Week 1 Flashcards
Name the vertical/sagittal planes
A) & C)
1) Midpoint of the clavicle to the midinguinial point
** Used to divide abdomen into 9 quadrants
B)
1) Passes through the umbilicus along the linea alba
** Used to divide abdomen into 4 general quadrants
1) Midclavicular (lateral)
2) Midsagittal (median)
Name the quadrant using the midsagittal and transumbilical plane
1) Stomach
2) Duodenum
3) Cecum
4) Descending and Sigmoid colon
5) Ilial diverticulum
6) Gallbladder
7) Vermiform appendix
8) Left pleura
9) Right lobe of the liver
10) Spleen
11) Right ureter
12) Left ureter
13) Right pleura
14) Tail of the pancreas
15) Right kidney
16) Left kidney
** Quadrants describe general location of pain, palpable or audible abnormalities or specific viscera
1) LUQ
2) RUQ
3) RLQ
4) LLQ
5) RLQ
6) RUQ
7) RLQ
8) LUQ
9) RUQ
10) LUQ
11) RLQ
12) LLQ
13) RUQ
14) LUQ
15) RUQ
16) LUQ
Name the 9 regions via the midclavicular plane and the subcostal/transtubercular or transpyloric/interspinous planes
RH and LH (Right and left hypochondriac region)
RL and LL (Right and left lumbar aka lateral region)
RI and LI (Right and left iliac aka inguinal region)
Epigastric region
^ Umbilical region
^ Hypogastric region (pubic)
The muscles and aponeuroses of the abdominal wall consist of 1 anterior muscle called ___, 3 anterolateral muscles called __ and 4 posterior muscles called ___
Rectus abxominis
External and internal abdominal oblique, and transversus abdominis
Iliacus, psoas major and minor, and quadratus lumborum
BBQ***
In abdominal surgery, you want to cut __ to each layer’s fibers rather than cutting across the fibers (perpendicular) due to the fact that they will scar and make the layers adhere to one another
Gridiron (muscle splitting) incisions are often used for an appenidectomy. The first incision through the external abdominal obliques is called the ___ incision in an inferomedial direction.
Next, the internal oblique and transversus abdominis muscles are cut in a __ incision
Finally, the __ nerve is identified and preserved so now injury occurs
For suprapubic incisions, what nerves are identified and preserved?
Parallel
McBurney, transverse, Iliohypogastric
Iliohypogastric and ilio-inguinal nerves
The external and internal oblique aponeurosis begins at the ___ and the transversus abdominis begins around the ___
The ___ abdominal oblique muscle fibers run inferolateral origin to superomedial insertion and the __ abdominal oblique muscle fibers run superolateral origin to inferomedial insertion
MCL (midclavicular line), Linea semilunaris
Internal, External
******* Nerves and vessels (neurovascular plane) can be found between the __ and __ muscles
Internal abdominal oblique and transverses abdominis muscle layers
The __ muscle lies anterior to the inferior end of the rectus abdominis and extends from the linea alba to the pubic crest
** It functions via tensing the linea alba
Pyramidalis muscle
___ fascia is continuous with superficial fatty fascia of the thorax, thigh, and superficial perineal fascia
^ Superficial blood vessels run here also
__ fascia is continuous with the deep layer of superficial perineal fascia (aka Colles fascia), fascia lata in the thigh
** Both are considered superficial fascia
So which layer once again fuses with the fascia lata?
Also, where can fluid leak into that is a potential space?
Campers (fatty superficial layer)
Scarpas (deep membranous layer)
Scarpas
Between scarpas and deep fascia of external abdominal oblique muscle
The deep fascia of the abdominal wall (investing facia) is the origin for which muscles?
**Fluid can leak into the space between the Scarpa’s fascia and deep fascia of the external abdominal oblique muscle (aka superficial investing deep fascia)
Internal oblique and transversus abdominis muscle
The abdomen is the region of the trunk that is below the respiratory diaphragm and above the pelvic brim (aka inlet). The respiratory diaphragm is placed anteriorly at the costal cartilage of rib __ and posteriorly at the vertebral body of __
6, T12
The __ separates the “false pelvis” aka abdomen from the “true pelvis” and consists of what three things?
Linea terminalis (aka pelvic inlet)
Pectin pubis, arcuate line, and sacral promontory
The aponeurosis from both sides of the External Abdominal Oblique come together to form the ___
The ___ is another specialized part of the EAO and is part of the lower free margin of the aponeurosis and attatches at the ___ and ___
Linea alba
Ingunal ligament, ASIS and Pubic tubercle
** An extension of the inguinal ligament is the ___ ligament and this is important in ___ because its sharp free edge cuts into the femoral canal, which enlarges with a femoral hernia.
The ___ ligament is the lateral-posterior extension of the lacunar ligament and runs along the pectineal line. It can also form a sharp border that can constrict a femoral hernia
Lacunar ligament, femoral hernias
Pectineal
The cremaster muscle comes from the __ muscle and the conjoint tendon (also called the falx inguinalis) comes from the ___ and __ muscles
Internal abdominal oblique
Internal abdominal oblique and transversus abdominis
The rectus abdominus muscle is crossed by ____ intersections
Tendinous
The ___ is formed by the fusion of the abdominal muscles and their associated fascias and encloses what two muscles?
The ___ is where the layers of fascia and aponeuroses of the msucles forming the rectus sheath become arranged differently
___ the line there is more tissue anterior to the rectus abdominis
Rectus sheath
Rectus abdominis and pyramidalis muscle
Arcuate line
Below
What layer would you find the superficial arteries And veins in?
