Suspends jejunum and ileum
- Fan-shaped
- Root (15 cm long) is directed obliquely, inferiorly, and to the right
- Root crosses the following structures:
o 3rd part of duodenum
o Aorta
o IVC
o Psoas major
o Right ureter
o Right gonadal vessels - Consists of 2 layers of peritoneum
- Between are jejunal and ileal blood vessels, lymphatics, and nerves
MESENTERY
Mesentery: Named after viscus it attaches
o Stomach – mesogastrium
o Transverse colon – transverse mesocolon
o Sigmoid colon – mesosigmoid
o Ovary – mesovarium
o Meso + latin/englishh term for the organ
Absent in retroperitoneal viscus: (no mesentery)
o Ascending colon
o Kidney
o Parts of duodenum
ARTERIAL SUPPLY OF JEJUNUM AND ILEUM
- Superior Mesenteric Artery (SMA)
- Branches: Jejunal artery and Ileal artery
- Usually arises from abdominal aorta at the level of L1, approximately 1 cm to celiac trunk
- Runs between the layers of the mesentery, sending L5-L8 branches to jejunum and ileum - Arterial Arcades
- Arteries in mesentery unite
- Shorter and more complex in ileum - Vasa Recta
- Straight vessels which arise from arterial arcades
- Longer in jejunum
VENOUS DRAINAGE (JEJUNUM AND ILEUM)
- Accompanies the SMA
- Crosses 3rd part (horizontal) of duodenum and uncinated process
- Terminates by uniting with splenic vein to become portal vein
Superior Mesenteric Vein (SMV)
LYMPHATIC DRAINAGE (JEJUNUM AND ILEUM)
Juxta-intestinal lymph nodes – located close to the intestinal wall
Mesenteric lymph nodes – scattered along the arterial arcades
Superior central nodes – located along the proximal part of the SMA
NERVE SUPPLY (JEJUNUM AND ILEUM)
Parasympathetic Innervation Vagus nerve (CN X) Stimulates: o Increase motility of the bowel o Increase secretion of intestinal gland o Vasodilation of blood vessels
Sympathetic Innervation Superior mesentery ganglion Stimulate: o Reduce motility of the bowel o Reduce secretion of intestinal gland o Vasoconstriction of blood vessels
Diameter: Large Wall: Thick Plicae circulares: Many Arterial arcade: 1-2 (Few) Vasa recta: Long Fat in mesentery: Less X-ray: Feathery (rough)
JEJUNUM
Diameter: Small Wall: Thin Plicae circulares: Few Arterial arcade: Many Vasa recta: Short Fat in mesentery: More X-ray: Smooth
ILEUM
Remember (Jejunum and Ileum)
Lamang si jejunum sa lahat, pero ang ileum lamang siya sa
arterial arcades and sa fat in mesentery.
- The largest gland; Approximately 1500 g
- Lies in right upper and left upper quadrants (RUQ, LUQ)
o Mainly on the right - Inferior to diaphragm
- Function: Stores glycogen; Secretes bile
- Except for fat, all nutrients absorbed from the digestive tract are initially conveyed to the liver by the portal venous
system - Located in RUQ of abdomen where it is protected by the
thoracic cage and diaphragm - Occupies most of the right hypochondrium and upper
epigastrium and extends into the left hypochondrium
LIVER
An investment of loose connective tissue entering the liver
with the portal vessels and sheathing the larger vessels in
their course through the organ
Glisson’s Capsule
SURFACES OF THE LIVER
The liver has a convex DIAPHRAGMATIC SURFACE (ANTERIOR, SUPERIOR, AND SOME POSTERIOR) and a relatively flat or even concave VISCERAL SURFACE (POSTEROINFERIOR), which are separated anteriorly by its sharp inferior border
- Smooth and dome shaped
- Related to the concavity of the inferior surface of diaphragm
Diaphragmatic
- recess between diaphragm and liver
Subphrenic
- between liver and right kidney
- A gravity-dependent part of peritoneal cavity in supine position
- Fluid draining from the omental bursa flows into this
recess - Communicates anteriorly with the right subphrenic
recess
Hepatorenal
There are left and right subphrenic recesses divided by __
falciform ligament
- The recess between the liver and transverse colon
- Contains the right subhepatic recess and hepatorenal recess
- It is also where the gallbladder lies
- Hepatorenal recess / Hepatorenal pouch
- The posterosuperior extension of subhepatic space
Morison’s pouch
- Inferiorly located and within the lesser sac
- Can be seen by pulling the stomach caudally and
