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274 Cards in this Set
- Front
- Back
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Boundaries of abdomen
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Superior - diaphragm
Inferior - plane of pelvic inlet (pelvic brim) from superior pubic symphysis to sacral promontory Laterally - lateral abdominal walls Posterior - posterior abdominal wall |
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Iliopectineal line
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Pecten pubis + arcuate line
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Linea terminalis
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Pubic symphysis + arcuate line
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Superior surface landmarks
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xiphoid process
costal margin |
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Inferior surface landmarks
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Iliac crests (LV4)
ASIS inguinal lig Pubic crests Pubic tubercle Pubic symphysis |
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Lateral surface landmarks
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Anterior axillary folds
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Other surface landmarks
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Umbilicus
Linea semilunaris Linea alba Tendinous intersections Rectus abdominus |
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Linea semilunaris
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Lateral border of rectus abdominus
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Linea alba
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fibrous band from xiphoid process to pubic symphysis
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Abdominal quadrants
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Horizontal plane - transumbilical plane: umbilicus; IV disc b/w L3/L4
Vertical plane-median plane: position of linea alba |
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Horizontal planes of abdomen
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Subcostal: 10th costal cartilages, body of L3
Transtubercular plane: iliac tubercles, body of L5 |
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Vertical planes of abdomen
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midclavicular planes: L & R; midpoint of clavicle to midinguinal point
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Abdominal regions
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1. R hypochondriac
2. L hypochondriac 3. Epigastric 4. R lumbar 5. L lumbar 6. Umbilical 7. R inguinal 8. L inguinal 9. Hypogastric (pubic) |
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Transpyloric plane
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Imaginary line through tips of 9th costal cartilages and L1
Includes: 1. pylorus 2. duodenal junction 3. origin of sup. mesenteric artery 4. hila of kidneys 5. neck and body of pancreas 6. 9th costal cartilages 7. body of L1 |
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Lateral components of anterior abdominal wall
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1. Skin
2. Camper's fascia 3. Scarpa's fascia 4. Deep fascia 5. External abd. oblique m. 6. Internal abd. oblique m. 7. Transversus abd. m. 8. Tranversalis fascia 9. Extraperitoneal fatty layer 10. Parietal peritoneum |
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Medial components of anterior abdominal wall
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1. Skin
2. Camper's fascia 3. Scarpa's fascia 4. Deep fascia 5. Anterior rectus sheath 6. Rectus abdominis m. 7. Posterior rectus sheath 8. Transversalis fascia 9. Extraperitoneal fatty layer 10. Parietal peritoneum |
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Camper's fascia
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Superficial fatty layer
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Scarpa's fascia
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Superficial layer
Deep membranous layer Inserts on fascia lata of thigh |
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Extravasated urine
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If urethra is ruptured, urine may travel between superficial and deep fasciae in ant. ab wall and perineum but not into thigh
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Muscles of anterior ab. wall
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1. External oblique
2. Internal oblique 3. Tranversus abdominis 4. Rectus abdominis 5. Pyramidalis |
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External oblique
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Runs inferomedially
1. Ext. oblique aponeurosis 2. Anterior rectus sheath 3. Linea alba 4. Inguinal ligament 5. Lacunar ligament 6. External spermatic fascia 7. Lumbar triangle of petit |
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Internal oblique
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Superoanteriorly
1. Internal oblique aponeurosis 2. Ant./Post. rectus sheath 3. Linea alba 4. Conjoint tendon (falx inguinalis) 5. Cremaster muscle |
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Transversus abdominis
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Horizontally
1. Transversus abdominis aponeurosis 2. Ant./Post. rectus sheath 3. Linea alba 4. Conjoint tendon (falx inguinalis) Does not cover spermatic cord |
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Rectus abdominis
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Vertically within rectus sheath
1. Tendinous intersections 2. Linea semilunaris (lateral border) |
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Pyramidalis m.
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Tenses linea alba
1. Tendinous intersections 2. Linea semilunaris (lateral border) |
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Inguinal ligament
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Inferior border of external oblique aponeurosis; attaches to ASIS and pubic tubercle
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Lacunar ligament
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Extension of medial fibers of inguinal ligament that attach to pecten pubis
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External spermatic fascia
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Outer covering of spermatic cord
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Lumbar triangle of petit
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Lateral border of triangle
Possible site of herniation |
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Pectineal (Cooper's) ligament
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Fibers from lacunar ligament along the pecten pubis
Lateral extension of lacunar ligament |
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Conjoint tendon (falx inguinalis)
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Common tendon of internal oblique and transverse abdominis muscles inserted on pecten pubis
Helps resist formation of direct inguinal hernia |
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Cremaster muscle
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Supplied by genital branch of genitofemoral nerve (L1-L2)
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Rectus sheath formation
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1. Above costal margin: anterior - external oblique
posterior - absent (lies on costal cartilages) 2. Between costal margin and arcuate line: Anterior - ext. and int. obliques Posterior - int. oblique and transversus abdominis 3. Between arcuate line and pubic crest: Ant - ext. and int. obliques and transversus ab. Post. - absent (lies on transversalis fascia) |
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Contents of rectus sheath
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1. Rectus abdominis muscle
2. Pyramidalis muscle 3. Sup. and inf. epigastric vessels 4. Lymphatic vessels 5. Terminal parts of ventral primary rami of T7 - T12 |
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Transversalis fascia
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Lines cavity, deep to transversus abdominis, in contact with rectus abdominis below arcuate line
Derives deep inguinal ring and internal spermatic fascia |
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Exploratory incisions
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Median/midline
L paramedian |
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Appendix incisions
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Gridiron
Transverse |
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Uterus incision
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Pfannenstiel
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Gallbladder incision
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Subcostal
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Arterial supply to anterior abdominal wall
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Superficial: superf. epigastric aa., superf. circumflex aa., superf. ext. pudendal aa.
