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RA week 5 Flashcards

1
Q

organs of the foregut?

A

stomach
distal oesophagus
liver
spleen
proximal duodenum
part of pancreas

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2
Q

blood supply foregut?
drainage?

A 
supply = branches from coeliac axis (aorta T12)
drainage = hepatic portal vein
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3
Q

lymph from foregut?

A

pre-aortic nodes T12

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4
Q

digestive system begins?

A

in oral cavity

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5
Q

peritoneal relations stomach?

A 
intra-peritoneal
lesser omentum (LO) from lesser curvature
greater omentum (GO) from greater curvature
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6
Q

layers of stomach wall?

A

(outer to inner)
serosa
muscularis externa (outer longitudinal, middle circular, inner oblique)
submucosa
mucosa

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7
Q

functions of stomach regions?

A

fundus rises up above entrance of oesophagus to fill left dome of diaphragm
body forms greater and lesser curvatures
pyloric region leads to pyloric valve which controls outflow of stomach contents into 1st part of duodenum

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8
Q

stomach external features?
Internal features?

A 
external = cardiac notch + angular notch
internal = rugae
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9
Q

shape of stomach?
movement?

A

taller, more slender individuals likely to have a long ‘J’ shaped stomach
stomach will move as it contracts - there are 2 fixed points
1 - where fundus lies under diaphragm (5th-6th rib)
2 - where pyloric valve meets duodenum (trans-pyloric plane rib 8/L1)

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10
Q

which abdominal region(s) is stomach found?
relations of the stomach?

A

stomach found on left side of body - left hypochondrium + epigastric region

posterior to stomach = lesser sac, pancreas, spleen + top pole of left kidney

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11
Q

lesser omentum found between?

A

lesser curvature of stomach + liver

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12
Q

blood supply to stomach?

A

remember foregut organ so branches form coeliac axis T12 supply stomach:-
1 - smallest branch is left gastric artery (passes towards lesser curvature of stomach)
2 - splenic passes along superior surface of pancreas

3 - common hepatic artery passes towards liver

right gastric artery is not direct branch from coeliac axis but originates from common hepatic artery

also right + left gastro-epiploic arteries

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13
Q
A

if a vessel appears to be originating at the coeliac axis and running across the superior surface of the pancreas then it is the splenic artery regardless of whether it is a different size or colourfrom the splenic artery you may have observed in the body you dissected in the DR

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14
Q

which arteries supply lesser curvature of stomach?

distal oesophagus?

fundus?

A

lesser curvature = right + left gastric arteries (anastamose)

distal oesophagus = left gastric artery

fundus = short gastric arteries from splenic artery

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15
Q

greater curvature of stomach supplied by?

where do they branch from?

A

greater curvature (+ greater omentum) supplied by gastro-epiploic arteries - anastamose

left gastro-epiploic artery = from splenic artery

right = from gastroduodenal artery (which is a branch of hepatic artery)

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16
Q

venous drainage stomach?

where does it drain to?

A

gastric veins (L+R) - into hepatic portal vein

L gastro-epiploic + short gastric into splenic vein then hepatic portal

R gastro-epiploic into superior mesenteric vein then hepatic portal

splenic and superior mesenteric veins unite to form hepatic portal vein - so all drain into hepatic portal system

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17
Q

which vein drains lesser curvature of stomach?

fundus?

greater curvature?

A

lesser curvature = R+L gastric veins

fundus = short gastric vein

greater curvature = R+L gastro-epiploic veins

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18
Q

lymph drainage stomach?

A

cardiac ring around entrance of oesophagus

gastro-omental, gastric, pyloric, pancreaticosplenic + pancreaticoduodenal lymph nodes

will all eventually drain into coeliac nodes = pre-aortic coeliac nodes at T12 → cisterna chyli → thoracic duct

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19
Q

nerve supply stomach?

A

autonomic nerves - coeliac plexus

sympathetic = carried by greater splanchnic nerves to coeliac plexus

parasympathetic = from anterior and posterior vagal trunks (posterior trunk to coeliac plexus)

so posterior vagal trunk and greater splanchnic nerves contribute to coeliac plexus

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20
Q

duodenum shape + length?

relations?