make an incision on the lesser omentum to expose the lesser sac - The portion of the supracolic compartment of the peritoneal cavity that is immediately inferior to the liver
Infrahepatic recess
Ligaments of Liver:
Bare area of liver - Not covered with peritoneum; No glisson’s capsule
Coronary ligament – superior
o Anterior layer – continuous with right layer of falciform
ligament
o Posterior layer – continuous with right layer of lesser
omentum
Triangular ligament – lateral
Falciform ligament – anterior, middle; Cut during exploratory laparotomy
Round ligament – inferior, remnant of umbilical vein
- Covered with peritoneum except at the bed of gallbladder
and porta hepatis - Relations:
o Stomach: gastric impression
o 1st part of duodenum: duodenal impression
o Esophagus: esophageal impression
o Gallbladder
o Right colic flexure: colic impression
o Right kidney: renal impression
o Right adrenal gland: suprarenal impression
Visceral
There are 2 sagitally oriented fissures (linked centrally by the porta hepatis) forms the letter H on the visceral surface:
Right sagittal fissure – continuous groove formed anteriorly by the fossa for gallbladder and posteriorly by the groove for IVC
Left sagittal fissure / Umbilical fissure – the continuous groove formed anteriorly by the fissure for the round ligament and posteriorly by the fissure for the ligamentum venosum
Structures on the visceral surface of the Liver
- Inferior Vena Cava
- Portal triad - Hepatic artery; Portal vein; Hepatic duct
- Caudate lobe
- Quadrate lobe
Caudate vs Quadrate Lobe
Caudate lobe – posterior and superior
Quadrate lobe – anterior and inferior
FUNCTIONAL PARTS
Functionally independent right and left lobes
o Can donate one lobe to relative
o Transplant: sa Philippines, mas prefer and left liver to be donated; sa Taiwan, it’s the right liver
Each lobe has its own:
o Blood supply
o Venous drainage
o Biliary drainage
Division into right and left lobes:
o Gallbladder fossa inferiorly and IVC fossa superiorly
o Falciform ligament (old terminology)
o Line of Cantlie – imaginary line between gallbladder fossa and IVC; hindi nakikita sa radioimaging!
Current Functional Terminology
Left liver = caudate + quadrate + left lobe
Right liver = right lobe
Old Terminology
Falciform Ligament – divides the liver into right and left lobes
Remnant of umbilical vein that carried oxygenated blood from placenta to fetus
Round Ligament (Ligamentum Teres)
- Transverse fissure on visceral surface of liver between caudate and quadrate lobes
- Passage for portal triad, hepatic nerve plexus and lymph
Porta Hepatis
PERITONEAL RELATIONS
Lesser Omentum - From liver to lesser curvature of stomach and 1st part of duodenum - Parts: o Hepatoduodenal ligament o Hepatogastric ligament
Hepatoduodenal Ligament
- Extends between porta hepatis and duodenum
- Encloses the portal triad
Hepatogastric Ligament
- Extends between liver and lesser curvature of stomach
- Magpapasok ng cord sa Foramen of Winslow so mabubutas ang hepatigastric ligament
- Tighten the hepatoduodenal ligament to block the portal triad decrease blood supply to liver
- This is done in surgeries concerning the liver to decrease bleeding
- You can only clamp the ligament for 15 minutes to prevent necrosis of liver tissue
Pringles Maneuver
SEGMENTS OF THE LIVER
- Horizontal plane through right lobe and lateral division of left lobe plus caudate lobe
- Divides liver into 8 vascular segments
- Based on divisions of the hepatic artery, portal vein, and hepatic ducts
- Each segment is supplied by branch of hepatic artery and hepatic duct and is drained by branch of portal vein
- Hepatic veins – divide the liver into 4 divisions
- A horizontal plane through the portal vein divides the 4 divisions into superior and inferior segments
- Segments numbered in clockwise direction starting tat caudate lobe (segment 1)
- Segment 4 is often divided into segment 4a and 4b according to Bismuth.
- The numbering of the segments is in a clockwise manner
- Segment 1 (caudate lobe) is located posteriorly. It is not visible on a frontal view.