Deep: brs. of post. intercostal aa., brs. of subcostal aa., lumbar aa. from abd. aorta, deep circumflex iliac aa. & ext. iliac a., inf. epigastric aa., sup. epigastric aa. Epigastric aa. are in rectus sheath |
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Superficial veins of anterior ab. wall
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Lateral thoracic vv.
Superficial circumflex iliac vv. Superficial epigastric vv. Superficial ext. pudendal vv. Thoracoepigastric vv. Paraumbilical vv. |
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Thoracoepigastric vv.
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Connect lateral thoracic and superficial epigastric vv.
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Enlarged thoracoepigastric vv.
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Due to compression of IVC cava during pregnancy
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Paraumbilical vv.
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Drain into portal v.
May shunt portal blood into superficial vv. around umbilicus (caput medusae) in portal HPN |
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Nerve supply to anterior abd. wall
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Ventral rami of T7-T12: Thoracoabdominal nn., T10, T12
Ventral rami of L1: Iliohypogastric n., ilioinguinal n. |
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What does T10 supply?
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Skin and tissues at level of umbilicus
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Cremaster reflex
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Sensory component by ilioinguinal n.
Motor served by genital br. of genitofemoral n. (L1-L2) Elicited by stroking medial aspect of thigh (groin) |
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GSA in ant. abd. wall
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Skin, superficial fascia --> anterior/lateral cut. brs. of intercostal nn., dorsal root, DRG, dorsal root --> spinal cord
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GSE in ant. abd. wall
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Ventral horn, ventral root, spinal nerve ventral ramus, intercostal nn. (T7-L1) --> muscles
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GVE in ant. abd. wall
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IMLCC, ventral root, spinal nerve, ventral ramus, white ramus --> paravertebral sympathetic ganglion, gray ramus intercostal nn. T7-L1 --> smooth muscle of blood vessels and glands of abd. wall
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Lymphatic drainage of superficial tissues in ant. abd. wall
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Skin and fascia
1. above umbilicus - axillary lymph nodes 2. below umbilicus - superficial inguinal nodes, drain to iliac nodes |
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Lymphatic drainage of deep tissues in ant. abd. wall
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Muscles - eventually drain to para-aortic nodes
1. Lumbar nodes 2. Common iliac nodes 3. External iliac nodes |
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Primitive umbilical ring
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Temporary defect in body wall
Caused by vitelline duct and connecting stalk |
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What happens to the R and L intraembryonic cavities?
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Merge into a single intraembryonic cavity
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Umbilical hernia
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Protrusion of peritoneum or abdominal organs around the navel
Midgut protrudes thru defect when crying, straining, or coughing Not covered with amnion |
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Omphalocele
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Due to failure of midgut to return to body cavity after physiological herniation
Viscera protruding through umbilicus are covered by amnion High alpha-fetoprotein levels |
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Gastroschisis
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Incomplete closure of lateral folds allowing gut to protrude into amniotic cavity
Loops of bowel herniate through weakness in body wall, lateral to umbilicus Not covered by amnion High alpha-fetoprotein levels in maternal serum and amniotic fluid |
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Injury to upper abdominal organs
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May be due to fractures of the lower ribs
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Formation of thoracoepigastric vein
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Anastomoses between superficial epigastric vein and lateral thoracic vein
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Fundus of gallbladder
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At junction between linea semilunaris and 9th costal cartilage
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Anastomoses between superior and inferior epigastric arteries
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May bypass in postductal coarctation of aorta
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Anastomoses between superior and inferior epigastric veins
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Alt. route to heart if vena cavae blocked
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Indirect inguinal hernia in men
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From posterior abdominal wall through deep inguinal ring, inguinal canal, superficial inguinal ring into scrotum
Leaves abdominal cavity lateral to inferior epigastric vessels Failure of closure of peritoneal evagination during testes descent |
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Processus vaginalis
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Peritoneal evagination during testes descent in men
Persists as tunica vaginalis Associated with gubernaculum Same 3 coverings as spermatic cord |
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Direct inguinal hernia
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Forward through abdominal wall at superficial inguinal ring
Leaves medial to inferior epigastric vessels through inguinal triangle Does not have same coverings as spermatic cord Covering of external spermatic fascia |
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Coverings of spermatic cord
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External spermatic fascia
Cremasteric muscle and fascia Internal spermatic fascia |
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Normal temperature for testes
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Need to be 2 - 7 * C lower than body temp
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Crytorchidism
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Undescended testes
Leads to sterility Increased risk of testicular cancer |
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Testes development
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Primordial testes/ovaries develop in extraperitoneal fatty layer (9) in posterior ab wall
By 3rd - 7th mth of pregnancy, they descend retroperitoneally to deep inguinal rings Gubernaculum testes attaches caudal pole of testes and guides their descent |
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Descent of testes
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Begin descent through ab wall due to growth processes and hormonal influences
Follow gubernaculum testis toward scrotum Processus vaginalis (evagination of peritoneum) accompanies them Descent creates inguinal canal, which eventually closes |
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Coverings of testes
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External spermatic fascia (from oblique aponeurosis)
Cremaster m. and its fascia (from internal oblique mm) Internal spermatic fascia (from transversalis fascia) |
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Walls of inguinal canal
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Post.: transversalis fascia and conjoint tendon (medial 3rd canal)
Ant.: ext. oblique apopneurosis, int. oblique m (lateral part) |
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Roof and floor of inguinal canal
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Roof: transversus abdominis and internal oblique muscles
Floor: inguinal and lacunar ligaments |
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Deep inguinal ring
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Opening in transversalis fascia leading to inguinal canal