A

c-shaped, 25cm

2nd, 3rd, 4th parts retro-peritoneal, wraps around head of pancreas between pyloric valve + jejunum

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21
Q

parts of duodenum?

what crosses 3rd part?

what joins to 4th part?

A

1st = duodenal cap, has mesentry

2nd = descending entrance of bile and pancreatic ducts

3rd = transverse

4th = ascending to jejunum

3rd part crossed by superior mesenteric vessels

4th part joins to jejunum

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22
Q

external vs internal surface duodenum?

A

outer surface = smooth

inner surface = many folds called plicae circulares

note - pancreas and duodenum are different coloursin the Thiel embalmed tissue

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23
Q

ampulla of vater?

what does it connect to?

how is bile release controlled?

A

also called hepatopancreatic ampulla - union of common bile duct + main pancreatic duct

opens into duodenum via small mound on inner surface called major duodenal papilla

sphincter of Oddi (hepato-pancreatic sphincter) controls release of bile into duodenum

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24
Q

where is bile made?

stored?

A

bile made in liver + passes into biliary tree

sphincter of oddi at end of biliary tree normally closed to bile backs up into gallbladder + cystic duct

bile stored in gallbladder until sphincter opens

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25
what abdominal region is duodenum found?
lies between vertebral levels L1-L3 in umbilical region begins just above trans-pyloric plane + ends 2-3cm left of midline of body (**duodenal-jejunal junction**)
26
relations of duodenum?
1st part (related to liver and associated structures) = liver, gallbladder, bile duct, portal vein, IVC 2nd part = transverse colon, right kidney, ureter, pancreas 3rd part = superior mesenteric vessels, jejunum, right ureter, right psoas, IVC, aorta, pancreas 4th part = root of mesentry, jejunum, aorta, left psoas
27
blood supply duodenum?
proximal ½ = superior pancreaticoduodenal artery (branch of gastroduodenal from common hepatic from coeliac axis) distal ½ = inferior pancreaticoduodenal artery (branch of superior mesenteric) (**so part coeliac axis, part superior mesenteric - junction between foregut and midgut**)
28
venous drainage duodenum?
all drain into portal system proximal ½ = superior pancreaticoduodenal vein drains directly to hepatic portal vein distal ½ = inferior pencreaticoduodenal drains into superior mesenteric
29
nerve supply duodenum? referred pain?
sympathetic = greater + lesser splanchnic parasympathetic = vagus from coeliac + superior mesenteric plexuses pain referred to epigastric region
30
lymph drainage duodenum?
general rule = lymph drainage follows arterial supply duodeum has dual artery supply so dual lymph drainage proximal = follow pancreaticodiodenal, gastroduodenal and pyloric nodes to pre-aortic coeliac axis nodes at T12 distal = follow pancreaticoduodenal nodes to pre-partic superior mesenteric nodes at L1
31
liver morphology? anterior surface? what is ligament formed from?
4 lobes from anterior surface = can see large right and smaller left lobes seperated by **falciform ligament** falciform ligament = peritoneum reflects over surface of liver ligamentum teres = remnant of umbilical vein
32
posterior surface of liver? where are these found? what can be seen on superior surface of right lobe?
can still see left and right lobes but also 2 smaller lobes - **caudate + quadrate lobes** caudate lobe = sits between IVC and left lobe quadrate lobe = between left love and gallbladder bare area of the liver can be seen on superior surface of the right lobe = area that is not covered in peritoneum due to the way the peritoneum reflects away from the surface of the right dome of the diaphragm
33
hilum of liver? what attaches here? contents of porta hepatis?
called porta hepatis free edge of lesser omentum attaches here carrying **bile duct, portal vein and hepatic artery** contents = right + left hepatic ducts, hepatic arteries, portal vein, ANS fibres, lymph nodes NOT HEPATIC VEINS!!! - these drain directly into IVC
34
liver found in what abdominal region? relations?