Campers fascia
If the aorta is occluded, what anastomosis can provide collateral circulation to the lower part of the body and is seen radiographically as a “notched rib” sign
If inferior vena cava is obstructed, blood will flow from the ___ vein to the ___ vein via anastomoses and then can move to the ___ vein, which empties into the SVC (this is via deep veins). It can also use a more superficial anastomoses, called the ___ vein
Epigastric arterial anastomosis (superior and inferior) To be extremely precise… Aorta -> Brachiocephalic A -> Subclavian A -> Internal thoracic A -> Superior epigastric A -> Inferior epigastric A -> External Iliac A -> Rest of body
Inferior epigastric vein -> superior epigastric vein, subclavian vein, thoraco-epigastric vein
To be more precise for the superficial anastomoses, it would be… Femoral V -> Superficial epigastric V -> Thoraco-epigastric V -> Lateral thoracic V -> Axillary V -> Subclavian V -> Brachiocephalic V -> SVC
The skin and subcutaneous tissue of the abdominal wall drain superiorly via the __ or __ veins and inferiorly via the __ or __ veins
If the IVC or SVC is obstructed, which two anastomoses (name both superficial and deep) would supply collateral circulation?
Superficial vein drainage goes to the axillary vein via the ___ vein which exists between the ___ vein (a femoral vein tributary) and the ___ vein (an axillary vein tributary)
Internal thoracic, Lateral thoracic
Inferior epigastric, superficial epigastric
Superficial: thoraco-epigastric (between superficial epigastric and lateral thoracic veins)
Deep: Inferior epigastric and superior epigastric anastomoses (within the rectus sheath)
***** PROBS A TEST QUESTION
Above the umbilicus, cutaneous and subcutaneous lymphatics drain toward the ___ lymph nodes
Below the umbilicus, cutaneous and subcutaneous lymphatics drain toward the ___ lymph nodes
Axillary (and some into parasternal)
Superficial inguinal
Muscles of the abdominal wall are innervated by the __ rami of spinal nerves __-__
Anterior abdominal wall nerves ___ supply the skin superior to the umbilicus, ___ supplies the skin around the umbilicus, and __ supplies the skin inferior to the umbilicus
Landmark dermatomes are dermatome ___, which is the xiphoid region tip, ___ which includes the umbilicus and dermatome ___, which includes the inguinal fold
Ventral, T7-L4
T7-T9
T10
T11-L1
**Intercostal nerves T7-T11, subcostal nerve T12, Lumbar nerves L1-L4
T7, T10, L1
The thoracoabdominal intercostal nerves make up T__-T__ have anterior and lateral branches
**These nerves supply muscles of the anterolateral abdominal wall and overlying skin
T7-T11
The lumbar plexus consists of…
The __ nerve is L1, with sometimes a contribution from T12 or L2
The __ nerve is solely L1
The __ nerve is L1 and L2
What two muscles of the anterior abdominal wall are supplied by the thoracoabdominal nerves (T7-T11), the subcostal nerve (T12) AND L1?
Iliohypogastric
Ilioinguinal
Genitofemoral
Internal oblique and Transversus Abdominis
** ^ External oblique and rectus abdominis are supplied by all the nerves mentioned except L1
The iliohypogastric nerve sends a lateral branch to the skin of the __ region and an anterior cutaneous branch to the __ region, it can also supply the skin overlying the iliac crest
** Sometimes if L1 is injured you can get some pain along the inguinal region as well (via skin overlying the iliac crest)
Gluteal, suprapubic (also called hypogastric or pelvic)
The ___ nerve enters the inguinal canal and emerges through the superficial inguinal ring in order to supply the groin, thigh, scrotum/labium majus
The __ branch of the genitofemoral nerve enters the inguinal canal and innervates the cremaster muscle or is cutaneous to the labium majus and the ___ branch exits inferior to the inguinal ligament and supplies the skin of the thigh over the femoral triangle
What muscle does the genital branch innervate?
ilioinguinal
Genital branch
Femoral branch
Cremaster muscle
***BBQ
The anterolateral wall can be the site of abdominal hernias. Name them
1) Increased intra-abdominal pressure in the presence of weakness and incomplete closure of the anterior abdominal wall after ligation of the umbilical cord (aka the scar of the umbilicus does not heal completely)
* *Occur in infants
2) Occurs most commonly in women and obese people due to extraperitonral fat and/or peritoneum protruding into the hernial sac. Results from weakened abdominal wall around the umbilicus most commonly from a scar
* *Occur in adults
3) A hernia that protrudes through the linea alba and usually superior to the umbilicus. Also most common in men
4) Hernias that occur along the semilunar lines and usually in obese people over the age of 40. The hernia is composed of peritoneum and covered with only skin and fatty subcutaneous tissue
5) Hernias that occur at surgical/laparotomy sites that are postoperative scar hernias
1) Umbilical hernia
2) Acquired umbilical hernias
3) Epigastric hernia
4) Spigelian hernias
5) Incisional hernias
Name the floor, Roof, Anterior wall, and posterior wall of the inguinal canal
Floor: Inguinal ligament and lacunar ligament
Roof: Internal abdominal oblique fibers
Anterior wall: External abdominal oblique
Posterior wall: Transversalis fascia and conjoint tendon
The inguinal canal starts at the ___ and ends at the __
Deep inguinal ring, superficial inguinal ring
**IN MALES
During the descent of the testes, they first develop retroperitoneally from the urogenital ridge of mesoderm in the upper lumbar/lower thoracic region on the ___ wall and they migrate inferiorly.
