Week 1 Flashcards by Stephen Barna

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)

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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

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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)

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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

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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

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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

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******* Nerves and vessels (neurovascular plane) can be found between the __ and __ muscles

Internal abdominal oblique and transverses abdominis muscle layers

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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

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___ 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

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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

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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

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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

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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

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** 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

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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

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The rectus abdominus muscle is crossed by ____ intersections

Tendinous

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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

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What layer would you find the superficial arteries And veins in?

Campers fascia

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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

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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)

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***** 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

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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

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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

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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

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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