Anatomy - The Alimentary System

Front 1

Structure of the walls of the digestive tract proper

Back 1

1. Mucosa
I. Epithelial lining - characteristic for each segment
II. Lamina propria mucosae
III. Muscularis mucosae

2. Submucosa
I. Loose CT
II. The submucosal\Meissner's nervous plexus

3. Muscular layer - smooth muscle
I. Circular layer
II. The myenteric\Auerbach's nervous plexus
III. Longitudinal layer

4. Serosa with subserosa (peritoneal) or adventitia (retro-peritoneal)

(The nervous plexuses are autonomic)

(Thieme)

Front 2

The oral cavity
a. Parts
b. Isthmus of fauces\Oropharyngeal isthmus
c. Gingiva
d. Palatine tonsil

Back 2

a. Parts
1. Oral vestibule
(Bordered by lips anteriorly, cheeks laterally, and teeth and alveolar processes internally)
2. The oral cavity proper
(Bordered anteriorly by the oral vestibule and posterior with the fauces, where the border is the isthmus of the fauces\oro-pharynx)

b. Isthmus of fauces\Oropharyngeal isthmus
The constricted space which connect the oral cavity proper and the oro-pharynx.
Consist of
1. Palatoglossal folds anteriorly
2. Palatopharyngeal folds posteriorly

c. Gingiva
The part of the mucous membrane that overlies the alveolar processes and is firmly adherent to the bone.
(Reflects on to the lips and cheeks and forms the fornix which has a freely movable mucous membrane)

d. Palatine tonsil
Mass of lymphoid tissue located in the oropharyngeal isthmus on the lateral wall, between the palatoglossal and palatopharyngeal folds.

(Thieme)

Front 3

The lips
a. Vermilion border
b. Histology\Components of the lips

Back 3

a. Vermilion border
Transition zone where the skin of the face meets the mucous membrane of the mouth.
(A thckening of the vermilion border on the upper lip forms a tubercle from which a furrow in the skin called the philtrum passes toward the nose)

b. Histology\Components of the lips
1. Orbicularis oris - internally
2. Mucosa\skin
I. Outer surface - epidermis (stratified keratinized squamous epithelium), hair, sweat and sebaceous glands)
II. The vermilion border\transition zone - lightly keratinized stratified squamous epithelium
III. The inner surface of the vermilion border - oral mucosa (stratified, nonkeratinized squamous epithelium), seromucous labial glands

(Thieme)

Front 4

The oral cavity
a. Associated glands
b. Palatine muscles (4)

Back 4

a. Aossicated glands
1. Labial glands - seromucous
2. Buccal glands - small salivary glands
3. Palatine glands - mucous

b. Palatine muscles
(All insert into the palatine aponeurosis)
1. Tensor veli palatini
(<- cranial base and wall of the auditory tube, its tendon of insertion pass around the pterygoid hamulus. Tense and elevate the soft palate, this also opens the auditory tube, CN V3)

2. Levator veli palatini
(<- Cranial base posterior and medial to the tensor veli palatini. Elevates and retracts the soft palate. CN IX\X \ pharyngeal plexus)

3. Palatoglossus
(In the anterior palatine parch, <- palatine aponeurosis, -> base of tongue, constrict the isthmus of fauces, CN IX)

4. Palatopharyngeus
(In the posterior palatine arch, <- palatine aponeurosis, -> pharynx. elevate pharynx. CN IX)

5. Musculus uvulae
(Paired, <- hard palate, -> palatine aponeurosis, shortens the uvula, CN IX\X \ pharyngeal plexus)

(Thieme)

Front 5

The tongue
a. Epithelium
b. The four papilla and their characteristics

Back 5

a. Stratified, nonkerartinized squamous epithelium.

b. Papillae of the tongue
1. Filiform ('filamentous')
I. Threadlike, split at the tips
II. Distributed over most of the tongue
III. Tactile information, no taste buds

2. Fungiform papillae
I. Mushroom-shaped
II. Margin of the tongue
III. Teste buds, mechanoreceptors, thermoreceptors

3. Foliate ('leaf-like') papillae
I. Posterior margin of tongue
II. Taste buds

4. Vallate papillae
I. Largest
II. Anterior to the terminal sulcus
III. Taste buds
IV. Surrounded by a circular sulcus with a raised wall

(Papillae in general consist of a CT core with an epithelial covering)

(Thieme)

Front 6

The tongue
a. Which structures are located dorsal to the terminal sulcus
b. Name the mucosal folds connecting the base of the tongue to the epiglottis, and the name of the space in between the folds

Back 6

a. The lingual tonsil.
(Subepithelial lymphoid follicles - lingual follicles)

b. Median glossoepiglottic fold and two lateral glossoepiglottic folds.
The space in between the median and lateral glossoepiglottic folds are called the epiglottic valleculae ('valley')