The testes are attached to the ___, a fibrous tract connecting the primordial testis to the anterolateral abdominal wall, which is attached inferiorly to the labial-scrotal fold and guides the migration of the testes. It eventually becomes the ___
The testes move into the site of the deep inguinal ring and while this migration is occurring, a pouch of peritoneum called the __ develops and is pushed into the labial scrotal swelling aka the primordial scrotum. It eventually becomes the __ when it closes off
** If this doesn’t close off, an indirect hernia can occur
Posterior
Gubernaculum, scrotal ligament
Processus vaginalis, tunica vaginalis
BBQ***
Below the umbilicus, surgeons include the __ layer during sutures because of its strength
Deep membranous layer (scarpas)
BBQ***
The ____ fascia is important in surgery because it enables the establishment of an extraperitoneal space that allows anterior access to retroperitoneal structures without entering the peritoneal cavity
Endoabdominal fascia
Which two muscles draw the testis in closer to the body?
What layer does the Dartos come from?
Dartos muscle and cremaster muscle
Scarpa’s fascia mainly, although some campers is involved
Name what the layers of the anterior abdominal wall become when they move into the scrotum and coverings of the testis
1) Skin
2) Subcutaneous tissue (fatty/membranous) ** But mainly Scarpa’s fascia
3) External oblique muscle and fascia
4) Internal oblique muscle
5) Internal oblique muscle fascia (both superficial and deep surfaces)
6) Transversus abdominis muscle
7) Transversalis fascia
8) Peritoneum
1) Skin
2) Dartos muscle/fascia
3) External spermatic fascia
4) Cremaster muscle
5) Cremasteric fascia
6) Nothing
7) Internal spermatic fascia
8) Tunica vaginalis
**IN FEMALES
Just like in the male, the ovaries develop on the posterior abdominal wall and then move to the lateral wall of the pelvis.
Also just like the males, the processus vaginalis of the peritoneum transverses the transversalis fascia at the site of the deep inguinal ring and then protrudes into the ___
The upper gubernaculum of the female becomes the ___ between the ovary and uterus and the lower gubernaculum becomes the ___ between the uterus and labium majus
** The round ligament of the uterus passes through the inguinal canal just like the spermatic cord in males
Labium majus
Ovarian ligament, Round ligament of the uterus
Name the horizontal/transverse planes
A)
1) Passes through the inferior border of the 10th costal cartilage and superior border of LV3
2) Passes through the iliac tubercles and the body of LV5
** These two divide abdomen into 9 quadrants
B)
3) Passes through LV3-LV4 intervertebral disc
** This divides abdomen into 4 general quadrants
C)
4) Located halway between the jugular notch and pubic symphysis and intersects the body of LV1. It also passes through the pyloric sphincter
5) Passes through ASIS on each side
1) Subcostal
2) Transtubercular
3) Transumbilical (also called supracristal)
4) Transpyloric
5) Interspinous
BBQ***
___ is the name for an undescended testi and this is problematic because it comes with a great increased risk for developing malignancy in the undescended testi and can not be palpated
The suprvesicular fossa, located between the median and medial umbilical folds, can have a hernia called an external supravesicular hernia and this is bad because the __ nerves is in danger of injury during the repair
Since the ___ nerve supplies the skin of the adjacent medial thigh and the anterior scrotum, if you rub the the thigh of a child, it will cause the cremasteric muscle to contract and you will get a cremasteric reflex
Cryptorchidism
Iliohypogastric nerve
Ilioinguinal nerve
When the processus vaginalis persists in females (does not close properly) it is called the ___
A ___ is the presences of excess fluid in a persistent processus vaginalis and it can be confined to the spermatic cord of the testis
A ___ of the testis is a collection of blood in the tunica vaginalis due to the rupture of branches of the testicular artery
If you want to distinguish between a hydrocele and a hematocele, a transillumination test can be performed. Would you see blood or fluid in the test?
Canal of Nuck
Hydroceles
Hematoceles
Fluid, because blood does not transilluminate
A ___ is the retention of fluid in the epididymis’s head, and ___ is the retention of fluid anywhere in the epididymis
*****If cancer is found in the lumbar lymph nodes (Also called pre-aortic), it is ___ cancer
If cancer is found in the superficial inguinal lymph nodes, it is __ cancer
Spermatocele, epididymal cyst
Testicular cancer (*Think because the testes had to relocate from the posterior abdominal wall)
Scrotal cancer
__ hernias exit the abdomen through the femoral canal, ___ to the inguinal ligament
___ hernias are lateral to the inferior epigastric artery
__ hernias are medial to the inferior epigastric artery
Femoral, inferior
Indirect inguinal hernia
Direct inguinal hernia
In direct inguinal hernias, they are medial to the inferior epigastric artery and push directly through the anterior abdominal wall via a “weak” inguinal triangle (Hesselbach’s triangle), usually due to a weak ___
**The spot this hernia occurs is also sometimes referred to as a medial inguinal fossa and occurs between which two umbilical folds?
**Does not descend into the scrotum
** AKA does not pass through the deep inguinal ring, instead, it passes through or around the inguinal canal (usually only 2/3rds of it) and comes out at superficial ring
Conjoint tendon
Medial and lateral
Indirect inguinal hernias are lateral to the inferior epigastric artery and push through the deep inguinal ring, through the canal, and exit the superficial ring. These are most commonly due to incomplete closure of the ___, and therefore occur most often in children
**The spot this hernia occurs is also sometimes called the lateral inguinal fossa and is lateral to which umbilical fold?