fills right hypochondrium and crosses through epigastric region, fills right dome of diaphragm reaches up to ribs 5-6 anterior surface = covered by ribs, costal cartilages superior surface = covered by diaphragm posterior surface = oesophagus, stomach, duodenum, right colic flexure, right kidney, supra-renal gland, gallbladder
35
surface marker of gall bladder?
right 9th costal cartilge mid-clavicular line
36
venogram of portal vein
37
liver peritoneum? forms? function?
apart from area attached to diaphragm (bare area) liver covered in visceral peritoneum peritoneum folds back on itself to mak falciform and right an left triangular ligaments falciform ligament passes to umbilicus and contains remnants of umbilical vein (ligamentum teres) right layer of falciform ligament creates coronary ligament and left layer forms left triangular ligament
38
blood supply liver? portal vein blood? how is tissue actually supplied? drains to?
30% blood from hepatic artery (branch of coeliac trunk), 70% from portal vein portal vein is deoxygenated but rich in nutrients arterial + venous blood passes to central vein of each liver lobule by sinusoids central veins drain into right and left hepatic veins (4 total) directly into IVC
39
lymph % liver? lymph drainage liver?
lymph from liver makes up ⅓-½ of total body lymph nodes at porta hepatis then coeliac nodes (T12) small amount through diaphragm into thoracic lymph system
40
nerve supply liver? referred pain?
ANS from coeliac plexus – pain to epigastric region or small amount via diaphragm to right shoulder (C3, C4, C5 phrenic nerve)
41
bile secreted and stored? bile duct terminates? then…
bile secreted by liver and stored by gallbladder bile duct ends by piercing medial wall of **2nd part of duodenum** joined by main pancreatic duct and opens into **hepatopancreatic ampulla (of Vater)** ampulla opens into duodenum via **major duodenal papilla (sphincter of Oddi)**
42
gallbladder parts?
fundus hangs below liver body contacts visceral surface of liver neck joins cystic duct
43
gallbladder covered in? function? How is bile released into duodenum?
covered in visceral peritoneum folds + microvilli = store and concentrate bile fat in duodenum = releases cholecystokinin causing GB to contract smooth muscle distal end of bile duct and ampulla relax = bile into duodenum to emulsify fat
44
blood supply gallbladder? drainage?
cystic artery from right hepatic artery cystic vein drains into portal vein
45
lymph drainage gallbladder? nerve supply? referred pain?
lymph to cystic node then hepatic then coeliac nerve supply = from coeliac plexus pain to epigastric region
46
gallstones? components?
crystalline bodies made from bile components cholesterol = green or yellow/white pigment stones = bilirubin and calcium salts, small and dark
47
pancreas morphology?
endocrine + exocrine head = lies in concavity of duodenum, uncinate process behind superior mesenteric vessels neck = narrow area from head to body anterior to origin of superior mesenteric artery body = across laterally and superiorly tail = passes in lienorenal ligament and into contact with hilus of spleen
48
relations of pancreas?
pancreas is retroperitoneal anterior = transverse colon, stomach posterior = bile duct, portal vein, splenic vein, IVC, aorta, superior mesenteric artery, left psoas, left supra-renal gland, left kidney, spleen
49
main pancreatic duct? what is sometimes present?
main duct from tail to ampulla of Vater accessory duct may be present - drains into upper part of head + into duodenum (not at ampulla of Vater)
50
note close relationship beteen pancreas and superior mesenteric + splenic vessels
51
arterial supply to pancreas?
dual blood supply like duodenum dorsal pancreatic artery - from splenic artery superior pancreaticoduodenal - from gastroduodenal inferior pancreaticoduodenal - from superior mesenteric
52
venous drainage pancreas?
veins = drain into splenic or superior mesenteric veins (into portal system)
53
lymph drainage pancreas? nerve supply + referred pain?
lymph to coeliac (T12) and superior mesenteric (L1) pre-aortic nodes nerves from coeliac + superior mesenteric plexuses pain referred to epigastric region
54
spleen? found in which abdominal region? associated ligaments?
largest single mass of lymphoid tissue in the body lies inferior to ribs 9-11 in left hypochondrium (posterior to stomach) gastrosplenic ligament - carrying short gastric + gastro-epiploic vessels lienorenal ligament to left kidney carrying splenic vessels
55
spleen hilum?