(Thieme)

Front 7

The tongue
a. List the extrinsic muscles of the tongue and their innervation
b. The intrinsic muscles of the tongue
c. What happens with paralysis of the hypoglossal nerve

Back 7

a. The extrinsic muscles of the tongue
1. Genioglossus
(mental spine of mandible -> body of the tongue, A: protrude and depress the tongue)

2. Hyoglossus
(Greater horn and body of the hyoid bone -> body of the tongue, A: retract and elevate the tongue if the hyoid bone is fixed)

3. Styloglossus
(Styloid process -> apex, A: retract and elevate)

4. Palatoglossus

Palatoglossus is innervated by CN X, the rest is innervated by CN XII.
(CN XII lie on the hyoglossus, then run under the duct of the submandibular gland and the lingual nerve)

b. The intrinsic muscles of the tongue
1. Superior and inferior longitudinal muscles
(Near dorsum, tip->base)

2. Transverse muscles of tongue

3. Vertical muscles fo tongue
(Dorsum->inferior surface)
(All are innervated by CN XII)

(Lingual septum - median sagittal fibrous septum that divide the tongue in two halves, lingual aponeurosis - CT sheet, separate the mucous membrane and muscles of the tongue on the dorsal side)

c. Paralysis of the hypoglossal nerve
The unaffected half moves toward the affected half -> the tip of the tongue point toward the side affected by paralysis

(Thieme)

Front 8

Pharyngeal constrictor muscles - list the three with their origin and insertion

Back 8

1. Superior pharyngeal constrictor muscle
Medial pterygoid plate and pterygomandibular raphe -> pharyngeal raphe in the posterior wall.

2. Middle pharyngeal constrictor muscle
The hyoid bone (lesser and greater horns, + some from the stylohyoid ligament) -> pharyngeal raphe

3. Inferior pharyngeal constrictor
Thyroid cartilage and cricoid cartilage -> pharyngeal raphe

(Innervation - pharyngeal plexus)
(The pharyngeal raphe is connected superiorly to the pharyngeal tubercle on the base of the cranium)
(In the gap between the superior constrictor muscle and the cranium is the pharyngobasilar fascia)
(The middle lie inside the inferior and the superior lie inside the middle)
(Collectively they narrow the pharynx and elevate the larynx)

(Stedman, Thieme)

Front 9

List the minor salivary glands

Back 9

a. Minor salivary glands - small 'package' of glandular tissue lying in the mucosa of the
1. Lips - labial glands
2. Cheeks - buccal glands
3. Tongue -
I. Lingual glands
II. Anterior lingual glands (on the tip\apex)
III. Cleansing serous glands on top of the papillae
4. Palate - palatine glands

(Thieme)

Front 10

The parotid gland
a. Boundaries
b. Path of the parotid duct
c. Type of gland
d. Autonomic innervation

Back 10

a.
Zygomatic arch superiorly
Angle of mandible inferiorly, Anteriorly the ramus of the mandible,
Posteriorly the external acoustic meatus.

b. Anterior border of the gland -> over masseter -> penetrate buccinator -> open in the oral vestibule at the level of the upper 2nd molar tooth on the parotid papilla.

c. Purely serous.

d. Autonomic innervation
I. Parasympathetic - CN IX -> otic ganglion -> branches of CN VII
II. Sympathetic - from external carotid plexus

(Thieme)

Front 11

Salivary glands
a. Submandibular gland - type of gland
b. Submandibular gland - position
c. Submandibular gland - path of the duct
d. Sublingual gland - type
e. Sublingual gland - path of duct

Back 11

a. Submandibular gland - mixed, mainly serous

b. Submandibular gland - position
In the submandibular triangle
(bounded by the mandible, digastric, and mylohyoid)

c. Submandibular gland - duct
Medial to the sublingual gland -> sublingual caruncle (on each side of the frenulum of the tongue)

d. Sublingual gland - type
Mixed, predominantly mucous

e. Sublingual gland - path of duct
Major sublingual duct joins the submandibular duct and opens in the sublingual caruncle
The minor sublingual glands have short ducts that open along the sublingual fold
(It's located in the sublingual fold on each side of the frenulum of the tongue)

(Thieme)

Front 12

Teeth
a. The three segments
b. The permanent teeth - name and number

Back 12

a. The three segments
1. Crown
2. Neck
(Junction between the root and crown, covered by gingiva)
3. Root
(In the bony socket, secured by the peridontium)

c. The permanent teeth - in each quadrant
2 Incisor teeth (biting, single root)
1 Canine tooth (tearing and grasping)
2 Premolar teeth (Grinding, two cusps
3. Molar teeth (the bulk of chewing, four cusps)
(8 -> x2 = 16 teeth on upper or lower dental arch, 32 combined)
(5 deciduous, two incisior, one canine, two primary molars)