** Descends all the way down into the testes
** AKA transverses the ENTIRE inguinal canal (from the deep inguinal ring to the superficial inguinal ring)
Processus vaginalis
Lateral fold
So if you feel an impulse at the superficial ring and a mass at the site of the deep ring it is a __ hernia
If an impulse is felt in the inguinal triangle or a medial impulse at the superficial ring is felt, it is a __ hernia
Indirect
Direct
Know the Foregut, Midgut, and Hidgut contents and also the Main arteries and the Main artery branches for all of them
This is in the slide 10 and 11 “Peritoneum”
Out of the two layers of the peritoneum, the ___ layer has abundant pain fibers via nerves from the body wall and the ___ layer has no pain fibers
The two layer fold of the peritoneum is referred to as the ___
Parietal (outer) (Somatic innervation)
Visceral (Autonomic innervation)
** So depending on the type of pain, you can tell if it is an injury to the body wall, or injury the the viscera (guts)
Mesentery
___peritoneal organs are covered on most sides by visceral peritoneum and suspended by mesentery from the body wall
___peritoneal organs lie deep to the parietal peritoneum and are covered by parietal peritoneum on one side only (the anterior side)
^ There are two types of retroperitoneal organs, both do not contain a mesentery when developed, however, if the organs are part of the gut, they once had a mesentery and are therefore ___ retroperitoneal organs. If the organs are not part of the gut, they never had and never will have a mesentery and are ___ retroperitoneal organs
Intraperitoneal
Retroperitoneal
Secondary, Primary
Most of the mesentery is ___, because the __ mesentery only extends from the respiratory diaphragm to the duodenum aka **mainly covers the liver
Dorsal, ventral
Broad, 2 layered sheets of peritoneum that attatch the stomach to other viscera are called ___
The lesser omentum develops from the ___ mesentery (mesogastrium) and is subdivided into two parts, the part the connects the stomach to the liver called the ___ and the part that connects the duodenum to the liver called the ___
The greater Omentum develops from the __ mesentery and is subdivided into parts including the stomach to transverse colon called the ___, the stomach to diaphragm called the ___, and the stomach to spleen called the ___
Since we are on the subject of the peritoneal ligaments, what are the 4 peritoneal ligaments of the liver?
** The greater omentum prevents visceral peritoneum from adhering to the parietal peritoneum
** The omentum is sometimes referred to the policeman of the abdomen
Omentum
Ventral
Hepatogastric ligament Hepatoduodenal ligament (**CONTAINS THE PORTAL TRIAD)
Dorsal
Gastrocolic ligament
Gastrophrenic ligament
Gastrosplenic ligament
Right triangular, left triangular, coronary, and falciform ligaments (teres ligament is not derived from ventral so it isn’t included)
**Lienorenal and Phrenicocolic ligaments are also peritoneal ligaments
From the ventral mesogastrium, the ___ ligament contains the portal triad. What 3 things does this include?
During a Cholecystectomy, a surgeon cuts through the Hepatoduodenal ligament to reach the cystic artery, which must be ligated before removing the gall bladder. In order to locate the cystic artery, the Calots triangle is used. Name the medial, lateral, and superior border
What else can also be found in here?
Hepatoduodenal
Proper hepatic artery
Hepatic portal vein
Common bile duct
Medial: Common hepatic duct
Lateral: Cystic duct
Superior: Edge of liver
*** ^ KNOW THIS
Calot’s node (the main route of lymphatic drainage of the gallbladder)
There are three folds, the median umbilical fold is formed by the underlying median umbilical ligament, via obliterated ___, the medial umbilical fold is formed by the medial umbilical ligaments via obliterated ___, and the lateral umbilical fold is formed via ___, which are patent and functional
**When fossae are abnormally deep, they can cause an ___ hernia
Urachus (Connected fetal bladder to the umbilicus), Fetal umbilical arteries, Inferior epigastric vessels
Internal
What use to be the umbilical vein?
Also note that the falciform ligament is formed from a remnant of the ___ mesogastrium
Ligamentum teres hepatis (round ligament of the liver)
Ventral
There is a structure called the iliopubic tract, which runs parallel with the inguinal ligament, and between these two structures is where weakness occurs and therefore direct and indirect inguinal and femoral hernias occur, this space is called ___
Myopectineal orifice
BBQ** Infection and inflammation of the peritoneum is called peritonitis, and this can cause excess fluid in the peritoneal cavity called __ fluid, leading to the condition called ascites
Ascitic
BBQ**
Peritoneal ___ are of clinical importance in connection with the spread of pathological fluids such as pus, a product of inflammation
Free communication occurs between the supracolic and infracolic compartments via ___ and these are of clinical importance because they provide pathways for the flow of ascitic fluid and spread of intraperitoneal infections
A pancreatic psuedo-cyst is when fluid is inside the __
Common places that abscesses may develop in the supracolic region of the greater sac is in the ___ or ___ pouch and this is due to the accumulation of pus aka peritonitis
Recesses
Paracolic gutters
Omental Bursa (aka lesser sac)
Subhepatic (hepatorenal) and right subphrenic pouch
The lesser sac (omental bursa) communicates with the greater sac (most of the peritoneal cavity) via the ___
Omental foramen (also called epiploic foramen also called of Winslow)
What are the anterior, posterior, superior, and inferior boarders of the Omental (epiploic) Foramen (of Winslow)?