SEGMENTAL ANATOMY (COUINAUD SYSTEM)
Segments
I – Caudate II – Lateral superior III – Lateral inferior IVa – Medial superior IVb – Medial inferior V – Anterior inferior VI – Posterior inferior VII – Posterior superior VIII – Anterior superior
- Divides the liver into 8 functionally independent segments
- Each segment has its own vascular flow, outflow, and biliary drainage
- At the center of each segment, there is a branch of the portal vein, hepatic artery, and bile duct
- In the periphery of each segment, there is vascular outflow through the hepatic veins
Couinaud Classification
DIVISIONS OF LIVER
ANATOMIC - 2 lobes
- Divided by Falciform ligament
FUNCTIONAL - 2 lobes
- Left = quadrate + caudate + left anatomic lobe
- Right = right anatomic lobe
- Based on blood supply and venus drainage
SURGICAL - 4 parts
- Right lateral; Right medial; Left lateral; Left medial
SEGMENTS - 8 parts
- Couinauds
- Removal of the right or left liver, without excessive bleeding
- Possible because the right and left hepatic arteries, ducts, branches of the right and left hepatic portal veins do not communicate
Hepatic Lobectomies
- Remove only those segments that have sustained a severe injury or are affected by a tumor
- The right, intermediate, and left hepatic veins serve as guides to the plans between the hepatic divisions
- Each hepatic resection is empirical, requiring ultrasonography, injection of dye, or balloon cathether occlusion to establish the patient’s segmental pattern
Hepatic Segmentectomies
Liver receives blood from 2 sources:
o Portal vein – 70%
o Hepatic artery – 30%
- Formed by union of Superior mesenteric vein (SMV) and Splenic vein
- Ascends anterior to IVC
- Posterior to the neck of the pancreas
- Has right and left branches
- Carries poorly oxygenated but nutrient rich blood from GIT to liver
Portal Vein
- Branch of Celiac artery
- Divides into right and left hepatic artery
- Carries well-oxygenated blood from aorta to liver
- may be divided into the common hepatic artery (from celiac trunk) and hepatic artery proper (from origin of gastroduodenal artery and bifurcation of the hepatic artery).
Hepatic Artery
- Formed by union of central veins of lliver
Intersegmental - Do not run with the structures of the portal triad
- Right, middle, and left hepatic veins drain corresponding thirds of the liver
- All drain into the IVC without an extrahepatic tissue
- Inferior group of small veins from right lobe also drains to IVC
Hepatic vein
HEPATIC VEIN
o Middle hepatic vein – lies in principal plane between right and left lobes
o Left hepatic vein – lies between medial and lateral segments of the left lobe
o Right hepatic vein – lies between anterior and posterior segments of the right lobe
- Major lymph-producing organ
- Occur as superficial lymphatics in Glisson’s capsule and as deep lymphatics in connective tissue that accompany the portal triad and hepatic veins
LIVER
Lymphatics of the Liver
Anterior superficial lymph»_space; hepatic LN»_space; celiac LN – chyle cistern (dilated sac of thoracic duct)
Posterior superficial lymph»_space; phrenic LN»_space; posterior mediastinal LN»_space; thoracic duct
(Liver)
Most lymph is formed in the __ and drains to the deep lymphatics in the surrounding intralobular portal triads.
perisinusoidal spaces of Disse
(Nerve Supply of the Liver)
- Largest derivative of Celiac plexus
- Accompany branches of portal triad to the liver
- Consists of sympathetic and parasympathetic fibers from the anterior and posterior vagal trunks
- Function: vasoconstriction
Hepatic Nerve Plexus
- Produced by hepatocytes
- Yellow fluid
- Stored and concentrated in gallbladder
- Pass to duodenum via bile ducts
- Function: emulsifies fat
BILE
Location of Gallbladder
- Epigastric and right hypochondriac regions
- Inferior surface of liver
- Between quadrate and right lobes
- Pear shaped
- Hollow structure; Thin-walled
- Greenish
- Fundus slants inferiorly to the right
- Attached to liver by loose (areolar) connective tissue
- Peritoneum covers free surfaces
- Normal measurements:
o 7-10 cm long
o 4-6 cm wide
o 30-60 cc of bile
Gallbladder
Remember (Gallbladder)
When the infundibulum is enlarged, it is called Hartmann’s pouch. So technically, they are just the same.
PARTS OF GALLBLADDER
- Fundus - Wide end; Projects from inferior border of liver
- Body - Main part; Contacts the right part of transverse colon and 1st part (superior) of duodenum
- Neck- Narrow, tapered
- Mucosa thrown into spiral fold (Valve of Heister)
- Serves a guide to omental bursa
- Continuous with cystic duct
o 2-4 cm long
o Cystic duct + Common hepatic duct Common bile duct (CBD)
o Mucous membrane thrown into spiral fold
o Typically makes an S-shaped bend and joins the cystic duct
o Passes between the layers of the lesser omentum
BLOOD SUPPLY, VENOUS DRAINAGE, NERVE SUPPLY, LYMPHATIC DRAINAGE OF GALLBLADDER
- Blood Supply
Cystic artery
- From Right hepatic artery - Venous Drainage
Cystic vein - Drains to Right branch of portal vein - Lymphatic Drainage
Hepatic LN - Nerve Supply
SNS: Celiac plexus
PSNS: CN X
Right phrenic nerve – somatic afferent fibers
- Cystic node at neck of gallbladder
- Behind is cystic artery
- Guide for laparoscopic surgeons
Cystic node of Calot
The __ convey bile from the liver to the duodenum.
