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pancrease and spleen Flashcards

1
Q

what pancrease?

A

retroperitoneal gland/organ

lobulated organ extend from the :

Curve of duodenum to the hilus of the spleen

EXOCRINE + ENDOCRINE

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2
Q

what is the location of pancrease?

A

Epigastrium

Left hypochondrium

DEEP IN the abdominal wall– POSTERIOR TO STOMACH and omental bursa

it extends posteriorly and superiorly (from duodenum to hilum of spleen which mean the spleen is at a higher lvl than pancreas )

its not palpable

less likely to accessible to trauma ( BUT ITS VERY CLOSE TO VERTEBRALE and trauma to vertebral body could severely injure it or crush it )

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3
Q

is pancrease seen on Cross sections ?

A

Cuz the pancreas usually slops upwards its whole length is not necessarily seen on one axial section ( deep and retroperitoneal )

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4
Q

What is the vertebral lvl of pancreaS?

A

L1

L2

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5
Q

parts of pancreas?

A

Head

Neck

Body

Tail

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6
Q

what is the neck of pancreas anterior to?

A

anterior to the portal vein

the portal vein forms behind it by the joining of the splenic vein and superior mesenteric vein

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7
Q

describe the head of pancreas ?

A

2 surfaces ( anterior and posterior )

4 borders ( Superior , inferior , right and left )

1 process : Uncinate

Flattened in shape

Located within the duodenal curve –> thats where you would see the uncinate process ( extending from the head )

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8
Q

what does the uncinate process extend to?

A

posteriorly and wraps around the MESENTERIC VESSELS

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9
Q

describe the neck of pancreas ?

A

2 surface —> Anterior an posterior

2 borders —> Upper and lower

Crucial region where portal vein forms

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10
Q

describe body of pancreas ?

A

triangular tube

extends across the midline

3 borders : Anterior, superior , inferior ( like triangular )

3 surface : Anterior, posterior and inferior ( like toblerone chocolate bar )

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11
Q

what does the body of pancreas extend in front of?

A

aorta, left kidney

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12
Q

what does the anterior shard border attach to?

A

Attachment site for TRANSVERSE MESOCOLON REFLECTION

which help anchor pancreas in its location

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13
Q

what are the peritoneal relation of pancreas?

A

its retroperitoneal ( behind peritoneum )

Receives attachment for transverse mesocolon ( At the anterior border of body )

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14
Q

what is the body relation to peritoneum ?

A

Superiorly —> LESSER SAC ( omental bursa , cuz it peritoneal layer reflects posteriorly onto abdominal wall b4 ascending will not continue descending down )

Inferiorly —> Greater sac ( main peritoneal cavity )

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14
Q

which part of pancreas mobile?

A

Tail is relatively mobile

cuz it lies with the splenic vessels within :

LEINORONEAL LIGAMENT –> reaches the hilus of the spleen

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15
Q

what is leinorenal ligament?

A

AKA splenorenal ligament

Ligament connects the SPLEEN to the LEFT KIDNEY

Contains important structure INCLUDING :

tail of pancreas and SPLENIC VESSELS

support spleen and provide passage for vessels between these organs

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16
Q

what is the postero-superior surface relation of the HEAD?

A

bile duct

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17
Q

what is the posterior surface relation of the NECK?

A

portal vein

cancer of neck and head of pancreas may cause portal or inferior venacaval obstruction

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18
Q

what happens if we pinch the bile duct, common hepatic artery ,portal vein?

A

we are compressing hepatoduodenal ligament

located near epiploic foramen ( omental )

which connects the greater and lesser sac of the peritoneal cavity

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19
Q

what is the clinical significance of epiploic foramen ?

A

Hernias and tumors in this region need to be treated CAREFULLY cuz :

When moving posteriorly = IVC ( right behind the foramen )

the common hepatic artery and portal veins and bile duct are anterior to the EPIPLOIC FORAMEN

tumor anteriory will compress these leading to jaundice ( bile flow ), impaired liver blood supply

IF tumor posteriorly will compress IVC and lead to venous congestion and lower limb swelling

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20
Q

describe man pancreatic duct? duct of wirsung

A

HERRING BONE PATTERN ( has branches )

Begins at the tail traversing of the length of gland

Receive smaller ducts ( receiving small tributary duct )

In the HEAD of pancreas :

JOINS THE BILE DUCT to form : DILATED HEPATOPANCREATIC AMPULLA OF VATER

then ampulla opens at the summit of the major duodenal papilla ( secrete bile for fat digestion ) —> its at the second part of the duodenum

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21
Q

describe accessory pancreatic duct ? of santorini ?