Anterior: The hepatoduodenal ligament (the free edge of the lesser omentum), which contains the hepatic portal vein, hepatic artery, and bile duct
Posterior: IVC and right crus of the diaphragm
Superior: The liver (caudate lobe)
Inferior: The superior aka first part of the duodenum
The esophagus pierces the diaphragm (esophageal hiatus) at ___ and then the esophagus enters into the stomach at its cardiac orifice around ___
The inferior vena cava pass through the diaphragm at __ and the Aorta at ___
T10, T11
T8, T12
I Ate Ten Eggs At Noon - mnemonic
I = inferior vena cava -> Ate = T8
Eggs = Esophagus -> Ten = T10
At = Aorta -> noon = T12
A ___ hernia is when the esophageal hiatus of the diaphragm enlarges or weakens and this causes the abdominal esophagus and parts of the stomach to be pushed up into the thorax and can cause problems
A __ hernia is a defect in the diaphragm NEXT TO the esophageal hiatus and this causes just the ___ of the stomach to herniate next to the esophagus
Sliding hiatal
Paraesophageal hiatal, fundus
Comparing the Jejunum vs Ileum, fill in the blank
2) ___ Arcades (give both)
3) Which has longer Vasa Recta?
4) Which has a more vascular blood supply?
5) Which has a greater diameter and thicker wall?
6) Which has more Plicae circularis?
The ___ part of the duodenum is held in place by the hepatoduodenal ligament
The ___ part of the duodenum has the superior mesenteric artery and vein cross in front of it
THe 4th part of the duodenum is held in place by the ___ ligament, which anchors it to the right crus of the diaphragm
2) Simple Arcades for Jejunum and Complex Arcades for Ileum
3) Jejunum
4) Jejunum
5) Jejunum
6) Jejunum
1st part (superior part) 3rd part (horizontal part) Ligamentum Treitz (suspensory ligament of the duodenum)
___ is a feature of the ileum when the vitelline duct fails to close and associated with the rules of 2.
Occurs in 2% of population, 2 feet from the __ junction, about 2 inches long in length, and contains 2 types of epithelial, Gastric and pancreatic
It is also always found at the site of attachment of the omphaloenteric (yolk stalk) duct on the ___ border of the ileum
Meckel’s (ileal) diverticulum
Ileocecal junction (where ilium and colon fuse)
Anti-mesenteric
The ___ attatches the jejunum and ileum to the posterior body wall
** Basically everything needed to supply the small intestine is embedded in the mesentery
Mesentery
The ___line joins the inferior end of the anal valves
Name both above and below the line
1) Epithelium
2) Embryo
3) Artery and veins
4) Nerves
5) Hemorrhoid
___ hemorrhoids are painful and __ are not
Below the line, the internal venous plexus drains into the inferior rectal veins of the ___ system and above the line, the internal venous plexus drains superiorly into the ___ system
Pectinate (also called the dentate line)
1) Above - Simple Columnar Below - Stratified Squamous 2) Above - Endoderm Below - Ectoderm 3) Above - Superior rectal A and V Below - Middle and Inferior Rectal A and V 4) Above - Inferior Hypogastreic plexus Below - Inferior Rectal N. 5) Above - Internal Below - External
External, Internal
Caval, portal
The spleen develops from ___ mesentery from mesoderm and is held in place by what two ligaments?
Dorsal
Gastrosplenic and splenorenal
The pancreas is located at about the levels of __-__
The Duodenum at the levels of __-__
L1-L2
L1-L4
The main (aka major) pancriatic duct forms from ___ mesentery and the minor (aka accessory) pancriatic duct forms from __ mesentery
Ventral, Dorsal
What connects the liver to the anterior abdominal wall?
Falciform ligament
The __ is a fibrous remnant of the fetal ductus venosus found on the visceral surface of the liver, which shunted blood from the umbilical vein to the IVC, short-circuiting the liver
The __ is a fibrous remnant of the umbilical vein, which carried well-oxygenated and nutrient rich blood from the placenta to the fetus
ligamentum venosum
Round ligament of the liver (also called ligamentum teres hepatis)
** ^ I would know both names
The portal triad (portal vein, hepatic artery, and bile passage) enters the liver at the __
Porta hepatis
The falciform ligament runs with the ___ and the lesser omentum with the __ and ___ ligaments
Ligamentum teres hepatis (round ligament of liver)
Hepatoduodenal and hepatogastric
The Gall bladder and biliary tract are located near the ___ or ___ costal cartilage, usually located on the __ line
9th or 10th, transpyloric
The common bile duct is formed from what two ducts?
Cystic and common hepatic ducts
The left atrium contacts the __
Esophagus
The ligament of Treitz (aka the suspensory muscle of the duodenum) is attatched to the __ part of the duodenum
The superior mesenteric artery and vein cross the __ part of the duodenum anteriorly
4th (ascending)
3rd (Horizontal)
***This is a repeat question, but I bet it’ll be on the test
Diverticulum Ilea aka Meckel’s Diverticulum is associated with the __ and represents remnants of persistent embryonic ___
Ileum, Vitelline duct (yolk stalk) also called Omphaloenteric duct
When we talk about THE mesentery, we are referring to the __ and __ that is attatched to the ___ body wall via the mesentery
Jejunum and Ileum, Dorsal
For appendicitis, if inflamed, often early in appendicitis the appendix goes into spasm and pain is felt in the __ region
If the peritoneum ADJACENT to the appendix is inflamed, the pain is felt at the __, overlying the appendix
** So in other words, early on you might have some pain around your belly button (non-specific irritation), but as it gets worse, it can irritate the peritoneum and become localized, so if you apply pressure on the opposite side of the appendix, the peritoneum fibers will still stretch on the left side where the appendix is located and pain will be felt at the McBurney’s point
Peri-umbilical (Although notes say Epigastric??????)