Lateral to inferior epigastric vessels Entrance of: vas deferens testicular artery and vv genital br of genitofemoral n. cremasteri br of inf epigastric a a of vas def. from inf. vesicula a |
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Superficial inguinal ring
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Opening created due to defect in external oblique aponeurosis
Next to pubic tubercle Posterior wall is conjoint tendon Exit of spermatic cord or ligamentum teres uteri and ilioinguinal nerve |
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Inguinal nerve
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Passes through inguinal canal and exist superficial ring but does not enter deep ring
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Contents of spermatic cord
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Vas deferens
a. to vas deferens testicular a. pampiniform plexus of vv lymphatic vessels autonomic nn remnants of processus vaginalis cremasteric a genital br of genitofemoral n - motor component of cremaster reflex |
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Most common sites of hernia
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Inguinal
Femoral Umbilical Spigelian Epigastric Lumbar Incisional Internal |
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Femoral hernia
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in femoral canal
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Spigelian hernia
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linea semilunaris, usually at arcuate line
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Lumbar hernia
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triangle of petit
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Internal hernia
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peritoneal cavity
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Direct inguinal hernia
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Common in old men
Sac bulges directly through weakened conjoint tendon In inguinal (Hesselbach's) triangle in medial inguinal fossa bulge is medial to inferior eipgastric vessels Exits through superficial ring, lateral to spermatic cord |
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Indirect inguinal hernia
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Most common form, more in men
Congenital Patent remnant of processus vaginalis Passes through inguinal canal Covered by 3 layers of ant. wall mm Sac enters deep ring, lateral to inf. epigastric vessels Bulges above and medial to pubic tubercle Exits through superficial ring within spermatic cord Extends into scrotum or labium majus |
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Inguinal triangle (Hesselbach's)
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Inferior epigastric vessels
Inguinal lig Rectus abdominis m. |
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Lesser sac/omental bursa
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Epiploic foramen
Omental foramen Foramen of Winslow |
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Greater sac
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Subphrenic spaces - L & R
Hepatorenal recess paracolic gutters paravertebral gutters |
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Omental or epiploic foramen
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Communication between greater and lesser sacs
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Hepatorenal Recess (pouch)
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AKA Morrison's Pouch
Between visceral surface of liver and right kidney Epiploic foramen, subphrenic recess, and R lateral paracolic gutter, open to recess Most dependent portion of the peritoneal cavity in a supine individual May be site of abnormal fluid accumulation in a bedridden patient |
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Fluid movement in greater sac
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?
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Parietal peritoneum
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Lines internal surface of abdominal and pelvic cavities
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Visceral peritoneum
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Covers viscera or abdominal organs
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Peritoneal derivatives
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Connect visceral organs to each, to ab walls, and to diaphragm
Convey vessels and nerves to viscera Hold organs in place |
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Intraperitoneal organs
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Stomach
Duodenum (1st) Jejunum/ileum v. appendix cecum tranverse colon sigmoid colon liver/gall bladder spleen |
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Retroperitoneal
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Duodenum (rest)
Ascending colon Descending colon Rectum Pancreas Kidneys/adrenals Ureters Blood vessels (aorta, IVC) |
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Mesentary
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Mesentary - small intestines
Transverse mesocolon Sigmoid mesocolon |
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Contents of spermatic cord
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Vas deferens
a. to vas deferens testicular a. pampiniform plexus of vv lymphatic vessels autonomic nn remnants of processus vaginalis cremasteric a genital br of genitofemoral n - motor component of cremaster reflex |
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Most common sites of hernia
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Inguinal
Femoral Umbilical Spigelian Epigastric Lumbar Incisional Internal |
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Femoral hernia
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in femoral canal
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Spigelian hernia
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linea semilunaris, usually at arcuate line
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Lumbar hernia
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triangle of petit
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Internal hernia
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Peritoneal cavity
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Direct inguinal hernia
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common in old men with weak abdominal muscles
-sac bulges directly thru weakened conjoint tendon -in inguinal (Hesselbach’s) triangle -in medial inguinal fossa -bulge is medial to inferior epigastric vessels -exits thru superficial ring, lateral to spermatic cord |
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Indirect inguinal hernia
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most common form of inguinal hernia; more in men
-patent remnant of processus vaginalis; congenital -more common in children and young adults -passes thru the inguinal canal -covered by 3 layers of ant. wall mm. -sac enters deep ring, lateral to inf. epigastric vessels -sac bulges above and medial to pubic tubercle -exits thru superficial ring within the spermatic cord -sac often extends into the scrotum or labium majus |
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Inguinal triangle (Hesselbach's triangle)
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1. inferior epigastric vessels
2. inguinal ligament 3. rectus abdominis muscle |
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Lesser sac/omental bursa
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Epiploic foramen
Omental foramen Foramen of Winslow |
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Greater sac
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1. subphrenic spaces-L and R
2. hepatorenal recess 3. paracolic gutters |
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Omental or epiploic foramen
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communication between greater and lesser sac
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Hepatorenal recess
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AKA Morrison's Pouch
B. between visceral surface of liver and right kidney C. epiploic foramen (of Winslow), subphrenic recess, and right lateral paracolic gutter open to the recess D. most dependent portion of the peritoneal cavity in a supine individual E. may be site of abnormal fluid accumulation in a bedridden patient |
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Fluid movement in greater sac
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?