biliary ducts
Bile Flow
The hepatocytes secrete bile into bile canaliculi»_space; small interlobular biliary ducts»_space; collecting bile ducts»_space; hepatic ducts»_space; right and left hepatic ducts unite to form the common hepatic duct»_space; joined by cystic duct to form the common bile duct
- Drain the liver
- Right lobe»_space; right hepatic duct
- Left lobe»_space; left hepatic duct
Hepatic Ducts
- When right and left hepatic ducts unite; 4 cm; In lesser omentum
Common Hepatic Ducts
- After giving off cystic duct on right
- Cystic duct + Common hepatic ducts CBD
- 8-10 cm long, 5-6 mm wide
- In lesser omentum
- Passes behind 1st part (superior) of duodenum
- CBD + Main pancreatic duct»_space; Hepatopancreatic ampulla »_space; opens into duodenum through the major duodenal papilla
o The circular muscle around the distal end of the bile duct is thickened to form the sphincter of the bile duct (L. ductus choledochus)
o When this sphincter contracts, bile cannot enter the ampulla and the duodenum; hence bile backs up and passes along the cystic duct to the gallbladder for concentration and storage. - Opens into 2nd part (descending) of duodenum
Common Bile Duct (CBD)
Common Bile Duct
- Blood Supply
Proximal: Cystic artery
Middle: Right hepatic artery
Distal: Posterior superior pancreaticoduodenal artery - Venous Drainage
Posterior superior pancreaticoduodenal vein - Drains to portal vein - Lymphatic Drainage
Cystic LN
Hepatic LN
Celiac LN
- supply the retroduodenal part of duct
Posterior superior pancreaticoduodenal artery and Gastroduodenal artery
Cholecystitis vs Cholelithiasis
Cholecystitis – inflammation of gallbladder
Cholelithiasis – stones in gallbladder
Cholelithiasis vs Choledolithiasis
Cholecystolithiasis – stone in gallbladder
Choledolithiasis – stone in CBD
- Intraluminal echogenic projections
- Do not change position with patient
- Must be differentiated from stones
- 1cm – surgery (for possibility of developing malignancy)
- Nakadikit sa wall (immobile)
- Sa imaging, ang purpose ng different position is to determine kung gagalaw or mag-iiba ng position ang mass. Kapag nagchange ng location, means it is a stone. Kapag same location, it means nakadikit sa wall. Therefore, it’s a polyp.
- Number 1 cause is fatty food consumption
POLYPS OF BALLBLADDER
- Often replaces the open-incision surgical method
- The cystic artery commonly arises from the right hepatic artery in the cystohepatic triangle (Triangle of Calot)
- Before dividing any structure and removing the gallbladder, surgeons identify all three biliary ducts, as well as the cytic and hepatic arteries.
- It is usually the right hepatic artery that is in danger during surgery and must be located before ligating the cystic artery.
Laparoscopic Cholecystectomy
- Area formed by the cystc duct, hepatic duct, and edge of liver
o Inferior: Cystic duct
o Medial: Common hepatic duct
o Superior: Inferior surface of liver - The cystic artery will be located in this triangle
Triangle of Calot
- Due to intermittent obstruction of CBD or cystic duct
- Seen in patients with bile stasis
- Produces linear, echogenic interface within gallbladder
- Nonsurgical treatment: Rowachol
VISCID BILE (SLUDGE)
- Diet high in fat produces cholesterol stones inside gallbladder
- After eating, gallbladder contracts. It epels stone which
lodges at cystic duct - Trigger inflammation of gallbladder (Cholecystitis)
- Diagnosed by: History, PE, ultrasound
CALCULOUS CHOLECYSTITIS
- Longstanding impaction of stone at cystic duct
- Remaining bile cannot exit the gallbladder because of
impacted stone - Bacteria will set in
- Abscess forms inside gallbladder
- Gallbladder enlarges, wall thickens
- Clinical: fever, RUQ pain, palpable gallbladder at RUQ
- Common among diabetics and noncompliant patients
EMPYEMA OF GALLBLADDER
- Contacts the right part of transverse colon and 1st part of
duodenum - Chronic cholecystitis (inflammation), body forms connection with:
o Colon: Cholecystocolonic fistula
o Duodenum: Cholecystoduodenal fistula
BODY OF GALLBLADDER
Bounded by: o Posterior: Coccyx o Lateral: - Ischial tuberosity - Sacrotuberous ligament - Overlapped by border of Gluteus maximus
ANAL TRIANGLE
- Lower opening of anal canal
- Nerve supply to surrounding skin: Inferior rectal (hemorrhoidal) nerve
- Lymphatic drainage: Superficial inguinal LN
- Anal verge (Anocutaneous line) - The epithelium is thrown into folds
- Anoderm - Part of anal canal without skin appendages
ANUS
RELATIONS (ANUS)
Posterior: Anococcygeal body
Lateral: Ischiorectal fossa
Anterior:
o Male: Perineal body, urogenital diaphragm, membranous urethra, bulb of penis
o Female: Perineal body, urogenital diaphragm, lower vagina
- 1 ½ in (4 cm) long
- Passes inferiorly and posteriorly
- Divided into upper half and lower half (anatomic anal canal) by the Dentate line / Pectinate line
- The terminal part of the large intestine and of entire digestive canal