McBurney’s Point
The “Critical Point” of Sudeck is the area on the colon where the lowest ___ artery has a poor anastomoses with the __ artery
Sigmoid, superior rectal
** The rectosigmoid junction gets blood from both of these sources
The ___ muscle, which is part of the levator ani muscle and forms a sling at the anorectal junction is ___ (voluntary or involuntary) and allows for the control of defecation
Puborectalis muscle, Voluntary
The abdominal aorta begins at ___ and terminates at ___ to bifurcate into the left and right common iliac arteries
The IVC bifurcates into the common iliac veins at ___ and lies to the ___ and parallel to the aorta. It also pierces the diaphragm at ___
T12, L4
L5, right, T8
Where does the thoracic duct drain into?
Left subclavian vein
A balloon like dilation of the abdominal aorta that usually arises below the renal arteries and above the aortic bifurcation is ___, and is primarily due to atherosclerosis and common with hypotension
** A ___ is a sign that this is about to occur
Abdominal Aortic Aneurysm (AAA)
False Lumen
What artery is inside the splenorenal ligmanet?
Splenic A
**** The superior mesenteric artery emerges from the aorta posterior to the __ of the pancreas
Neck
If the abdominal aorta is blocked between the celiac trunk and the SMA, why don’t we die… Aka what anastomoses keeps blood circulating
Also, where does this anastomoses occur?
Anastomoses between Superior and Inferior Pancreaticoduodenal A
Ciliac trunk -> Gastroduodenal A -> Superior Pancreaticoduodenal A
SMA -> Inferior Pancreaticoduodenal A
Head of Pancreas
Above the pectinate line, superior rectal arteries and veins drain into __
Below the line, Middle A and V drain into ___ and Inferior A and V drain into ___
Inferior mesenteric vein
Internal iliac vein
Internal pudendal vein to internal iliac vein
The lumbar lymphatic trunk and Intestinal lymphatic trunk drain into the ___, which goes to the thoracic duct and into the left subclavian vein
Cisterna Chyli
The nerve plexi have both sympathetic and parasympathetic fibers. The sympathetic innervation has preganglionic fibers arising from the levels of __-__ and these travel in respective __ nerves and synapse on prevertebral sympathetic ganglia, and then the postganglionic fibers travel from the ganglia to the abdominal organs
Parasympathetic innervation is supplied mainly by the __ nerve (foregut and midgut), however the hindgut is supplied by the __ nerve
T5-L1, Splanchinc nerves
Vagus, pelvic splanchnic nerves
The preganglionic fibers for parasympathetic innervation travel through the __ plexus, but DO NOT synapse there due to the fact that they synapse in the ___ nervous system contained in the gut wall
You have two principle components of the enteric NS, the ___ plexus which is located between the outer longitudinal and inner circular muscle layers and this allows for __
The other component is the ___ plexus, which is on top of the submucosa and is responsible for secretions, blood flow, and absorption
*** THE ENTERIC NERVOUS SYSTEM IS A SUBDIVISION OF THE AUTONOMIC NERVOUS SYSTEM (ANS) that directly controls the GI system
Celiac, Enteric (Intrinsic)
Myenteric (Auerbach’s), motility
Submocosal (Meissner’s)
*** POSSIBLY A TEST QUESTION The failure of neural crest cells to migrate during intestinal development, causing no Myenteric plexus to form (since the neural crest cells are suppose to become the ganglion cells), is ___ disease
So another way it could be asked, is… If a patient has no myenteric plexus upon biopsy, what innervation is not working and what is the disease called? Also what layer MUST be biopsied in order to get a correct diagnosis?
Hirschsprung
Parasympathetics (since the myenteric plexus is part of it), Hirschsprung disease
Muscularis externa (because remember, this is talking about the myenteric plexus, which is found between the outer longitudinal and inner circular muscle layers)
In ___ disease, you have can have a megacolon, no myenteric plexus, etc (similar to hirschsprung disease), however, this occurs via the parasite, T. Cruzi
Chagas Disease
GVA pain reflexes follow ___ innervation and GVA fibers for visceral reflexes (like peristalisis aka movement of stuff in the stomach) follow ___ innervation
Sympathetic, parasympathetic
^** Parasympathetic are unconscious and mostly from stretch receptors
The ___ of the small and large intestines are relevant sites of immune responses since they contain Peyer’s Patches or GALT in lymphatic nodules
Lamina propria (called Peyer’s patches or GALT)
Some of the ___ make mucous as a protective coat, and other parts will make enzymes and acids to breakdown food
Mucosal glands
Folds consisting of the mucosa layer and submucosa layer are called ___ in the stomach and ___ in the small intestine
And if the folds contain ONLY the muscosa alone, it’s called ___
Rugae, Plicae
Villi
What do contractions of the circular and longitudinal layers both do?
Circular = smooth fibers contract the lumen
Longitudinal = shortens the tube
**Both important for peristalsis
The outer layer is called ___ if inside the peritoneal cavity, or __ if outside the peritoneal cavity (like retroperitoneal or the esophagus and most of duodenum)
Serosa, Adventitia
The innervation of the GI is both extrinsic and intrinsic (aka enteric).