(Thieme)

Front 13

Teeth
a. Eruption of primary\deciduous teeth - period, order
b. Eruption of secondary\permanent teeth, period, order
c. Time of eruption of the third molar

Back 13

a. Eruption of primary\deciduous teeth - period, order
I. 6 months to 2 years
II. 1st incisor -> 2nd premolar, with one exception, the first premolar comes before the canine

b. Eruption of secondary\permanent teeth, period, order
I. 7-40 years
II. 1st molar -> Incisor 1 and then 2 -> 1st premolar -> 2nd premolar\canine -> 2,3 molar

c. Time of eruption of the third molar
17-40 years

(Thieme)

Front 14

Pharynx
a. Upper and lower border
b. Describe the structure of the pharyngeal wall

Back 14

a. The pharynx extends from the base of the cranium to the level of the cricoid cartilage.

b. The pharyngeal wall
1. Mucosa
I. Nasopharynx - ciliated respiratory epithelium
II. Oro- and laryngopharynx - stratified, nonkeratinized, squamous epithelium (like the oral cavity)
(Numerous mucus producing pharyngeal glands, subepithelial connective tissue rich in elastic fibers)
2. The muscular layer
(Superior, middle, and inferior pharyngeal constrictors, posterior pharyngeal raphe, -> pharyngeal tubercle on the base of the cranium. Pharyngobasilar fascia superior to superior constrictor muscle)
3. The Adventitia

(Thieme)

Front 15

The peripharyngeal space
a. What
b. Components
c. Borders - anterior, posterior, inferior

Back 15

a. Space filled with loose connective tissue that allows for free movement of the pharynx against the vertebral column and other adjacent structures.

b. Components
1. Retropharyngeal - between the posterior pharyngeal wall and the prevertebral layer of cervical fascia
2. Parapharyngeal space - lateral to the pharynx

c. Borders
Anterior - buccopharyngeal fascia (overlie muscular layer of the pharynx)
Posterior - alar fascia (loose areolar CT overlying prevertebral layer of cervical fascia)
Inferior - mediastinum (at t2)

Front 16

Pharynx
a. Arterial supply
b. Venous drainage
c. Innervation
d. Lymphatic drainage

Back 16

a. Arterial supply
I. Ascending pharyngeal artery
II. Pharngeal branches from inferior (<- thyrocervical trunk) and superior thyroid arteries (external carotid)

b. Venous drainage
Pharyngeal plexus posterior to pharynx -> internal jugular vein

c. Innervation
CN IX and X make up the pharyngeal plexus of vagus nerve.

d. Lymphatic drainage
Retropharyngeal lymph nodes -> deep cervical lymph nodes

(Thieme)

Front 17

Esophagus
a. Length
b. Upper and lower borders
c. The esophageal constrictions
d. Laimer's triangle

Back 17

a. 25 cm

b.
Superior - cricoid cartilage (C6\7)
Inferior - cardial orifice (T10\11)

c. The esophageal constrictions
1. The Upper\Pharyngoesophageal constriction
(Behind the cricoid cartilage, produced by the circular fibers of esophageal muscle, the narrowest, horizontal slit - 14 mm max when open)
2. The middle\bronchoaortic constriction
(Near the crossing of the aortic arch over the esophagus)

3. The lower\diaphragmatic constriction
(Produced by the spiral arrangement of muscle fibers in the wall of the esophagus and venous plexuses beneath the mucosa. Both serve to seal the cardial orifice)

d. Laimer's triangle
Weaekning in the wall posteriorly between the inferior constrictor muscle and the circular layer of muscle. Can give rise to diverticula.

(Thieme)

Front 18

Esophagus - components of the wall

Back 18

1. Mucosa
I. Stratified, nonkeratinized, squamous epithelium
(Replaced by columnar epithelium of the gastric mucosa at the junction with the cardial orifice)
II. Lamina propria mucosae
III. Muscularis mucosae

2. Submucosa
I. Loose CT
II. Venous plexus
III. Submucosal\Meissner's nervous plexus
IV. Esophageal glands - mixed

3. Muscular layer
I. Inner layer of circular muscle
(Propel bolus)
II. Myenteric\Auerbach nervous plexus
III. Outer layer of longitudinal muscle
(Shorten esophagus, hold tension)
(Upper 1\3 - only striated muscle, middle 1\3 - mixed, lower 1\3 smooth muscle)

4. Adventitia ('foreign')
I. Esophageal venous plexus
II. Esophageal nervous plexus

(Thieme)

Front 19

Peritoneum
a. Intraperitoneal organ
b. Retroperitoneal organ
c. Secondary retroperitoneal organ
d. Extraperitoneal organ
e. Mesentery\Peritoneal ligament