splenic artery and vein usually pass into/ out of the hilum but you can see from the Thiel photograph that there are occasionally small variations and some vessels may pass into an upper (as in the photograph) or lower pole of the spleen
56
…
57
blood supply to spleen? venous drainage? what drains into this?
splenic artery (largest branch of coeliac trunk) - passes along superior surface of pancreas to reach hilum of spleen splenic vein exits hilum and passes posterior to pancreas - forms portal vein alongside superior mesenteric vein posterior to pancreas inferior mesenteric vein drains into splenic vein
58
lymph drainage spleen? nerve supply?
pancreaticoduodenal nodes then coeliac nodes (T12) nerves derived from coeliac plexus
59
midgut? what does it contain? blood supply?
midgut = from ½ way along duodenum, jejunum, ileum, caecum, appendix, ascending colon to ⅔rds way across transverse colon contains small and large intestine blood from branches of superior mesenteric artery (aorta L1)
60
small intestine length? jejunum begins where? ileum?
6m jejunum begins at duodeno-jejunal junction (proximal 2/5ths) ileum spans from jejunum to ileocaecal junction (distal 3/5ths)
61
jejunum and ileum attached to? allows?
mesentery allows vessels, lymph and nerve supply
62
what lies in junction of foregut and midgut?
duodenum
63
…
64
blood supply to jejunum and ileum? feature?
arterial supply = jejunal and ileal branches of superior mesenteric artery (branches from left side and run in mesentery) anastamose to form arcades lower part of ileum also supplied by ileocolic artery
65
venous drainage of jejunum and ileum? lymph drainage? nerve supply? pain referred?
ileocolic, ileal and jejunal veins drain into superior mesenteric veins lymph = mesenteric nodes then pre-aortic nodes around superior mesenteric artery (L1) nerves = ANS from superior mesenteric plexus pain referred to umbilical region
66
arteriogram where dye has been added into the superior mesenteric artery. The many small branches passing to the left side of the patient are jejunal and ileal branches sitting in the mesentery.
67
function of large intestine? features large intestine?
Absorb water and electrolytes + store undigested material until expelled from the body ## Footnote features: * Haustra= sacculations of the wall (small intestine looks smooth) * Appendices epiploicae= fatty tags (none on small intestine) * Teniae coli = longitudinal muscle collected into 3 bands (small intestine smooth muscle continuous layer)
68
The slide shows a radiograph of a barium enema. The haustra of the large intestine are very clear on this image particularly in the transverse colon. The CT scan shows part of the transverse colon passing across the abdominal cavity – the haustra are also shown on this image due to barium and air/gas in the intestine.
69
caecum peritoneum? where is it found? opening of ileum?
caecum covered in peritoneum in right iliac fossa opening of ileum has 2 folds = ileocaecal valve
70
caecum relations? arterial supply? venous drainage? lymph? nerve supply?
small intestine, psoas, iliacus arterial supply = caecal arteries from ileocolic (from superior mesenteric) caecal veins drain into superior mesenteric vein lymph to mesenteric then superior mesenteric nodes (L1) nerves = ANS superior mesenteric plexus
71
vermiform appendix has? where is it found? where is it found abdomial region?
appendix has small mesoappendix mesentery tip is often retro-caecal found right iliac region (1//3rd along line from ASIS to umbilicus)
72
blood supply appendix? venous drainage? lymph drainage? nerve supply? referred pain?
appendicular artery runs in mesoappendix to supply appendix appendicular vein runs in mesoappendix and drains into posterior caecal vein lymph same as caecum - to mesenteric nodes then superior mesenteric nodes (L1) nerves same as caecum - ANS superior mesenteric plexus pain to umbilicus (T10)
73
ascending colon spans? peritoneum? relations? when does it become transverse colon?
15cm long from caecum to transverse colon retroperitoneal relations = small instestine, greater omentum, iliacus, iliac crest, quadratus lumborum, R kidney, ilioinguinal + iliohypogastric nerves ascends in right colic gutter towards liver and turns at hepatic flexure to become transverse colon
74
blood supply ascending colon? venous drainage? lymph? nerves?