The extrinsic innervation is the ANS (symp and parasympathetics)
___ decreases motility and secretions, where as ___ increase the motility/secretions
The intrinsic (aka enteric) has two parts like we mentioned before, submucosal and myenteric plexi. This system is responsible for peristaltic contractions to move food bolus and secretory activity of mucosal/submucosal
Sympathetics, Parasympathetics
The ___, lies just anterior to the gastroesophageal junction and helps prevent reflux and regurgitation of stomach contents and must relax to allow food passage with swallowing. This is a ___ sphincter (involuntary or voluntary?_
GERD (Gastroesophageal Reflux), where some contents of the stomach come back up from the stomach to the esophagus is due to a defect in the ___
**** THIS WILL ALMOST FO SHO BE A TEST QUESTION
^If this condition continues, it can result in ___, a condition in which you can have changes in the epithelium from stratified squamous epithelium to ___
LES (lower esophageal sphincter)
**Functionally defined as the gastroesophageal sphincter (not anatomically defined)
Involuntary
** The upper sphincter is voluntary
LES (lower esophageal sphincter)
Barrett’s Esophagus, Simple columnar epithelium (trying to adapt to the acidic environment so it mimics the epithelium that you see in the stomach and this can predispose people to esophageal cancer)
For the esophagus, the epithelium is a non-keratinized ___.
The lamina propria contains ___ connective tissue and some superficial mucosal glands
**The upper third of the esophagus is ___ muscle and the lower thirds is __ muscle in the muscularis externa
Stratified squamous epithelium, Elastic
Skeletal (for voluntary swallowing), Smooth (for peristalsis)
At the gastroesophageal junction, the mucosa transitions from stratified squamous epithelium to ___ and glandular secretoy mucosa
Simple columnar epithelium
If there is an increase in portal venous pressure, aka Portal ___the veins in the esophagus can become dilated (called esophageal ___) and the pressure is so great that it makes blood flow into the liver more difficult. Since the portal vein system is valveless, you don’t get anything from stopping the blood from backing itself up
Hypertension, varicies (Dialted veins, think varicies)
___ cells predominate in the lower portion of the gastric gland and secrete the proenzyme ___, stored in the zymogen granules
This enzyme is released into the lumen of the gland and converted in the acidic environment of the stomach to ___, an enzyme that helps digest proteins
** This is stimulated by eating
Cheif cells, Pepsinogen, pepsin
Parietal cells secrete ___ and ___
___ is needed to absorb vitamin B12
Hydrochloric acid and intrinsic factor
Intrinsic factor
___ is a disease when ___ cells are destroyed due to autoantibodies to H+,K+ dependent ATPase and therefore, less hydrochloric acid is released and no intrinsic factor synthesis occurs
You can now end up with a ___ deficiency that disrupts the formation of red blood cells in the bone marrow, leading to pernicious anemia
Autoimmune gastritis, parietal
Vitamin B12
What two things can increase the release of HCL (hydrochloric acid) by parietal cells?
Acetylcholine and gastrin
In the mucus blanket lining the gastric epithelium, in particular the pyloric ___, the bacterium ____ can reside and it’s associated with acid peptic ulcers and adenocarcinoma of the stomach
Antrum (end of stomach), Helicobacter pylori (H. Pylori)
G-cells (Gastroenteroendocrine cells) secrete 6 peptides. Name the peptide based in its function
1) When gastric contents enter the duodenum, this is released in order to stimulate pancreatic and duodenal glands to secrete bicrobonate in order to moderate PH of the duodenal contents. It also stimulates chief cells to secrete pepsinogen and inhibit gastrin released to reduce HCL secretion
2) Stimulates the production of HCL by parietal cells
3) Stimulates gallbladder contraction and relaxation of the sphincter of Oddi (common bile duct and main pancreatic duct come together) aka regulates movement of bile from the gallbladder and pancreatic enzymes and juice into the duodenum
4) Stimulates insulin release when glucose is detected in the small intestine (aka helps to maintain right insulin balance)
5) Important during fasting or between meals and stimulates GI motility (acts on stomach to contract the fundus so it can push everything out of the stomach to use all it possibly can)
6) Produced in the stomach and binds to cells in the anterior pituitary (anterior hypophysis) that make growth hormone in order to release it in order to try to get you to eat
1) Secretin
2) Gastrin
3) CCK
4) GIP (GLucose-dependent insulinotropic peptide
5) Motilin
6) Ghrelin
What layers expand in the pylorus to make the the annular pyloric sphincter?
The circular muscle layer of the muscularis externa
In the hepatic portal system, the hepatic portal vein goes into the liver and is formed by what three other veins?
**Also, this vein has (a valve, or no valve?)
Splenic vein, superior mesenteric vein, inferior mesenteric vein
No valve
The portal traid runs through the ___ ligament and enters the liver at the ____
Hepatoduodenal ligament (part of the lesser omentum), Porta Hepatis
In the esophagus, the blood superior is drained by the ___ system and blood inferiorly is drained by the ___ system
Systemic system (azygos system)
Portal system (portal vein)
Off of the IVC, you have suprarenal veins, renal veins, and gonadal veins at the level of ___, and on the right side, how are they oriented, and what about the left side?