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Parietal peritoneum
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lines internal surface of abdominal and pelvic cavitities
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Visceral peritoneum
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covers viscera or abdominal organs
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Peritoneal derivatives
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- connect visceral organs to each other, to abdominal walls, and to diaphragm
- convey blood vesssels and nerves to viscera - hold abdominal organs in place |
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Intraperitoneal
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stomach
duodenum (first) jejunum/ileum v. appendix cecum transverse colon sigmoid colon liver/gall baldder spleen |
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Retroperitoneal
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duodenum (rest)
ascending colon descending colon rectum pancreas kidneys/adrenals ureters major blood vessels (aorta, IVC) |
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Mesentary
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Intestines
1.mesentery-small intestines 2.transverse mesocolon 3.sigmoid mesocolon |
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Omentum
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Stomach
greater omentum lesser omentum |
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Ligaments around stomach
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gastrocolic,
gastrosplenic, gastrophrenic |
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Ligaments of liver
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falciform,
gastrohepatic, hepatoduodenal, coronary, triangular |
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Ligaments around spleen
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gastrosplenic,
splenonorenal, phrenicocolic |
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Peritoneal folds
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On the ant. abd. wall:
1. Median umbilical fold 2. Medial umbilical fold 3. Lateral umbilical fold Spaces associated with folds: A. Supravesical fossa B. Medial inguinal fossa C. Lateral inguinal fossa |
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Median umbilical fold
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1. from apex of urinary bladder to umbilicus
2. contains median umbilical ligament or urachus (remnant of fetal allantois 3. patent allantois may manifest as leakage of urine from the umbilicus |
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Medial umbilical fold
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1. from apex of urinary bladder to umbilicus
2. contains median umbilical ligament or urachus (remnant of fetal allantois) 3. patent allantois may manifest as leakage of urine from the umbilicus |
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Lateral umbilical fold
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1.contains inf. epigastric vessels
2.deep inguinal ring is lateral 3.inguinal triangle is medial |
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Associations with peritoneal folds
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D. Associated with duodenal recesses (site for internal hernias)
E. Associated with cecal recesses (most common location of vermiform appendix) F. Associated with intersigmoid recess (site for internal hernias) |
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Ascites
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Fluid accumulation in peritoneal cavity
Can result from cirrhosis, cancer, infection |
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Paracentesis
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Aspiration of peritoneal fluid
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Hysterosalpingography
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Examination (by radiopaque) of the patency of the uterine tubes
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Urachal fistula
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Patent urachus in newborn
May result in urine leaking from umbilicus |
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Suphrenic recesses
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Frequent sites of abscess formation, which may result in referred pain to shoulder
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Significance of greater omentum
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Mobile structure
Walls off areas of localized infection by forming adhesions around them May prevent spread of infection throughout peritoneal cavity which could result in development of potentially fatal general peritonitis |
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Liver biopsy
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Trocar or needle inserted through R 9th or 10th intercostal space in midaxillary line
Penetrates (in order): Skin, superficial fascia, intercostal mm, endothoracic (Extrapleural) fascia, costal pleura, costodiaphragmatic recess, visceral peritoneum, liver |
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Transjugular approach to liver biopsy
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internal jugular v --> brachiocephalic v --> SVC --> R atrium --> IVC --> hepatic v --> liver
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Ileocecal valve
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Prevents reflux of chyme into terminal ileum
May be obstructed by gallstone (ileus) that has entered lumen of intestine via fistula with gallbladder |
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Retrocecal position
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Normal position of appendix
Extends superiorly behind cecum toward R colic flexure |
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Appendix pain
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Initially GVA, then sharp pain from GSA
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R and L paracolic
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Pathways for movement of infectious fluid or cancer cells into pelvic cavity in upright patient
Approach to surgical mobilization of ascending and descending colons |
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Volvulus
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Twisting of colon
Usually in sigmoid colon May result in intestinal obstruction and necrosis |
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Diverticulosis
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Usually sigmoid colon
Development of outpouchings of intestinal mucosa probably due to fiber insufficiency Prone to infection, inflammation, hemorrhage, perforation |
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Pancreatic pseudocyst
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Collection of pancreatic fluid in posterior wall of omental bursa
May be due to pancreatitis |
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Cystohepatic/hepatobiliary triangle
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Cystic a. crosses triangle bound on L side by common hepatic duct, on R side by cystic duct and above by liver
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Calot's lymph node
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In triangle
Becomes enlarged during gallbladder or bile duct inflammation |
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Peptic ulcer
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May result in hemorrhage of gastroduodenal a. if erosion through post. wall of 1st part of duodenum
May also cause pancreatitis or peritonitis |
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Fatal hemorrhage
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May be due to:
erosion of peptic ulcer through posterior wall of stomach rupture of a splenic artery aneurysm |
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Chronic reflux of gastric contents
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Barrett's esophagus
Associated with GERD Metaplastic change of mucosa (intestinal metaplasia) Ulceration stricture formation Esophageal adenocarcinoma |
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Fundus of gallbladder
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Surface projection near tip of 9th costal cartilage and linea semilunaris (midclavi. line)
Pain at this sign due to cholecystitis May refer pain to shoulder |