blood supply = ileocolic and right colic branches of superior mesenteric artery veins to superior mesenteric vein lymph to superior mesenteric nodes (L1) aorta nerves = ANS from superior mesenteric plexus
75
transvserse colon spans? peritoneum? feature of left colic flexure?
38cm long from right colic to left colic flexures hangs from transverse mesocolon left colic flexure has **phrenicocolic ligament** from diaphragm
76
relations of transverse colon? blood supply? veins?
relations = greater omentum, pancreas, small intestine blood supply: * proximal ⅔rds = middle colic artery (sup. mesenteric) * distal ⅓rd = left colic artery (inf. mesenteric) veins to superior + inferior mesenteric veins
77
junction between midgut and hindgut?
transverse colon = supplied by branches of both the superior and inferior mesenteric arteries drains blood into superior and inferior mesenteric veins dual lymphatic drainage to pre-aortic nodes at L1 and at L3 parasympathetic nerve supply also comes from two sources = vagus nerve proximal 2/3rds (midgut pattern) + pelvic splanchnic nerves distal ⅓d (hindgut pattern)
78
lymph transverse colon? nerves?
lymph * proximal ⅔ = superior mesenteric nodes (L1) * distal ⅓ = inferior mesenteric nodes (L3) nerves = ANS from sup. + inf. mesenteric plexuses * proximal ⅔ = vagus * distal ⅓ = pelvic splanchnic nerves
79
ascending + transverse colons ileocolic and right colic arteries can be seen passing to the wall of the ascending colon Once transverse mesocolon dissected away, marginal artery that anastomoses between the right colic, middle colic and left colic arteries can be seen passing alongside the transverse colon. This arterial arcade supplies the transverse colon.
80
hindgut? blood supply?
distal ⅓ transverse colon, descending colon, sigmoid colon, rectum + anal canal branches from inferior mesenteric artery (aorta L3)
81
descending colon spans? peritoneum? relations?
25cm long from left colic flexure to pelvic brim where it becomes the sigmoid colon ## Footnote retroperitoneal relations = small intestine, greater omentum, L kidney, quadratu slumborum, psoas, femoral, iliohypogastric + ilioingual nerves
82
blood supply descending colon? venous drainage? lymph? nerves?
left colic + sigmoid arteries (inferior mesenteric) veins to inferior mesenteric vein lymph to inferior mesenteric pre-aortic nodes (L3) nerves = sympathetic from inferior mesenteric plexus + parasympathetic from pelvis
83
sigmoid colon spans? peritoneum? relations?
25-38cm long from descending colon in front of L external iliac artery to 3rdsacral vertebra where it becomes rectum Attached to posterior pelvic wall by mesocolon relations = bladder (males), uterus + vagina (females), rectum, sarcum
84
blood supply sigmoid colon? venous drainage? lymph? nerves?
blood supply = sigmoid branches (inf. mesenteric) veins to inf. mesenteric vein lymph to inf. mesneteric nodes at aorta (L3) nerves = ANS from inferior hypogastric plexus
85
rectum spans? blood supply?
13cm long from 3rdsacral vertebra to 2cm in front of tip of coccyx where pierces pelvic diaphragm to become anal canal blood supply (from abdomen via inf. mesenteric + pelvis via middle + inf. rectal arteries) * superior rectal artery (inf. mesenteric) * middle rectal artery (internal iliac) * inf. rectal artery (internal pudendal)
86
venous drainage rectum?
venous drianage of rectum forms a **portal-systemic anastamosis** superior = **portal system** via inf. mesenteric vein distal = **systemic system (IVC)** via middle + inferior veins to internal iliac and internal pudendal then common iliac → IVC
87
lymph drainage rectum? significance? nerves?
lymph = upper to inf. mesenteric nodes (L3) lower to internal iliac nodes means infection or cancer from upper parts of rectum can spread into abdomen and lower parts spread locally in the pelvis nerves from inferior hypogastric plexus
88
slide shows the left colic, sigmoidal and superior rectal arteries supplying the structures of the hindgut
89
slide shows the left colic, sigmoidal and superior rectal arteries supplying the structures of the hindgut
90
…
91
re-cap of the venous drainage of the foregut, midgut and majority of the hindgut into the hepatic portal system. Blood returns to the systemic system after processing in the liver via hepatic veins that drain directly into the inferior vena cava
92
areas of dual supply

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