Back 19

a. Intraperitoneal organ
In the peritoneal cavity and are lined by visceral peritoneum.
(Stomach)

b. Retroperitoneal organ
In the posterior wall of the peritoneal cavity - behind the parietal peritoneum.

c. Secondary retroperitoneal organ
Organs that initially lied intraperitoneally in prenatal development, but later positioned themselves on the posterior abdominal wall where they grow behind the parietal peritoneum.
(Pancreas)

d. Extraperitoneal organ
One that has no relation to the peritoneum.

e. Mesenteries\Peritoneal ligaments
Folds\sites of reflections of peritoneum - double layers of peritoneum.
Connect an intraperitoneal organ to the abdominal wall.

(Intraperitoneal abdominal organs above the navel are attached by anterior and posterior mesenteries, below the navel they are just suspended by a posterior mesentery.)

(Thieme)

Front 20

Peritoneum
a. Omentum
b. Greater omentum
c. Lesser omentum

Back 20

a. Omentum (L. the membrane that enclose the bowels)
A fold of peritoneum passing from the stomach to another organ.

b. Greater omentum\Epiploon\Gastrocolic omentum
A peritoneal fold passing from the stomach to the transverse colon, hanging like an apron in front of the intestines.

c. Lesser omentum\Gastrohepatic omentum
A peritoneal fold passing from the margins of the portal fissure to the lesser curvature of the stomach and to the upper border of the duodenum.
I. The hepatoduodenal ligament extends between the liver adn the intraperitoneal part of the duodenum. It contains the bile duct, hepatic portal vein, and hepatic artery proper.
II. Hepatogastric
(The epiploic foramen of Winslow opens behind the lesser omentum to the omental bursa)

(Stedman)

Front 21

What are the three external differentiating characteristics of the colon

Back 21

1. Haustra of colon - evenly spaced sacculations in the colon wall caused by the teniae coli

2. Teniae coli - thickened part of the longitudinal muscle layer

3. Omental appendices - fatty appendages covered by peritoneum

(Thieme)

Front 22

List four recesses in the peritoneum and say what they are caused by

Back 22

1. The superior ileocecal recess, formed by the vascular fold of cecum.
(At the ileocecal junction with the intraperitoneal ileum and retroperitoneal cecum)

2. Superior duodenal fossa
Caused by the superior duodenal fold.

3. Inferior duodenal fossa
Caused by the inferior duodenal fold.
(In the junction between the retroperitoneal duodenum and intraperitoneal jejunum at the duodenojejunal flexure)

4. The Intersigmoid recess
In the sigmoid mesocolon.

(Thieme)

Front 23

Peritoneum
a. Intraperitoneal organs
b. Coronary ligament of the liver
c. Hepatorenal ligament
d. Right and left triangular ligaments of the liver

Back 23

a. Intraperitoneal organs
1. Liver
(Not covered by peritoneum at the bare area where it attach to the diaphragm
2. Stomach
3. Spleen
4. Jejunum
5. Ileum
6. Transverse colon
7. Sigmoid colon

b. Coronary ligament of the liver
Peritoneal reflections from the liver to the diaphragm at the margins of the bare area of the liver.

c. The part of the right coronary ligament that is attached to the right kidney bed.

d. Right and left triangular ligaments of the liver
Laterally extensions of the coronary ligament.

(Thieme)

Front 24

Peritoneum
a. Gastrophrenic ligament - what, what is the name of its continuation
b. Phrenicocolic ligament

Back 24

a. Gastrophrenic ligament
Peritoneal fold passing from the cardial orifice to the diaphragm. Continues as the gastrosplenic ligament between the greater curvature of the stoamch and the spleen.

b. Phrenicocolic ligament
Peritoneal fold that extends between the diaphragm and the descending colon.

(Thieme)

Front 25

Peritoneum - anterior abdominal wall
a. Median umbilical ligament
b. Medial umbilical ligaments
c. Lateral umbilical ligaments
d. Supravesical fossa
e. Medial inguinal fossa - what, correspond to
f. Lateral inguinal fossa - what, corresponds to

Back 25

a. Median umbilical ligament
Peritoneal fold that contains the obliterated urachus.

b. Medial umbilical ligaments
Peritoneal folds that cover the obliterated umbilical arteries.

c. Lateral umbilical ligaments
Umbilical folds that cover the inferior epigastric vessels.

d. Supravesical fossa
The area bounded by the medial umbilical folds and the urinary bladder.

e. Medial inguinal fossa - what, correspond to
Depression between the medial and lateral umbilical folds, correspond to the superficial inguinal ring beneath it.

f. Lateral inguinal fossa - what, corresponds to
Depression lateral to the lateral umbilical folds, correspond to the deep inguinal ring beneath it.

