RA week 5 Flashcards
organs of the foregut?
stomach
distal oesophagus
liver
spleen
proximal duodenum
part of pancreas
blood supply foregut?
drainage?
supply = branches from coeliac axis (aorta T12) drainage = hepatic portal vein
lymph from foregut?
pre-aortic nodes T12
digestive system begins?
in oral cavity
peritoneal relations stomach?
intra-peritoneal lesser omentum (LO) from lesser curvature greater omentum (GO) from greater curvature
layers of stomach wall?
(outer to inner)
serosa
muscularis externa (outer longitudinal, middle circular, inner oblique)
submucosa
mucosa
functions of stomach regions?
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
stomach external features?
Internal features?
external = cardiac notch + angular notch internal = rugae
shape of stomach?
movement?
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)
which abdominal region(s) is stomach found?
relations of the stomach?
stomach found on left side of body - left hypochondrium + epigastric region
posterior to stomach = lesser sac, pancreas, spleen + top pole of left kidney
lesser omentum found between?
lesser curvature of stomach + liver
blood supply to stomach?
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
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
which arteries supply lesser curvature of stomach?
distal oesophagus?
fundus?
lesser curvature = right + left gastric arteries (anastamose)
distal oesophagus = left gastric artery
fundus = short gastric arteries from splenic artery
greater curvature of stomach supplied by?
where do they branch from?
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)
venous drainage stomach?
where does it drain to?
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
which vein drains lesser curvature of stomach?
fundus?
greater curvature?
lesser curvature = R+L gastric veins
fundus = short gastric vein
greater curvature = R+L gastro-epiploic veins
lymph drainage stomach?
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
nerve supply stomach?
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
duodenum shape + length?
relations?
c-shaped, 25cm
2nd, 3rd, 4th parts retro-peritoneal, wraps around head of pancreas between pyloric valve + jejunum
parts of duodenum?
what crosses 3rd part?
what joins to 4th part?
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
external vs internal surface duodenum?
outer surface = smooth
inner surface = many folds called plicae circulares
note - pancreas and duodenum are different coloursin the Thiel embalmed tissue
ampulla of vater?
what does it connect to?
how is bile release controlled?
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
where is bile made?
stored?
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
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)
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
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)
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
nerve supply duodenum?
referred pain?
sympathetic = greater + lesser splanchnic
parasympathetic = vagus
from coeliac + superior mesenteric plexuses
pain referred to epigastric region
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
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
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
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
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
surface marker of gall bladder?
right 9th costal cartilge mid-clavicular line
venogram of portal vein
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
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
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
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)
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)
gallbladder parts?
fundus hangs below liver
body contacts visceral surface of liver
neck joins cystic duct
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
blood supply gallbladder?
drainage?
cystic artery from right hepatic artery
cystic vein drains into portal vein
lymph drainage gallbladder?
nerve supply? referred pain?
lymph to cystic node then hepatic then coeliac
nerve supply = from coeliac plexus
pain to epigastric region
gallstones?
components?
crystalline bodies made from bile components
cholesterol = green or yellow/white
pigment stones = bilirubin and calcium salts, small and dark
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
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
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)
note close relationship beteen pancreas and superior mesenteric + splenic vessels
arterial supply to pancreas?
dual blood supply like duodenum
dorsal pancreatic artery - from splenic artery
superior pancreaticoduodenal - from gastroduodenal
inferior pancreaticoduodenal - from superior mesenteric
venous drainage pancreas?
veins = drain into splenic or superior mesenteric veins (into portal system)
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
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
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
…
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
lymph drainage spleen?
nerve supply?
pancreaticoduodenal nodes then coeliac nodes (T12)
nerves derived from coeliac plexus
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)
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)
jejunum and ileum attached to?
allows?
mesentery
allows vessels, lymph and nerve supply
what lies in junction of foregut and midgut?
duodenum
…
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
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
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.
function of large intestine?
features large intestine?
Absorb water and electrolytes + store undigested material until expelled from the body
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)
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.
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
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
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)
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)
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
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
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
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
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)
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
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.
hindgut?
blood supply?
distal ⅓ transverse colon, descending colon, sigmoid colon, rectum + anal canal
branches from inferior mesenteric artery (aorta L3)
descending colon spans?
peritoneum?
relations?
25cm long from left colic flexure to pelvic brim where it becomes the sigmoid colon
retroperitoneal
relations = small intestine, greater omentum, L kidney, quadratu slumborum, psoas, femoral, iliohypogastric + ilioingual nerves
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
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
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
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)
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
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
slide shows the left colic, sigmoidal and superior rectal arteries supplying the structures of the hindgut
slide shows the left colic, sigmoidal and superior rectal arteries supplying the structures of the hindgut
…
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
areas of dual supply