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Gallstone
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May adhere to duodenum with development of cholecystenteric fistula
May obstruct ileoceal junction (gallstone ileus) |
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Hartman's Pouch
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Pouchlike dilatation of neck of gallbladder
May accumulate gallstones |
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Superior mesenteric syndrome
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Compression of duodenum by superior mesenteric vessels
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Acute mesenteric ischemia
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In superior mesenteric a
May be due to thromboembolus dislodged from heart or by sudden occlusion at focus of atherosclerosis |
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End artery
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Appendicular artery is an end artery (no anastamoses)
Becomes compressed due to edema and necrosis or perforation may result |
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Impaction of gall stone
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If gallstone goes through the cystic and bile ducts, may become stuck in hepatopancreatic ampulla, causing reflex of bile into pancreas with development of pancreatitis
May also be caused by hepatopancreatic tumor |
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Tail of pancreas
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Occupies splenorenal ligament with splenic vessels
In danger during removal of spleen |
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Adenocarcinoma of head of pancreas
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may cause extrahepatic obstruction of bile duct
Excess bile thus gets absobed into blood - obstructive jaundice |
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Duodenal cap (ampulla)
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Intraperitoneal part of duodenum
Distinct appearance on x-ray with contrast |
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Ligament of Treitz (suspensory muscle of duodenum)
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Supports duodenojejunal junction - connects flexure to R crus of diaphragm
Surgical landmark Where small intestine becomes intraperitoneal Demarcation between upper and lower GI bleeds Regulates passage of food |
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Anastomoses of ascending branch of left colic artery
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ascending br anastomoses with L br of middle colic a from superior mesenteric, helping form a marginal artery that extends from ileocecal junction to sigmoid colon
Important during atherosclerotic occlusion of ligation of inferior mesenteric a |
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Upper GI Tract
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Function: swallowing and digestion
Mouth Pharynx Esophagus Stomach |
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Lower GI Tract
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Function: absorption
Small intestines Large intestines |
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Junction of upper GI and lower GI
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junction of duodenum and jejunum (flexure)
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Gastroesophageal (cardiac) sphincter
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Physiological (not anatomical) sphincter
Prevents reflux of gastric contents into esophagus Circular muscle fibers under normal and vagal control |
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Esophageal veins
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Form submucosal venous plexus at distal end of esophagus
drain into tributaries of azygos system and of portal vein site of anastomosis between the portal vein and caval (azygos v to SVC) circulations |
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Esophageal varices
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Enlarged esophageal veins in the submucosa of esophagus
due to incr. pressure in portal vein (HPN) can rupture and cause massive bleed and hematemesis |
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Achalasia
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Esophagus becomes unable to propel food from mouth to stomach
Sphincter at lower end of esophagus fails to to relax to allow food into stomach |
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Parts of stomach
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Cardia
fundus (at cardiac notch) body pyloric part - antrum and canal marked by angular notch on the lesser curvature; pyloric canal contains pyloric sphincter |
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Curvatures of stomach
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Greater curvature
Lesser curvature |
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Peritoneal attachments of greater omentum
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Gastrocolic ligament
Gastrosplenic ligament Gastrophrenic ligament |
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Peritoneal attachments of lesser omentum
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Hepatogastric ligament
Hepatoduodenal ligament (supports duodenum but not stomach) |
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Internal features of stomach
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Cardiac orifice
Rugae - gastric folds/ridges Gastric mucosa - gastric pits lead to gastric glands in the lamina propria Gastric canal Pyloric orifice |
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Musculature of stomach
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3 layers (rest of GIT has 2)
Outer longitudinal Middle circular (in pylorus; thickened to form pyloric sphincter) Inner oblique |
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Pyloric stenosis
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Thickening of pyloric sphincter
Severe narrowing of pyloric canal and obstruction of passage of food Stomach is markedly distended Projectile vomiting Vomitus without bile Congenital condition |
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Stomach bed
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Pancreas - body/tail
Left kidney Spleen Diaphragm Left suprarenal gland Transverse mesocolon Omental bursa (lesser sac) |
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Acid peptic disease
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H. Pylori
Weakens protective mucous coating of the stomach and duodenum, allowing acid into mucosa Acid and bacteria irritate mucosa causing an ulcer H. Pylori is able to survive b/c it secretes acid neutralizing enzymes; its spiral shape helps it burrow through mucosa |
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Gastric ulcer
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Acid peptic disease
Range in size More common near pyloric part towards the lesser curvature Mainly presents as epigastric pain H. Pylori plays role |
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Gastric perforation
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Posterior perforation of ulcer in body of stomach can secondarily involve the structures of the stomach bed especially the pancreas
Can also involve the splenic artery resulting in intra-abdominal bleeding |
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Parts of the duodenum
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First part - superior
Second part - descending Third part - inferior/horizontal Fourth part - ascending |
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1st part of duodenum
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LV1
Liver Gallbladder Gastroduodenal artery passes posteriorly (may be perforated by posterior ulcer) |
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2nd part duodenum
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LV1-LV3
Transverse colon (anteriorly) Common bile duct & major pancreatic duct (posteriorly) Head of pancreas |
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3rd part of duodenum
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LV3
Superior mesenteric a and v pass anterior to duodenum Head of pancreas Uncinate process of pancreas |
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4th part of duodenum
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LV2 - LV3