(Thieme)

Front 26

The stomach
a. Cardial orifice
b. Cardia
c. Cardial notch
d. Fundus
e. Body
f. Pyloric part - components

Back 26

a. Cardial orifice
The opening of the esophagus into the stomach.

b. Cardia
The funnel-shaped entrance into the stomach.

c. Cardial notch
The sharp angle caused by the junction of the esophagus to the stomach and the fundus.

d. Fundus
The highest point on the stomach.
(Contains air when a person stands upright -> gastric bubble on x-ray)

e. Body
The greater part - contains the greater and lesser curvatures.

f. Pyloric part - components
I. Pyloric antrum - the initial pyloric part
II. Pyloric canal - from the pyloric antrum to the gastroduodenal junction.
III. Pylorus - ring of muscle, pyloric orifice\sphincter

(Thieme)

Front 27

The stomach
a. Cardial orifice
b. Cardia
c. Cardial notch
d. Fundus
e. Body
f. Pyloric part - components

Back 27

a. Cardial orifice
The opening of the esophagus into the stomach.

b. Cardia
The funnel-shaped entrance into the stomach.

c. Cardial notch
The sharp angle caused by the junction of the esophagus to the stomach and the fundus.

d. Fundus
The highest point on the stomach.
(Contains air when a person stands upright -> gastric bubble on x-ray)

e. Body
The greater part - contains the greater and lesser curvatures.

f. Pyloric part - components
I. Pyloric antrum - the initial pyloric part
II. Pyloric canal - from the pyloric antrum to the gastroduodenal junction.
III. Pylorus - ring of muscle, pyloric orifice\sphincter
(The beginning of the pyloric part is marked by the external angular incisure on the lesser curvature)

(Thieme)

Front 28

The stomach
a. Which three ligaments does the greater omentum that extends from the greater curvature of the
stomach form
b. Relation to the peritoneum
c. Gross structure of the mucosa

Back 28

a. Greater curvature -> greater omentum ->
I. Gastrocolic ligament (to transverse colon)
II. Gastrophrenic ligament (to diaphragm)
III. Gastrosplenic ligament

b. Intraperitoneal.

c. Into large, gastric folds.
(On the lesser curvature side these form a few longitudinal ridges forming the gastric canal)

(Thieme)

Front 29

The stomach
a. Arterial supply
b. Lymphatic drainage

Back 29

a. Arterial supply
1. Over the lesser curvature
I. The left gastric artery
(<- celiac trunk, via gastropancreatic fold)
II. The right gastric artery
(<- hepatic artery proper, via hepatoduodenal and then hepatogastric ligament)

2. The greater curvature
I. The left gastroomental artery
(<- splenic artery, via gastrosplenic ligament, runs in gastrocolic ligament (the major portion of the greater omentum)
II. The right gastroomental artery
(<- the gastroduodenal artery <- hepatic artery)

3. Short gastric arteries
(<- Splenic artery, over fundus)
(The veins parallel the arteries and drain into the hepatic portal vein via the left gastric vein, splenic vein, or superior mesenteric vein)

b. Lymphatic drainage
1. Cardia, much of anterior and posterior walls -> lesser curvature -> gastric nodes (most along left gastric artery)

2. Fundus and part of greater curvature (next to the spleen) -> splenic nodes

3. Rest of greater curvature -> gastroomental nodes

4. Pyloric region -> gastroomental and pyloric nodes

#1-4 -> celiac nodes, superior mesenteric nodes (small part)
(Subserous network)

(Thieme)

Front 30

The duodenum
a. The segments
b. Relation to the peritoneum

Back 30

a. Duodenal segments
1. 1st\Superior part
(L1, pylorus -> superior duodenal flexure. Dilated appearance on radiography -> 'duodenal cap' (clinical expression, duodenal ampulla (anatomical))
2. 2nd\Descending part
(L1->L3, superior duodenal flexure -> inferior duodenal flexure)
3. 3rd\horizontal part
(Travels below the head of the pancreas across the vertebral column, L3)
4. 4th\Ascending part
(L2, -> duodenojejunal flexure)

b. The superior part are intraperitoneal (hepatoduodenal ligament) the rest are secondarily retroperitoneal.
(The small intestien becomes intraperitoneal again at the duodenojejunal flexure)

Front 31

The small intestine
a. Proportion of the length that is jejunal and ileal
b. Meckel diverticulum - what, where, in how many percent
c. Relation to the peritoneum
d. Total length

Back 31

a. jejunum - 2\5, ileum 3\5

b. Meckel diverticulum
I. In ileum
II. 2% of people
III. Remnant of vitelline duct\yolk stalk (part connecting intraembryonic gut and yolk sac)
IV. 2 foot (60cm) from ileocecal valve
(Meckel diverticulitis can be mistaken for appendicitis)

c. Intraperitoneal by the mesentery.