L1,
Right side, all separately go to IVC
Left side, only left renal vein comes off IVC, and left suprarenal and left gonadal come off of the left renal vein
When blood flow into the liver is impeded, such as in portal hypertension, the ___-___ anastomoses aka collateral pathways become very important (connections between the portal venous system and the inferior vena cava system)
Name, or at least know the 4 main ways for blood to bypass the liver… KNOW ALL OF THESE**
Portal-Caval
Esophageal varicies, Rectal varicies, Caput medusa in belly button, colic veins to retroperitoneal veins
** Here are all the connections spelled out
The gastric mucosa of the fundus body has two classes of mucus producing cells called surface mucous cells and mucous neck cells and both cells produce ___, a type of glycoprotein that are designed to hold lots of water, so it acts as an insoluble protective gel that covers the surface of the epithelium of the stomach
**The mucins trap ___ ions and stabilizes the PH
Mucins
Bicarbonate
Up in the cardia region, cardiac glands are lined by mainly ___ cells
Mucus secreting cells
TIPS procedure is when a stent is placed between the __ and ___ veins in order to stop backflow and buildup from blood going into the liver
Hepatic portal vein and hepatic veins
___ are epithelial cells in the small and large intestine
___ is the partially digested food expelled by the stomach into the duodenum
The small intestine has an abundance of ___ in order to increase the surface area for absorption
Enterocytes
Chyme
Vili
There are four degrees of folding in order to increase absorption of the intestine
First, ___ are folds that include the mucosa and submucosa
Next, ___ are the folds of only the mucosa
Between the vili, ___ exists also known as crypts of Lieberkuhn
Last, the enterocytes (epithelial cells lining the lumen of the intestines) have small __ on the apical surface
Plicae circulares
Intestinal villi
Intestinal glands
Microvilli
** So know that all 4 of these increase surface area
Contents that advance along the intestine when proximal contraction is coordinated with relaxation below is called ___
When contents are mixed and circulated due to contraction that is NOT coordinated with relaxation below, it is called ___
** Both help mix the chyme within the small intestine
Peristalsis
Segmentation
The intestinal ___ is the main distribution site of blood and lymph flow
Small centrally located lymphatic vessels found in the core of a villus are called ___ and these convey ___ from the intestine to the lymphatic circulation and thereby to the thoracic duct and then systemic blood circulation
Submucosa
Lacteals, chyle (lipids absorbed from the meal and packages in chylomicrons)
*** KNOW THIS IT WILL BE A TEST QUESTION
In the duodenum, not seen anywhere else, you have submucosal glands called ___
**So glands in submucosa = duodenum
In the Jejunum, what is the distinguishing characteristic?
In the ileum, what is the distinguishing characteristic?
Brunner’s glands
Plicae circulares
Peyer’s patches
What are the 4 cell types in the intestinal glands?
Enterocytes (aka absorptive cells), Goblet cells, Paneth cells, and enteroendocrine cells
Intestinal glands (large and small intestines) are called ___, so if you see this then think of the enterocytes, goblet cells, paneth cells, and G-cells…
** Don’t confuse this with gastric glands that contain different cell types and are located ONLY in the stomach!
Crypts of Lieberkuhn
Name the enzyme
1) Stimulates gastric acid secretion
2) Stimulates secretion of pancreatic enzymes
3) Stimulates secretion of water and bicarbonate
4) Strong stimulant of appetite and growth hormone
5) Inhibits gastric secretion and mobility
1) Gastrin
2) Cholecystokinin (CCK)
3) Secretin
4) Ghrelin
5) Gastric inhibitory peptide
Name the intestinal gland cell based on its function
1) Mucus secreting cells and the secretory product contains glycoproteins to form a protective gel coat, which shields the epithelium from mechanical abrasion and bacterial invasion
2) Contain many microvilli, with enzymes that cause the digestion of carbohydrates. Also have tight junctions that act as a barrier
3) Secrete peptide hormones like Gastrin, Secretin, and CCK to control various GI functions (similar to G-cells)
4) Secrete antimicrobial proteins to limit bacteria-enterocyte contact
1) Goblet cells
2) Enterocytes
3) Enteroendocrine cells
4) Paneth cells
Lactose intolerance is due to a depletion of ___
Enterocytes
^^ Not sure if this is exactly true… But since enterocyte microvilli contain intramembranous enzymes including lactase, which is needed to break down lactose into glucose and galactose, I would assume its correct….
When ___ come in and start to destroy the intestinal glands, this causes you to knock out the activity of cells that help protect the intestines. To combat this, you get lots of lymphocytes (called granulomas) and these can get large enough that they occlude the lumen or you can get fibrosis and this disease is called ___
** A defect in the protective system
___ is a procedure used to replace good bacteria that has been killed or suppressed due to the use of antibiotics
neutrophils
IBD (inflammatory bowel disease) or Crohn’s disease
FMT (Fecal Microbiota Transplant)
Plicae circulares and intestinal villi are not found beyond the __ valve, but you still have intestinal glands with lots of goblet cells
The enterocytes of the large intestine (Colon) participate and Na and Cl- movement in order to do their main role, which is ___
Ileocecal (between ileum and cecum)
Water reabsorption
A characteristic feature of the large intestine, formed by fused bundles of the outer smooth muscle layer is the ___
A small blind-ended diveticulum off of the cecum, with lots accumulations of lymphoid tissue and NO taenia coli, is called the ___ (thinks its function is to act as a safehouse for good bacteria)
Although pretty much the same as the small intestine, the large intestine (Colon) does not contain which of the 4 cell types found in the small intestine?
Taeniae coli
Appendix
Paneth cells
At the Ano-rectal junction, the epithelium changes from ___ to ___ and this epithelial change marks the pectinate line
Simple columnar epithelium, stratified squamous epithelium
A defect in the protein ____ can predispose persons to Colorectal tumors
so if you have developed a cancer somewhere in the colon and gets spread through the venous of lymphatics system, where it spreads from its original point of origin to the next set of nodes depends on where you are in the gut **So knowing something about venous supply and lymphatics is clinically important
APC (Adenomatous polyposis coli)
The stomach has rugae (longitudinal folds of the gastric mucosa and submucosa) with many pits, these pits are also called gastric glands. These gastric glands do what two things?
secrete mucus and enzymes involved in the chemical digestion