Joins the jejunum ( attachment of ligament of treitz) Internal hernia here |
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Internal features of duodenum
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Smooth lining of duodenal cap (ampulla)
Plicae circulares (circular folds or valves of Kerkring) Major and minor duodenal papillae Longitudinal fold |
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Major duodenal papilla
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Demarcates junction of embryonic foregut and midgut
Has opening of hepatopancreatic ampulla (formed by pancreatic duct and common bile duct) |
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Development of the stomach
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Greater curvature, fundus, and cardiac incisure result from differential growth in dorsal wall
Lesser curvature is a result of slower expansion in ventral wall At 7th-8th wk, stomach rotates 90* clockwise around longitudinal axis to shift greater curvature to the L and rotates around dorsoventral axis to push the greater curvature inferiorly |
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Development of the duodenum
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From caudal part of the foregut, cranial part of the midgut, and associated splanchnic mesenchyme
Grows rapidly, forming C-shaped loop that projects ventrally As stomach rotates, duodenal loop rotates to R. Rotation with rapid growth of the head of pancreas pushes duodenum towards R side of ab *Dorsal mesoduodenum degenerates making the duodenum secondarily retroperitoneal EXCEPT at duodenal cap, where it keeps its mesentary |
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Jejunum
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1. Larger diameter
2. thicker walls 3. larger plicae circulares (feathery appearance) 4. more vascular, darker color 5. less fat in mesentary 6. windows 7. fewer arterial arcades 8. longer vasa rectae |
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Ileum
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1. Meckel's diverticulum
2. Peyer's patches lymph nodules 3. mesenteric fat encroaching the wall 4. more arcades 5. shorter vasa rectae |
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Physiological herniation
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Fast elongation of ileum throws midgut into dorsoventral hairpin loop (primary intestinal loop/midgut loop) and while the loop is forming, the cecum appears at the caudal end
Midgut loop goes into proximal part of umbilical cord and herniation can occur because of lack of room in abdomen |
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Rotation of midgut loop
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During herniation, midgut loop moves initial 90* CCW around an axis formed by superior mesenteric artery
Continued elongation of jejunum and ileum results in loops Cecum forms vermiform appendix |
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Retraction of herniated loops
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By 10th week, midgut retracts into ab cavity and rotates another 180* CCW, forcing the large intestine into arch around ab perimeter, creating ascending, transverse, and descending colons
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Fixation of intestines
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Most of duodenum and head of pancreas become retroperitoneal due to rotation
Ascending colon becomes secondarily retroperitoneal FIxation of hindgut - descending colon becomes secondarily retroperitoneal |
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Partitioning of cloaca
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Hindgut enters posterior part of cloaca (primitive anorectal canal)
Allantois enters anterior part (primitive urogenital sinus) Allantois and hingut are separated by the urorectal septum which migrates caudally toward the cloacal membrane Ectoderm at cloacal membrane creates anal pit By 7th wk, cloacal membrane degenerates so that the anal canal is made from the continuity of the hindgut and anal pit |
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Meckel's (ileal) diverticulum
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Remnant of vitelline duct, which normally regresses 5-8 weeks
Contains all layers of intestinal wall (true diverticulum) May appear in various stages of regression, including remaining patent to create an umbilicointestinal fistula |
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Rule of 2s
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For Meckel's diverticulum
2-3% infants 1-2 inches long 2-3 feet prox to ileocecal jxn 2 types tissues (gastric or pancreatic mucosa) 2 manifestations - intestinal obstruction or GI bleed |
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Manifestations of Meckel's diverticulum
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Intestinal obstruction or GI bleed, that may mimic appendicitis, presenting as periumbilical pain in R lower quad.
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Complications of Meckel's diverticulum
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Ulcerations, inflammation, torsion +/- strangulation, intussusception (telescoping) or herniation
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General features of large intestine
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Taeniae coli - longitudinal bands
Haustra coli - sacculations Omental (epiploic) appendages - fat tags |
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Taeniae Coli
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3 longitudinal bands representing outer longitudinal muscle layer
Absent in vermiform appendix and rectum Bands meet at roof of appendix |
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Parts of large intestine
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Cecum
Vermiform appendix Ascending colon (R colic flexure) Transverse colon (L colic flexure) Descending colon Sigmoid colon Rectum Anal canal |
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Vermiform appendix
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Mesoappendix-mesentary
No tenia coli (complete m. layers) Usually retrocecal or pelvic, but can be retrocolic, or subcecal 3 tenia coli converge at its base |
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McBurney's Point
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point of tenderness in acute appendicitis
Base of appendix Imaginary line from ASIS to umbilicus and the junction between the medial 2/3 and the lateral 1/3 on the line |
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Appendicitis
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Opening of v. appendix into cecum is blocked by thick mucus, stool (Fecalith) or lymphoid tissue
Initially: Diffuse pain (GVA fibers at T10) Later: Sharp localized pain due to parietal peritoneum (GSA fibers) Direct and rebound tenderness |
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Psoas sign
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Pain on passive extension of R thigh while laying on L side
Due to inflamed retrocecal appendix in retroperitoneal location in contact with fascia over psoas muscle |
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Obturator sign
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Pain on passive internal rotation of flexed R thigh
Due to inflamed appendix in pelvis that is in contact with fascia over obturator internus |
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Diverticulosis
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Sacs of intestinal wall in the colon, mostly sigmoid colon
Pouches do not contain full layer of intestinal wall Cramps, bloating, constipation May lead to bleeding, infections, perforations, blockages |
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Hirschsprung disease (congenital megacolon)
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Most commonly cause of neonatal colon obstruction
Mostly affects rectum and sigmoid colon Presents as abdominal enlargement and constipation Unable to pass meconium at birth Part of colon is dilated due to no autonomic ganglia (parasym) in wall distal to dilation (due to arrest in migration of neural crest cells) Mutations in RET gene (tyr-kinase) Dilation due to failure of peristalsis in aganglionic segment |
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Prenatal circulation
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aorta --> common iliac aa --> placenta (oxygenation) --> umbilical v --> portal v --> ductus venosus --> inferior vena cava --> R atrium