A

when they are present

they drain the head and uncinate process

May open separately into duodenal proximal to the main duct

The main and accessory ducts usually COMMUNICATE

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22
Q

what are the sphincters of pancreatic duct?

A

Smooth muscles that control bile and pancreatic juices into duodenum

they surround : Bile duct (sphincter of boyden ) and Hepatopancreatic ampulla of vater ( Sphincter of ODDI )

but b4 that, the muscles surround each duct individually ( Hepatic duct alone and pancreatic duct alone ) then when they join the sphincters also join

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23
Q

what happens in gallstone lodged in ampulla ?

A

lodging of the ampulla lead to

Spasms of hepatopancreatic sphincter
—->

Reflux of bile back into pancreatic
—> Activation of digestive enzymes within the pancreas —>

Pancreatitis

but if the accessory pancreatic duct ( santorini ) connect with the main duct it might compensate for the obstruction ( bile goes to tthem then to the duodenum )–> prevent significant pancreatic damage

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24
what happens in cases of pancreatic cancer?
Cases of extra-hepatic obstruction of biliary duct retention bile Enlargement of the gallblladder and obstructive jaundice
25
what happens when pancreas ruptures ?
tears the duct system Allowing pancreatic juices (digestive enzymes ) to enter : PARENCYHMA OF THE GLAND and invade adjacent tissues causing their digestion leading to autodigestion and severe inflammation can happen during vertebral column severe injury like car accident/falls
26
what is the blood supply of pancreas?
Celiac trunk : Superior pancreaticoduodenal artery ----> HEAD AND BODY Superior mesenteric artery : Inferior pancreaticoduodenal artery --> HEAD AND BODY HEAD AND BODY anterior and posterior from the anastomoses of super and inferior pancreaticoduodenal Splenic artery :( runs in a tortuous course along the superior border of pancreas ) Pancreatic branches ---> BODY AND TAIL
27
what is the venous drainage of pancreas?
Corresponds to arteries and drain into : Superior mesenteric Splenic vein ( in thormbosis can lead to portal hypertension and gastric varies + SPLENOMEGAY ) Trunk of portal vein ( pancreas cancer metastasize via portal vein )
28
what is the lymphatic drainage of head and neck?
drain into : Ventral Drosal pancreatico duodenal lymph nodes
29
what is the lymph drainage of body and tail?
Drain into : Pancreatic- splenic lymph nodes Ultimately drain into CELIACL and SUPERIOR MESENTERIC lymph nodes for all of the pancreas pancreatic cancer metastasize to relatively inaccessible lymph nodes
30
what is the sympathetic nerve supply of pancreas?
Derived from : Greater ( celiac ) Lesser splanchnic ( Superior mesenteric ) Pain fibers ACCOMPANY the SYMPATHETIC supply so that pancreatic pain may radiate to DISTRIBUTION OF THORACIC DERMATOMES
31
what is the parasympathetic nerve supply of pancreas ?
Vagus nerves Secretory activates of exocrine pancreas are partly controlled by nerves and partly by hormones ( Secretin and pancreozymin )
32
What is pancreatectomy ?
Anatomical relationships and the blood supply of head of the pancreas , bile duct and duodenum make it IMPOSSIBLE to remove the head of pancreas ( cuz bile and duodenum and it all share a blood supply ) Usually a rim of the pancreas is retained along the medial border of the duodenum to preserve the duodenal blood supply we do partial pancreatomy
33
what is annular type of head of pancreas?
head encircling the duodenum - duodenal obstructions
34
what location of spleen?
Left upper quadrant or Left hypochondrium
35
wheres the axis of spleen?
lies obliquely beneath the 9, 10,11 ribs PROTECTED BY 9-12 RIBS
36
what can injure the spleen?
its protected by 9-12 ribs BUT FRACTURE of them will injure it Blunt trauma in this region - impact of handlebars of motorbine Can tear the thin capsule of spleen leading to profuse BLEEDING Repair of ruptured spleen is difficult Hence why splenectomy is performed to stop bleeding
37
what is the extension of spleen?
Normally the spleen doesnt extend inferior to the left costal margin thus it is not palpable through the anterior abdominal wall unless its enlarged approx 3 its normal size 1 inch thickness , 3inch breadth, 5 inch length 7 oz - weight
38
what are the ends of spleen?
posterior Anterior Anterior ---> Flatter cuz its related to the transverse colon and descending colon ( splenic flexure ) Posterior end- --> SHARPE extending toward the vertebral column
39
what are the borders of spleen?
Superior Inferior Superior --> May have notches which can be palpable in splenomegay Inferior --->More rounded and less PROMINENT Intermediate border --> EXTENDS POSTERIORLY TO THE HILUM AND DOESNT REACH THE ANTERIOR SURFACE