- Extends from superior aspect of pelvic diaphragm to the anus
- Usually collapsed, except during passage of feces
ANAL CANAL
Anal Canal
Upper half – visceral; derived from embryonic hindgut
Lower half – somatic; derived from embryonic proctodeum
- Mucous membrane is derived from hindgut ectoderm
- Lined by columnar epithelium
- Thrown into folds
UPPER HALF OF ANAL CANAL
UPPER HALF OF ANAL CANAL
Anorectal line
o 1 ½ cm above the pectinate line
o Identified when the posterior wall appears while withdrawing the proctoscope
o Where the rectum joins the anal canal
o At this point, the wide rectal ampulla abruptly narrows as it traverses the pelvic diaphragm
Anal Columns of Morgagni
o A series of longitudinal ridges
o Contain the terminal branches of the superior rectal artery and vein
Anal Crypts of Morgagni
Anal Valves
o At inferior ends of anal columns
o Superior to the valves are small recesses called anal sinuses
o When compressed by feces, the anal sinuses exude mucus, which aids in evacuation of feces from the anal canal
- Mucous membrane is derived from ectoderm of proctodaeum
- Lined by stratified squamous epithelium
- No anal columns
LOWER HALF OF ANAL CANAL
LOWER HALF OF ANAL CANAL: LANDMARKS
o Hilton’s white line (Intersphincteric line)
- More palpable than visible
- Between internal and external sphincter
o Pecten
- Between Hilton’s line and Dentate line
o Pectinate line / Dentate line
- Comb-like arrangement
- Indicates the junction of the superior part of the anal canal and the inferior part
BS: Superior rectal artery
VD: Superior rectal vein
NS: Hypogastric plexus (Sensitive only to stretching)
LD: Pararectal LN
UPPER HALF OF ANAL CANAL
BS: Inferior rectal artery
VD: Inferior rectal vein
NS: Somatic inferior rectal nerves (Sensitive to pain, touch, temperature; Stimulate contraction of voluntary external anal sphincter)
LD: Superficial inguinal LN
LOWER HALF OF ANAL CANAL
RECTAL VEINS
Superior rectal vein – drains to inferior mesenteric vein
Middle rectal veins – drain to internal iliac veins; mainly drain the muscularis externa of the ampulla and form anastomoses with the superior and inferior rectal veins
- Involuntary
- Formed by the thickening of the circular smooth muscle at the upper end of anal canal
- Surrounds the superior 2/3 of anal canal
- Its contraction is stimulated and maintained by the sympathetic fibers from the superior rectal (periarterial) and hypogastric plexuses
- Its contraction is inhibited by the parasympathetic fibers stimulation through the pelvic splanchnic nerves
- Tonically contracted most of the time to prevent leakage of fluid or flatus
INTERNAL ANAL SPHINCTER
- Voluntary
- Forms a broad band on each side of the inferior 2/3 of the anal canal
- Attached anteriorly to perineal body and posteriorly to the coccyx via the anococcygeal ligament
- Supplied mainly by S4 through the inferior rectal nerve
EXTERNAL ANAL SPHINCTER
- Part of levator ani muscle
- Blends with deep part of external anal sphincter to form anorectal ring
Puborectalis
- Aka: Ischioanal fossa
- Wedge-shaped
- Contents: Dense fat; Pudendal nerve; Internal pudendal vessels
ISCHIORECTAL FOSSA
Levator ani muscle is composed of 3 muscles:
1. Puborectalis o Contributes to normal position of anus o Parang sling na nakakabit sa pubis 2. Pubococcygeus 3. Iliococcygeus
- Varicosities of the tributaries of superior rectal veins
- Lie in anal columns at 3, 7, and 11 o’clock position when patient is in lithotomy position
o Discussed during lab: Kapag naka-prone or Jack knife position, the internal hemorrhoid is at 1, 5, and 9 o’clock
position.
Causes:
o Congenital weakness of vein walls
o Gravid uterus
o Portal hypertension
o Constipation
INTERNAL HEMORRHOIDS
INTERNAL HEMORRHOIDS: DEGREE
1st degree - Contained within the anal canal
2nd degree - Extruded from the canal upon defecation, but return at the end of act
3rd degree - Prolapse on defecation but remains outside the anus, but can be reduced
4th degree - Remains outside the anus on defecation and cannot be reduced
- Varicosities of inferior rectal veins
- Associated with well-established internal hemorrhoids
- Sa lower half ng anus
- Kapag external, masakit dahil sa somatic muscle
EXTERNAL HEMORRHOIDS
- Intersphincteric abscess
- Perianal abscess (Abscess formed in the glands of the anal crypts)
- Ischiorectal abscess (In ischiorectal fossa)
- Horseshoe abscess
o From ischiorectal fossa to post-anal space
o Kabilaan siya, semicircular
o Tumatagos sa papunta sa kabila through the post-anal space - Pelvirectal (supralevator) abscess (Above the levator ani muscle)
ANAL ABSCESS
- Developed as a result of spread or inadequate treatment of anal abscess
- Internal opening: Inside the lumen
- External opening: Perianal skin
FISTULA IN ANO
o External opening situated behind the transverse anal line will open into the anal canal in the midline posteriorly. An interior opening is usually associated with a radial tract.