R atrium --> foramen ovale --> L atrium --> L ventricle --> aorta R atrium --> R ventricle --> pulmonary aa --> ductus arteriosus --> aorta |
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Diaphragmatic surface of liver
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Bare area of liver
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Visceral surface
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Ligamentum venosum
Ligamentum teres hepatis Porta hepatis IVC Gallbladder |
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Ligamentum venosum
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obliterated ductus venosus
Fissure between L lobe and caudate |
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Ligamentum teres hepatis
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obliterated umbilical v
Fissure between L lobe and quadrate |
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Porta hepatis
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doorway for passage of blood vessels, bile ducts, nerves
Separates caudate from quadrate (middle line of H) |
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Fossa for IVC
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Between R lobe and caudate
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Fossa for gallbladder
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Between R lobe and quadrate
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Anatomical lobes of liver
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Divided by falciform lig and fissures
R lobe L lobe Quadrate lobe Caudate lobe |
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Functional (portal lobes)
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Based on blood supply and bile drainage
R lobe - R lobe, caudate process of caudate lobe L lobe - left lobe, quadrate lobe, caudate lobe (except caudate process); important in liver resection |
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Falciform lig
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Has lig teres hepatis and paraumbilical vv on free border
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Coronary ligs
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Limit subphrenic recess posteriorly and connect to falciform and triangular ligs
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R and L triangular ligs
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ligs of liver
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Lesser omentum
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Hepatogastric and hepatoduodenal lig
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Liver cirrhosis
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Fibrosis, nodular liver
Caused usually by hep C or alcoholic liver disease |
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Symptoms of liver cirrhosis
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Jaundice
Ascites Ab enlargement Caput medasae Spider angiomatas Splenomegaly Esophageal varices (hematemesis) Bleeding Testicular atrophy Gynecomastia Hemorrhoids (hematochezia) |
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Bile ducts
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Hepatic ducts
Common hepatic duct Common bile duct Hepatopancreatic ampulla (vater) |
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Hepatic ducts
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R and L
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Common hepatic duct
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R and L hepatic ducts
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Common bile duct
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Common hepatic duct + cystic duct
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Hepatopancreatic ampulla (ampulla of vater)
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bile duct + main pancreatic duct
Opens into major papilla of duodenum |
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Gallbladder
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Fundus
Body Neck Cystic duct |
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Fundus of gallbladder
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tip of 9th costal cartilages and linea semilunaris
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Body of gallbladder
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Contacts visceral surface of liver and 1st part of duodenum
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Neck of gallbladder
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May have sacculation (Hartmann's pouch)
Mucosa thrown into spiral folds (spiral valve of heister) |
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Cystic duct
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Mucosa forms spiral fold
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Hepatoduodenal lig structures
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Structures within it form anterior border of epiploic foramen (of Winslow)
Anterior on R is common bile duct Anteriorly on L is hepatic a. proper Posteriorly is portal vein |
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Sphincter of the hepatopancreatic ampulla (Sphincter of Oddi)
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Formed by:
Bile duct sphincter Pancreatic sphincter Sphincter ampulla |
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Chole
Choledocho Cholecysto |
Chole = bile
Choledocho = bile duct Cholecysto = gallbladder |
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Gall stones
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Cholecystitis
Fistulas in stomach and 1st part of duodenum, transverse colon Intestinal obstruction at ileocecal valve |
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Pancreas
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Head
Neck Body Tail |
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Head of pancreas
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Common bile duct posteriorly
Uncinate process Superior mesenteric vessels that pass anterior to uncinate process (LV2) |
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Neck of pancreas
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Short, superior mesenteric vessels pass posterior to neck
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Body of pancreas
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Omental tuberosity on its superior border marks location of celiac trunk (LV1)
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Tail of pancreas
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Contacts hilum of spleen (TV12)
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Major pancreatic duct (of Wirsung)
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Opens into major duodenal papilla
Surrounded by pancreatic sphincter at entrance |
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Minor (accessory) duct (of Santorini)
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Into minor duodenal papilla
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Spleen
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Lymphatic
Related to 9th-11th ribs 10th rib along spleen axis Completely peritonealized Rests on L colic flexure and phrenicolic lig Attached to L kidney via splenorenal lig Attached to L border of stomach via gastrosplenic lig |
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Surfaces of spleen
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Convex diaphragmatic surface that faces posterolaterally
Anteromedial surface is related anteriorly to stomach, posteriorly to L kidney, inferiorly to L colic flexure, and phrenicolic lig At hilum, tail of pancreas contacts spleen, with splenic artery and vein |
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Development of liver and gallbladder
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From endodermal diverticula budding off duodenum
hepatic diverticulum or liver buds from ventral surface of duodenum on day 22 form liver which provides blood cells Cystic diverticulum buds caudal to hepatic bud on day 26 form gallbladder and cystic duct Connection between hepatic diverticulum and foregut narrows to form bile duct |
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Development of pancreas
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From 2 buds (ventral and dorsal)