40
what are the surfaces of spleen?
Diphragmatic and visceral hilus Diaphragmatic ( outer ) --> SMOOTH cuz lies against the diaphragm Visceral hilus ( Medial ) ---> Rough cuz it at the presence of hilum where we find the vessels
41
what is anterior basal angle?
Junction between : Superior border and Anterior end Most anteriorly projecting part of the spleen Located in the 9TH INTERCOSTAL SPACE , little behind the left mix axillary line When spleen is enlarged 2-3 times from normal size , the angle becomes palpable ---> AKA CLINICAL ANGLE OF SPLEEN
42
what are the impressions of the spleen ?
Stomach Left kidney and Suprarenal gland Splenic flexure of colon Tail of pancreas These are on the visceral hilus surface ( MEDIAL )
43
describe the notches ?
Superior border of the spleen is often notched when spleen is enlarged its notched Superior border lies inferomedially The notched border is helpful when palpating an enlarged spleen During embryonic development , the spleen begin as multiple small nodules ---> NODULES gradually fuse to form a single organ During it superior border may develop notches , which are remnants of OF INCOMPLETE FUSION
44
what are the visceral surface relation to?
Stomach --> anteriorly Left kidney and supra renal gland --> posteriorly Splenic flexure of the colon = inferiorly Tail of pancreas which lies in the lienorenal ligament reach as far as the hilus
45
what can happen during splenectomy ?
Tail of pancreas contain higher concentration of islets of langerhan which produce insulin during splenectomy Accidental damage to the pancreatic tail can occur --> REDUCE INSULIN PRODUCTION --> Post splenectomy diabetes
46
what are the relations on the diaphragmatic surface?
the diaphragm it separates the spleen surface from THE : Left pleural sac ( costo diaphragmatic recess ) The lung 9,10,11 ribs ( fractures of these ribs can lacerate the spleen ) the costo diaphragmatic recess extend to the lvl of the 10th rib in the mid axillary line
47
at what lvls you should do spleen procedures?
Below 9th rib angled carefully to prevent pleural injury
48
what are the variations in portal vein imaging ?
Inferior mesenteric vein is a tributary of superior mesenteric vein instead of joining the splenic vein like normally , it joins the superior mesenteric vein Results in PORTAL HYPERTENSION resulted in the visualization of esophageal varcies
49
what is the peritoneal relation of spleen ?
Spleen is invested peritoneum and suspended at its HILUS by : ( covered wholy except at the hilum ) Leinorenal ligament Gastro-splenic ligament Lei-renal ligament contain ( splenic vessels, and tail of pancreas ) the leino-renal and gastro-splenic ligament form the lateral limit of the OMENTAL BURSA ( so if we are in the lesser sac we cannot go to the left side due to these ligaments ) rupture of the spleen results in severe intra-peritoneal hemorrhage ( blood will pool in the lesser sac and can go to greater via EPIPLOIC FORAMEN) and spleen will need to be removed
50
What is wandering spleen?
very rare caused by : loss/weakening/malformation of the ligaments that help keep the spleen located in the upper left part of the abdomen Symptoms include : Enlargement in the size of the spleen or change in spleen original position to another location , usually either other parts of the abdomen or into pelvis this ability to move to other locations commonly attributed to the SPLEENS pedicle being abnormally log Blocking of the arteries and torsion in the spleen can also result in abdominal pain or swelling Treatment : splenopexy, fixation of the spleen but if theres no blood flow after unwinding the spleen then splenectomy must be performed
51
what is the blood supply of spleen?
Largest branch of celiac trunk Follows tortuous course along the superior border ( BODY ) of the pancreas Enters the lienorenal ligament where divides into branches that enter the hilum Gives off short gastric branch + left gastro epiploic
52
describe splenic vein?
emerges from the several tributaries at the hilum of the spleen Lies POSTERIOR to the tail and body of the pancreas at a LOWER level than artery Unites with the superior mesenteric vein posterior to the neck of pancreas to form portal vein RECEIVES INFERIOR MESENTERIC VEIN ( unless variation ) + Left gastro-epiploic vein, short gastric vein
53
what are the histological structure ?
1- Stroma ( provide support and framework ) 2- Parenchyma ( Splenic lobules ) -->functional components )
54
what are the components of stroma ?
Capsule Trabeculae Reticular network
55
what are the components of the parenchyma of spleen?
White pulp --> Malpighian corpuscle Red pulp White pulp = involved immune function ( rich in lymphocytes ) Red pulp = filtering blood , removing old RBC, storing platelets