o Kapag ang external opening ay nasa posterior, ang internal opening ay dapat nasa midline posterior. Ang line niya papuntang internal opening ay magiging curve para makapunta siya sa gitna.
o Kapag ang externa opening ay nasa anterior, ang line papuntang internal opening ay straight lang. Hindi kailangan sa midlne. Pwede sa any point sa internal opening.
o EXCEPTION: Kapag ang anterior external opening ay more than 3 cm from anal verge, ang internal opening niya ay nasa posterior midline na!
Goodsall’s Rule
Treatment: FISTULA IN ANO
Fistulotomy – hihiwain ang skin until sa tract para magheal
Before ang treatment ay Fistolectomy (tatanggalin ang buong fistula). Hindi na ginagawa kasi nadadamay ang sphincter (natatanggal) kaya nawawalan ng anal control
- Usual location: 6 o’clock position
- Associated with anal sentinel pile - Cause: high sphincteric tone – compresses the anal vessels resulting to fissure
- Treatment: lateral internal anal sphincterotomy
ANAL FISSURE
Imperforate anus
o Walang butas ang pwet
o Yung ibang babies nagkakaroon ng fistula kapag pinanganak
o Oligohydramnios
- Decreased ang amniotic fluid sa uterus
- May problem sa excrete ng amniotic fluid from the body
Diagnostic: Invertogram (X-ray na nakatuwad; Makikita mo yung air; Kapag malayo ang inabot ng air from the anus, pwede magcolostomy.)
Trauma (Impalement) - Any foreign object na nakatusok
CONGENITAL ANOMALY
- Aka: Vermiform appendix (L. vermis, wormlike)
- Blind intestinal diverticulum
- 6-10 cm long
- Contain masses of lymphoid tissue
- Arises from posteromedial aspect of cecum below ileocecal junction
APPENDIX
- triangular mesentery
- It’s the fatty portion. When you hear the word mesentery it is associated with blood supply and venous drainage because that’s where your arteries and veins will course through.
- Derived from the posterior side of the mesentery of the terminal ileum
- Attaches to the cecum and proximal part of the appendix
Mesoappendix
DIFFERENT POSITIONS OF THE APPENDIX
- Retrocecal – most common
* YOU MUST REMEMBER THIS. In clinical practice, this is what frequently occurs. 64% of patients/people may have a retrocecal appendix and the rest would be pelvic. - Pelvic - 2nd most common type (32%)
- Pre-ileal
- Sub-cecal
- Post-ileal
* Pre-ileal, sub-ileal and post-ileal are the rare types.
APPENDIX
Blood supply: Appendicular artery
Venous drainage: Appendicular vein
Lymphatic drainage: Ileocolic LN
Nerve supply
SNS: Superior mesenteric plexus
PSNS: CN X
- SMA»_space; Ileocolic artery»_space; Appendicular artery
- The most vascularized part of the appendix is the tip.
- S/sx: RLQ pain
- McBurney’s point
- Maximal point of tenderness
- Oblique line from right ASIS to umbilicus
o ASIS – anterior superior iliac spine - Distal end of outer third
- Approximates location of appendix
- Approximates placement of incision
Acute Appendicitis
Physical findings (Acute Appendicitis)
RLQ tenderness
- Visceral referred pain
- T10 sympathetic ganglion
Psoas sign
- Stretching of Psoas by right thigh extension causes pain
- Usually naka-bend. Side-lying to minimize the pain
Obturator sign
- Stretching of obturator internus by internal rotation causes pain
- Internal rotation – patient lie supine and bend their legs
Appendicitis: Causes
o Enlarge lymph node
o Fecalith
Nagbara yung dumi sa loob. Stool becomes stone-hard
o Young people: usually caused by hyperplasia of lymphatic follicles in the appendix that occludes the lumen
o Older people: the obstruction usually results from a fecalith, a concretion that forms around a center of fecal matter
Appendicitis
Treatment: Appendectomy (may be open or laparoscopic)
Incision: McBurney’s / Rocky-Davies
o Locate appendix: trace taenia coli towards posteromedial area of cecum which ends as appendix
o Ligate Appendicular artery and vein (branch of Ileocolic artery and vein)
Complication:
Perforation
- At midportion (because it has the least blood supply) – MUST KNOW!