d. 5 m

(Thieme)

Front 32

The small intestine
a. Duodenum - arterial supply
b. Duodenum - venous drainage
c. Duodenum - lymphatic drainage

Back 32

a. Duodenum - arterial supply
1. Anterior superior pancreaticoduodenal artery
2. Posterior superior pancreaticoduodenal artery
(1-2 <- gastroduodenal artery <- common hepatic artery)
3. Inferior pancreaticoduodenal artery
(<- superior mesenteric artery)

b. Duodenum - venous drainage
1. Splenic vein
2. Superior mesenteric vein

c. Duodenum - lymphatic drainage
1. Pyloric nodes
2. Pancreaticoduodenal nodes
1-2 -> hepatic nodes -> celiac nodes -> intestinal trunk

(Thieme)

Front 33

Jejunum and ileum
a. Arterial supply
b. Venous drainage
c. Lymphatic drainage

Back 33

a. Arterial supply
1. Branches of the superior mesenteric artery
I. 4-5 jejunal artery
II. 12 ileal arteries
-> Arterial arcades
(A series of anastomosing arterial arches in the mesentery)

b. Venous drainage - superior mesenteric vein

c. Lymphatic drainage
Juxtaintestinal mesenteric nodes (near the arterial arch in the mesentery) -> superior mesenteric nodes, celiac nodes -> intestinal trunks (-> cisterna chyli -> thoracic duct)

(Thieme)

Front 34

The large intestine
a. Total length
b. Components
c. Embryological origin

Back 34

a. 1.5-1.8 m

b. Components
1. The cecum
I. Vermiform appendix

2. The colon
I. Ascending colon
II. Transverse colon
III. Descending colon
IV. Sigmoid colon

3. The rectum

4. The anal canal

5. Endoderm, except the anal canal which originates from ectoderm.

(Thieme

Front 35

The large intestine - Typical features (4)

Back 35

a. Typical features
1. Teniae coli - thickened bands of the outer longitudinal layer of muscle
I. Mesocolic tenia
II. Omental tenia
III. Free tenia
(According to their location on the transverse colon)

2. Semilunar folds of colon - folds projecting into the intestinal lumen, produced by muscular contractions

3. Haustra of colon - sacculations produced by tension of teniae coli

4. Omental appendices - subserosal fatty tags

5. No intestinal villi
(Only crypts of Lieberkuhn\Intestinal glands)

(Thieme)

Front 36

The vermiform appendix
a. Relation to the cecum
b. Positions (4)
c. McBurney's point
d. Size
e. Relation to peritoneum

Back 36

a. Continuous posteromedially.

b. Location
1. Ascending retrocecal position - posterior to the cecum
(65%)

2. Subcecal position - extend beyond the linea terminalis into the lesser pelvis
(31%)

3. Transverse retrocecal position - posterior to the cecum
(2%)

4. Ascending paracecal\Preileal position
(1%)

5. Ascending paracecal\retroileal position
(0.5)

c. A point 1\3 the distance on an imaginary line drawn from the anterior superior iliac spine to the navel, which the base of the vermiform appendix project to when its in the most common position (ascending retrocecal position).

d. 10 cm long x 6 mm thick

e. Intraperitoneal (mesoappendix)

(The three teniae coli converge at the opening of the appendix)

(Thieme)

Front 37

The cecum and vermiform appendix
a. Branches of the ileocolic artery
b. Lymphatic drainage

Back 37

a. The ileocolic artery
1. The appendicular artery
(Reach the vermiform appendix via the mesoappendix)
2. The Anterior cecal artery
(via vascular fold of cecum)
3. The posterior cecal artery
4. Ileal branches
(The last branch of the superior mesenteric artery)
(Venous drainage is via equivalent veins)

b. Lymphatic drainage
Ileocolic, prececal, retrocecal, appendicular nodes -> mesenteric nodes -> intestinal trunks

(Thieme)

Front 38

The large intestine - peritoneal relations
a. The cecum
b. The appendix
c. The ascending colon
d. The transverse colon
e. The descending colon
f. The sigmoid colon

Back 38

a. can be free - intraperitoneal or fixed - secondarily retroperitoneal.

b. Intraperitoneal
(Mesoappendix)

c. Secondarily retroperitoneal

d. Intraperitoneal
(To posterior abdominal wall - transverse mesocolon, To the liver - hepatocolic ligament, to the stomach - gastrocolic ligament)

e. Secondarily retroperitoneal
(The left colic flexure is maintained by the phrenicocolic ligament)

f. Intraperitoneal
(Sigmoid mesocolon, intersigmoid recess, continuous with rectum at S2-S3)

(Thieme)