56
describe the capsule?
part of stroma : Thick fibrous connective tissue containing elastic fibers and smooth muscles fibers Covered by peritoneum
57
describe the trabeculae ?
part of the stroma : Arise from hilum of the spleen Fibrous connective tissue containing -- SMOOTH MUSCLE FIBERS ( cuz the spleen act as blood reservoir its needs mechanism to control blood flow efficiently hence need the muscles to control blood flow ) Divide the spleen, into incomplete inter communicating splenic lobule THE CAPSULE AND TRABECULAE CONTAIN BLOOD VESSELS AND NERVES --> After vessels enter the hilum they flow branching pattern through the trabeculae before supplying and draining the parenchyma
58
describe reticular network?
Similar to lymph nodes
59
what is a pulp?
Interior component of the spleen Upon gross examination of a slice of the of the spleen the pulp has 2 different appearances , red and white the organ appear as a large expanse of red pulp and white
60
why is the red pulp red?
large numbers of ERYTHROCYTES IN BLOOD vessels called sinuses
61
what is white pulp?
Due to lack of these sinuses and cuz no sinuses no blood , less erythrocytes
62
describe what happens when artery come enter spleen?
Splenic artery Travel within a trabeculae Give rise to CENTRAL ARTERIES which is SURROUNDED by WHITE PULP ( rich in T lymphocytes )---> security for the artery Central arteries branch into penicillar arterioles Penicillar arterioles art is surrounded by MACROPHAGE Penicillar arterioles open into SINUSOIDS ---> within REDPULP ---> AS ELLIPSOID ( thickened capillaries are surrounded by reticular fibers and macrophages ) from which blood can escape into red pulp -- ALSO SURROUNDED BY MACROPHAGES Blood enters red pulp SINUSOIDS space where RBC and lymphocytes interact with macrophage for filtration and immune surveillance ( macrophage is there to remove RBC ) Then from SINUSOID blood is drained by Red Pulp VEIN to TRABECULAR VEIN , to the splenic VEIN
63
describe white pulp?
is made of lymphocytes that surrounded arterioles like cords ( Central and penicillar ) At places the cords are thicker than elsewhere and contain lymphatic nodules bodies --> MALPIGHIAN LYMPH NODES Eccentrically placed arteriole
64
what is malpighian bodies ?
Is lymphatic follicle ( nodule ) with central artery of white pulp which ECCENTRICALLY in position They scattered allover the spleen may contain germinal layer
65
Describe red pulps?
Occupy the area between white pulp Formed by SPLENIC CORDS separated by blood sinusoids MACROPHAGEs associated with the endothelium of the blood sinusoids called --> LITTORAL CELLS they are responsible for blood filtration
66
describe splenic cords? of billroth ?
Irregular masses with diffuse lymphatic tissue mixed with blood cells ( RBC + all types of leukocytes ) + MACROPHAGES the cord occupy the irregular areas between the blood sinusoid found in red pulp Cords come from the elongated arrangement of lymphocytes Sinusoids --> blood filled spaces Splenic cords --> Dense with immune cells and fibers
67
describe functions of pancreas?
Exocrine and endocrine components Connective tissue capsule divide the parenchyma into lobules Exocrine pancreas : Secrete enzyme rich alkaline fluid into the duodenum VIA PANCREATIC DUCT Endocrine: Secretion ( glucagon and insulin ) FROM PANCREATIC ISLETS OF LANGERHANS --enter blood
68
what are the parts of the exocrine part of pancreas ?
Glands Acinar cells Duct system
69
describe glands of exocrine ?
Compound tubulo-alveolar serous gland Each acinus consist of 5-8 pyramidal cells lying on the basal lamina
70
describe acinar cells ?
Basally located nuclei with RER Zymogen granules containing digestive enzymes in apical region
71
describe duct system?
Centroacinar cells ( line the acinus lumen ) then Intercalated , intralobular, interlobar and main pancreatic duct SO: Centroacinar cells = inside acinus = start the duct system --> FLAT CUBOIDAL CELLS then intercalated ducts ( simple cuboidal ) Intralobular ducts Interlobular ducts ( stratified cuboidal or stratified columnar epithelium )
72
describe intercalated ducts?
smaller tributaries lined by simple low cuboidal epithelium which BECOME Stratified cuboidal in LARGER DUCTS the wall of the main pancreatic duct contains SMOOTH MUSCLES
73
describe endocrine histology ?
Islets of langerhans: Comprise 2% of pancreas Appear as pale staining spherical bodies among the serous HIGHLY VASCULARIZED PRIMARILY IN THE TAIL OF PANCREAS
74
What are the cells surrounding the langerhan cells?
reticular connective tissue composed of 5 main types : A cells = glucagon (20%) B cells = insulin ( 70% ) D cells = somatostatin G cells = gastrin PP cells = Pancreatic polypeptide cells

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