- Spreads infection to parietal peritoneum
- Greater omentum adheres to appendix to restrict spread of infection
- Consists of: o Cecum o Ascending colon o Transverse colon o Descending colon o Sigmoid colon
- encircles the small intestine, the ascending colon lying to the right of the small intestine, the transverse colon superior and/or anterior to it, the descending colon to the left of it, and the sigmoid colon inferior to it.
COLON
CHARACTERISTICS OF LARGE INTESTINE
- Taenia Coli - 3 thickened band of muscle
- Comprise longitudinal muscle of large intestine
- Absent in appendix and rectum
- Start: Base of appendix
- End: Rectosigmoid junction - Haustra - Sacculations between taenia
- Epiploic Appendices - Fatty projections of omentum
- Internal Diameter - Larger than the small intestines
3 Taenia
Omental – the greater omentum has to be dissected before makita yung omental; to which the omental appendices attach
Free – easy to identify; to which neither mesocolons nor omental appendices are attached
Mesocolic – kailangan i-lateralize mo yung colon para makita mo yung mesocolic; to which the omental appendices attach
- 1st part of large intestine
- Continuous with ascending colon
- About 7.5 cm; Located at RLQ
- Lies in iliac fossa inferior to the terminal ileum
- Palpable at abdominal wall if distended with gas or feces (mostly its gas rather than fecal contents)
- Enveloped by peritoneum
- Can be lifted freely
- Has no mesentery
o No mesentery – not well-vascularized kaya pag nabutas ang cecum, the concern is healing. It’s not gonna heal well
o Because of its relative freedom, it may be displaced from the iliac fossa - Attached to lateral abdominal wall by cecal folds
- Receives the terminal ileum obliquely
- Folds at ileocecal orifice form the ileocecal valve
CECUM
2 forms of ileocecal valve:
Papillary – common
Labial – folds meet laterally to form ridges called frenulum
Cecum
Blood supply: Ileocolic artery - Branch from SMA Venous drainage: Ileocolic vein Lymphatic drainage: Ileocolic LN Nerve supply SNS: Superior mesenteric plexus PSNS: CN X
- Circular muscle poorly developed around orifice
- Not a true sphincter
- Does not control passage of intestinal contents from ileum into the cecum
- Does not prevent reflux of intestinal contents from cecum back to ileum
Ileocolic Valve
- Passes superiorly on right side of abdominal cavity from the cecum to the right lobe of liver (One of the two parts of the colon that lies retroperitoneally, the other one is the descending colon)
- Turns to left below liver at Right colic flexure or Hepatic flexure
o Lies deep to the 9th and 10th ribs
o Overlapped by the inferior part of the liver
Narrower than cecum - Lies retroperitoneally on the right side of posterior abdominal wall
- Covered by peritoneum anteriorly and on its sides
- Separated from the anterolateral abdominal wall by the greater omentum
ASCENDING COLON
- a deep vertical groove lined with parietal peritoneum that lies between the lateral aspect of ascending colon and the adjacent abdominal wall (nasa gilid ng ascending colon, in between nila ng wall)
Right paracolic gutter
- 45 cm long
- Largest, most mobile
- Crosses abdomen from right colic flexure to left colic flexure
- Left colic flexure or Splenic Flexure – more superior, more acute, less mobile compared to right, below the spleen
o It lies anterior to the inferior part of the left kidney and attaches to the diaphragm through the phrenicocolic ligament - Transverse mesocolon
o Mesentery of transverse colon
o Loops down to pelvis
o Adherent to the posterior wall of the omental bursa - Variable in position
o Usually hanging to the level of the umbilicus
o Tall thin people: may extend into the pelvis
TRANSVERSE COLON
- From left colic flexure to sigmoid colon
- Located on the left side
- Retroperitoneal (It’s covered with peritoneum on its anterior and lateral sides)
- Has a short mesentery
- Has a paracolic gutter (left) on its side
- Passes anterior to the lateral border of the left kidney
DESCENDING COLON
- S-shaped loop
- 40 cm long
- Connects descending colon and rectum
- Has long mesentery (sigmoid mesocolon)
- Has considerable degree of freedom
- Termination in taenia coli indicates rectosigmoid junction (approximately 15 cm from the anus)
- Have long omental appendices
- Roof of sigmoid mescolon – inverted V-shaped attachment
- Various positions
- Twisting of root can cause obstruction
SIGMOID COLON
Ascending Colon
Blood Supply: Ileocolic artery; Right colic artery - Branch of SMA
Vein: Ileocolic vein; Right colic vein - Tributary of SMV
LD: Ileocolic LN; Right colic LN; Superior mesenteric LN
NERVE: Superior mesenteric nerve plexus
TRANSVERSE COLON
Blood Supply: Middle colic artery - Branch of SMA
Vein: Middle colic vein - Tributary of SMV
LD: Middle colic LN
NS: Superior mesenteric nerve plexus
DESCENDING AND SIGMOID COLON
BS: Left colic artery; Sigmoid arteries - Branch of IMA
Vein:Left colic vein; Sigmoid vein - Tributary of IMV
LD: Left colic LN; Sigmoid LN; Inferior mesenteric LN
NS:
SNS: Inferior mesenteric ganglion
PSNS: Inferior hypogastric plexus, Pelvic splanchnic nerves
The ileocolic and right colic arteries anastomose with each other and with the right branch of the middle colic artery, the first of a series of anastomotic arcades that is continued by the left colic and sigmoid arteries to orm a continuous arterial channel, the __.