Ventral bud sprouts caudal to cystic diverticulum Dorsal bud sprouts on dorsal side Duct of ventral bud connects with opening of developing bile duct in 5th week, ventral bud and proximal end of common bile duct migrate around gut tube to dorsal side and buds fuse Uncinate process, head, body, and tail, and ducts of pancreas form Pancreas becomes retroperitoneal |
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What does the uncinate process develop from
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Ventral pancreatic bud
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What do the head, body and tail of pancreas develop from
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dorsal bud
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What does the main pancreatic duct develop from
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Fusion of the duct of the ventral bud and most of the duct of the dorsal bud
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What does the minor pancreatic duct form from
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The rest of the duct of the dorsal bud
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Formation of the lesser sac
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Growth of liver subdivides into ventral mesentary into: falciform lig, visceral peritoneum of liver and gallbladder, and lesser omentum
Dorsal mesogastrium --> greater omentum Stomach rotates, duodenum fuses to posterior wall, to form lesser sac |
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Development of the spleen
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From mass of mesenchymal cells between layers of dorsal mesentary (mesogastrium)
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Extrahepatic biliary atresia
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Usually obstruction at ducts at or superior to porta hepatis
Failure of bile ducts to canalize Jaundice immediately after birth |
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Annular pancreas
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May cause duodenal obstruction
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Arteries of the abdomen
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Aortic hiatus
Celiac trunk Superior mesenteric artery Inferior mesenteric artery Abdominal aorta L common iliac artery |
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Arteries of te embryonic gut
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In foregut - abdominal aorta gives off celiac trunk
In midgut - abdominal aorta gives off superior mesenteric artery In hindgut - abdominal aorta gives off inferior mesenteric artery |
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Derivatives of embryonic foregut
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Celiac trunk (in abdomen)
Primitive pharynx and derivatives (oral cavity, pharynx, tongue, tonsils, salivary glands, upper resp tract) Lower resp tract Esophagus and stomach Duodenum, proximal to opening of common bile duct Liver, gallbladder, bile duct system, pancreas |
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Derivatives of embryonic midgut
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Superior mesenteric artery
Small intestines distal to opening of bile duct in duodenum Cecum, vermiform appendix, ascending colon, and proximal 2/3 of transverse colon |
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Derivatives of embryonic hindgut
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Inferior mesenteric artery
Distal 1/3 of transverse colon, descending colon, sigmoid colon, rectum, and superior portion of anal canal Epithelium of urinary bladder and most of urethra |
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Branches of celiac trunk
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Left gastric artery - stomach, esophagus
Common hepatic a - liver, sttomach, duodenum, pancreas; gives off hepatic a proper, and gastroduodenal a Splenic a - stomach, pancreas, spleen |
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Hepatic artery proper branches
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R gastric a - lesser curvature
R hepatic a - R lobe of liver and gallbladder [via cystic a in triangle of Calot] (common hepatic duct, cystic duct, liver) L hepatic a - L lobe of liver |
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Branches of gastroduodenal artery
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Supraduodenal a - duodenum
Superior pancreaticoduodenal aa - anterior and posterior branches supply head of pancreas and uncinate process of duodenum; anastamose with ant. and post. brs. of inferior pancreaticoduodenal arteries (post branch more proximal) R gastroepiploic a - supplies greater curvature of stomach |
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Branches of splenic artery
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Pancreatic aa - body/tail of pancreas
Short gastric aa - fundus of stomach L gastroepiploic a - greater curvature |
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Arteries of stomach
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?
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Branches of superior mesenteric artery
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Inferior pancreaticoduodenal aa - ant. and post. brs. supply the head and uncinate process of pancreas; duodenum
Intestinal (jejunal/ileal) aa Ileocolic a - vermiform appendix, cecum, ascending colon R colic a - ascending colon Middle colic a - transverse colon |
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Arteries of the duodenum
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Gastroduodenal and its branches
Sup. mesenteric a and its branches |
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Gastroduodenal brnaches to duodenum
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Supraduodenal aa
Ant. sup. PD a Post sup. PD a |
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Superior mesenteric a branches to duodenum
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Ant inf PD a
Post inf PD a |
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Inferior mesenteric a branches
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L colic a - descending colon
Sigmoid aa - sigmoid colon Superior rectal a - rectum, direct continuation of inf mesenteric a |
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Marginal artery of Drummond
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Anastomoses among terminal branches of superior and inferior mesenteric arteries
Forms a continuous marginal artery around the ascending, transverse, descending, and sigmoid colons |
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Portal vein
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Drains blood from GIT, spleen, and pancreas, into liver
Supplies 75% of blood to liver Formed by union of superior mesenteric and splenic vv posterior to head of pancreas Inferior mesenteric v may drain into splenic or portal vein Paraumbilical vv drain into portal v |
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Portocaval anastomoses
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Anastomoses between branches of portal and systemic circulations that become functional during portal hypertension
1. L gastric v with azygos v 2. Superior rectal v with middle rectal v and inferior rectal v 3. Paraumbilical vv with superficial vv of anterior abdominal wall 4. Retroperitoneal vv with lumbar vv 5. vv in bare area of liver with vv of diaphragm and internal thoracic v |
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Causes of portal hypertension
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Pre-hepatic - blockage of portal vein due to tumor of pancreas head compressing portal vein, portal vein thrombosis, portal vein stenosis
Hepatic - hepatic diseases w/ fibrosis blocking flow through liver sinusoids, such as cirrhosis, hep C, schistosomiasis, thrombosis of hepatic vv Post hepatic - increased pressure in IVC from heart failure of R heart, tricuspid regurg., IVC obstruction, pericarditis |
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Complications of portal hypertension
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Hematemesis - bleeding from esophageal varices (enlarged esophageal vv drain into azygos vv due to higher pressure in L gastric v)
Caput medusa - enlarged paraumbilical vv that drain into portal v dump portal blood into tributaries of superf epigastric vv Hematochezia - bleeding from hemorrhoids (enlarged inf and middle rectal vv that anastomose w/ sup. rectal v) Splenomegaly - enlarged due to blood in splenic v |