Front 39

The large intestine
a. Cannon-Boehm point
b. Lymphatic drainage

Back 39

a. Cannon-Boehm point
The point where the parasympathetic innervation of the transverse colon change from the vagus nerve to the sacral parasympathetic fibers. 2\3 the distance of the transverse colon.

b. Lymphatic drainage
Paracolic nodes (on the colon) -> colic nodes (on nourishing vessels) -> mesocolic nodes -> celiac nodes

(Thieme)

Front 40

The rectum
a. At which vertebral level is the junction between the sigmoid colon and the rectum
b. List the 3 flexures
c. Junction between the rectum and the anal canal
d. List the characteristics of the rectum

Back 40

a. At S2-3.

b. The three flexures
1. The sacral flexure of the rectum
(Follow the anterior concavity of the sacrococcygeal curve)
2. The anorectal flexure of the rectum
(Bends to pass posteriorly through the pelvic diaphragm)
3. The lateral flexures
(1-2 is in the sagittal plane, 3 is in the frontal plane)

c. At the anorectal flexure of the rectum as it pass through the pelvic diaphragm.

d. Rectum -
1. None of the typical large intestine characteristicsuch as omental appendices, haustra, and teniae coli (its longitudinal muscle layer is continuous)
2. 3 transverse folds - the lower is called Kohlrausch's fold
(Kohlrausch's fold is at the level of the rectuouterine pouch)

(15 cm)

(Thieme)

Front 41

The large intestine
a. The anal canal - length and superior and in inferior borders
b. Peritoneal relations to the rectum and anal canal

Back 41

a. The anal canal
I. 5 cm
II. From the anorectal flexure of the rectum through the pelvic diaphragm to the anus

b. The upper part of the rectum is intraperitoneal, the rest is extraperitoneal.
(Rectouterine\Rectovesical pouches)

(Thieme)

Front 42

The sphincter apparatus
a. Components
b. The internal anal sphincter - what, extend to
c. The external anal sphincter - part
d. The external anal sphincter - connects to the coccyx via
e. The external anal sphincter - which part of the levator ani does it blend with

Back 42

a. Components
1. The internal anal sphincter
2. The external anal sphincter

b. Smooth muscle, thickening of the circular muscle layer of the large intestine. the Anocutaneous line.
(Site where epithelium change from hairless (anoderm) to hairy (normal) stratified squamous epithelium)

c. The external anal sphincter
1. The subcutaneous part
2. The superficial part
3. The deep part
(Progressively deeper)

d. The anoccoygeal body\ligament
(Musculofibrous band from the anus to the coccyx)

e. Puborectalis.

(The internal and external sphincters are separated by a thin layer of longitudinal muscle - these terminate as the corrugator cuts muscle of anus)

(Thieme)

Front 43

The perineal body\Central tendon of perineum

Back 43

The fibromuscular mass between the anal canal and the urogenital diaphragm in the median plane. Onto which several perineal muscles insert -
1. Bulbospongiosus
2. External anal sphincter
3. Superficial, and deep transverse perineal muscles

(Midline episiotomies extend into this structure)
(Episiotomy - surgical incision of the vulva to prevent laceration at the time of delivery or to facilitate vaginal surgery)

(Stedman)

Front 44

The anal canal
a. Anal columns - what, what is the name of the structure between them, upper & lower borders
b. Pectinate line
c. Epithelium of the mucosal lining from the anal columns to the skin

Back 44

a. 6-10 longitudinal mucosal folds between which lie depressions called anal sinuses.
From the anorectal junction to the pectinate line.
(Internal hemorrhoids result from prolapse of the arteriovenous plexus underlying the anal columns)

b. Pectinate line
Transverse line formed by the inferior ends of the anal columns and transverse folds called anal valves connecting them.

c. Epithelium
1. Anal columns - alternate between columnar and stratified nonkeratinized squamous
2. Anal transition zone (distal to the anal columns) - stratified, nonkeratinized squamous epithelium
(White to the eye, highly sensitive to pain)
3. Anocutaneous line - change into stratified, keratinized squamous epithelium (skin)

(Thieme)

Front 45

Rectum and anal canal
a. Arterial supply
b. Lymphatic drainage
c. Factors responsible for continence

Back 45

a. Arterial supply
1. Inferior mesenteric artery -> superior rectal artery
2. Internal iliac artery -> middle rectal artery
(at the level of the pelvic floor)
3. Internal pudendal artery -> inferior rectal artery
(Supplies the anal canal and external anal sphincter)
(Veins corresponds to the arteries, but they form a rectal venous plexus)

b. Lymphatic drainage
1. Rectum -> superior rectal nodes -> inferior mesenteric nodes
2. Anal canal -> superficial inguinal nodes

c. Continence
1. Sustained tonic contraction of the sphincter - internal and external
2. Puborectalis
(Form a muscular sling around the anorectal flexure, drawing it forward and also closing the anal canal)
3. The blood-filled arteriovenous plexuses surrounding the body of the rectum