marginal channel (juxtacolic artery)
Key Points (Appendix and Colon)
- Blood supply and venous drainage
o Appendix, right colon, transverse colon – SMA
o Left colon, sigmoid colon - IMA - Ileocecal valve permits 2-way passage (incompetent ileocecal valve)
- 3 taenia coli: none in appendix and rectum
- Lymph nodes grouping follow blood vessels (veins in particular)
- MBurney’s point is very useful for clinicians
- May involve any segment
- Diagnostic tests:
o Barium enema – x-ray of colon
o Colonoscopy – direct visualization
o CT scan with oral and IV contrast - S/sx:
o Decreased size of stools
o Constipation
o Blood in stools - Treatment: colon containing the cancerous mass is resected including its blood supply, venous and lymphatic drainage
Colon Cancer
Segment: Ascending colon
Surgery: Right hemilectomy
Ligated Vessels: ___
Ileocolic
Right colic
Middle colic
Segment: Transverse colon
Surgery: Transverse colectomy
Ligated Vessels: ___
Right colic
Middle colic
Left colic
Segment: Descending colon
Surgery: Left hemilectomy
Ligated Vessel: __
Left colic
Segment: Sigmoid colon
Surgery: Sigmoidectomy
Ligated Vessel: __
Sigmoid
- Has a long mesentery; Very mobile
- Can be visualized with sigmoidoscope
- 25 cm from the anus
- Common site of large intestinal obstruction as:
o Valvulus – twisting of mesosigmoid
o Cancer – most common site
o Diverticulitis – connects to urinary bladder from fistula
o Fecal impaction – among the elderly
Sigmoid Colon
- Chronic inflammation of the colon
- Characterized by severe inflammation and ulceration of the colon and rectum
- Colectomy may be performed
- Ileostomy is then constructed to establish a stoma, an artificial opening of the ileum through the skin of the AAW
- Colostomy or sigmoidostomy is performed to create an artificial cutaneous opening for the terminal part of the colo
Colitis (Crohn Disease)
- A disorder in which multiple false diverticula (external evaginations or outpocketings of the mucosa of the colon) develop along the intestine
- Primarily affects middle-aged and elderly people
- Commonly found in the sigmoid colon
- They can distort and erode the nutrient arteries, leading to hemorrahage
- Diets high in fiber have proven beneficial in reducing the occurrence of diverticulosis
Diverticulosis
- Rotation and twisting of the mobile loop of sigmoid colon and mesocolon
- Results in obstruction of the lumen of the descending colon and any part of sigmoid colon proximal to the twisted segment
- Constipation and ischemia occur and may progress to fecal impaction (an immovable collection of compressed or hardened feces) and possible necrosis if untreated
Volvulus of Sigmoid Colon
- Pelvic organ
- Rectosigmoid junction (Superiorly lies at S3 vertebra)
- Peritoneal covering
o Superior 1/3: anterolateral surface
o Middle 1/3: anterior only
o Inferior 1/3: none (subperitoneal) - Sacral flexure
o Follows curve of sacrum and coccyx - Anorectal flexure
o End of rectum and beginning of anal canal
o Fecal continence - S-shaped on lateral view
- The fixed terminal part of the large intestine
- Continuous with the sigmoid colon at the level of S3 vertebra
RECTUM
- 3 sharp lateral flexures
- Transverse folds:
o Superior (on the left)
o Middle (on the right)
o Inferior (on the left) - Overlie thickened parts of circular muscle layer of rectal wall
*Rectum is 15-17 cm from the anal verge. Beyond that it’s the colon na.
Valves of Houston
- Dilated terminal part
- Supported by pelvic diaphragm
- Relax and receive fecal mass
- “Fecal reservoir
Rectal Ampulla
(MALE PELVIS) Peritoneal reflection from anterior rectum to posterior wall of urinary bladder - Related organs o Fundus of gallbladder o Terminal part of ureter o Ductus deferentes o Seminal vesicles o Prostate gland
Rectovesical Pouch
(FEMALE PELVIS)
- Cul-de-sac of Douglas
- Peritoneal reflection from rectum to posterior wall of vaginal fornix
Rectouterine Pouch