(Thieme)

Front 46

The liver
a. Attachments (3)
b. Which structure divides it into right and left lobes
c. List the 3 ligaments seen on a superior view

Back 46

a. Attachments
1. Falciform ligament - to the anterior abdominal wall and the diaphragm
2. Lesser omentum
I. Hepatoduodenal ligament
II. Hepatogastric ligament

b. The falciform ligament.

c. Ligaments seen on a superior view
1. Falciform ligament
2. Coronary ligament - lateral peritoneal reflections from the bare area, right and left
3. Triangular ligaments - extensions of the coronary ligaments, right and left, the fibrous appendix of the liver is the terminal extension of the left triangular ligament

(Thieme)

Front 47

The liver
a. Which structures forms the H-shaped structure on the visceral surface
b. How does this H-shape divide the liver
c. Glisson's capsule

Back 47

a. H-shaped structure on the visceral surface
I. Crossbar is formed by the porta hepatis (portal vein, two branches of hepatic artery proper, right and left hepatic duct, lymphatic vessels, nerves)

II. The left limb is formed by the
1. Fissure for round ligament (containing the round ligament of liver)
2. Fissure for ligamentum venosum

III. The right limb is formed by the
1. Groove called the fossa for gallbladder
2. Groove for vena cava

b. The left limb of the H divides the right and left lobes of the liver.
The right limb divides the right lobe from quadrate liver in front and the cauda lobe behind.

b. Glisson's capsule\Perivascular fibrous capsule
Connective tissue from the fibrous capsule that accompanies the hepatic vessels as they pass into the interior.

(Thieme)

Front 48

The liver
a. Classical lobule model
b. Classical lobule model - which hepatocytes are most susceptible for ischemia, why
c. Space of Disse
d. Which cells are found in proximity to the hepatic sinusoids

Back 48

a. Classical lobule model
I. Central vein (-> collecting vein -> hepatic veins) in the center
II. Polygonal
III. The corners form triangular regions called portal areas. These contain three main structures called the portal or Glisson's triad
1. Interlobular vein - a branch of the hepatic portal vein
2. Interlobular artery - a branch of the hepatic artery proper
3. Interlobular duct
(Surrounded by Glisson's capsule)
(The hepatocytes are composed of cell plates between which long sinusoidal capillaries are found)

b. Those near the center. Oxygenated and nutrient rich blood comes from the hepatic artery proper branches and hepatic portal vein branches in the corners.

c. Space of Disse\Perisinusoidal space
Space between the vessel walls of the hepatic sinusoids and the surfaces of the hepatocytes. Contains Ito cells (fat-containing cells)
(The brush border microvilli of the hepatocytes project into it)

d.
1. Hepatocytes
2. Epithelial cells of the endothelium
3. Ito cells
4. Hepatic stellate cells
(Phagocytic)

(Thieme)

Front 49

The liver
a. The portal lobule model
b. Flow of bile
c. Hepatic acinus

Back 49

a. The portal lobule model
1. Portal area (with portal\Glisson's triad) in the center
2. Triangular
3. Corners formed by central veins
(Emphasize flow direction of the bile)

b. Flow of bile
1. Hepatocytes ->
2. Bile canaliculi ->
(Channels whose sides are formed by cell contacts in the spaces between hepatocytes)
3. Interlobular ducts ->
4. Biliary ductules ->
5. Right and left hepatic duct ->

c. Hepatic acinus
Concentrical rings formed around two adjacent portal areas.
In the most central circle - the outer zone (zone 1) the adjacent hepatocytes have high metabolic rate due to proximity to arterial supply. In the inner zone (zone 3), the metabolic rate and oxygen supply rate are diminished.
(Outer\inner terminology from distance from central vein in a classic lobule model)

(Thieme)

Front 50

The liver
a. Lymphatic drainage
b. The hepatic portal vein - tributaries

Back 50

a. Lymphatic drainage
Hepatic nodes (along the porta hepatis) -> superior diaphragmatic nodes, parasternal nodes.

b. The hepatic portal vein
1. Splenic vein
I. Pancreatic veins
II. Short gastric veins
III. Left gastroomental veins

2. Inferior mesenteric vein
I. Left colic vein
II. sigmoid veins
III. Superior rectal vein
(Course in a fold of peritoneum known as the superior duodenal fold over the duodenojejunal flexure)
(1&2 join each other before connecting with the superior mesenteric vein)

3. Superior mesenteric vein
I. Jejunal and ileal veins
II. Right gastroomental vein
III. Pancreatic veins
IV. Pancreaticoduodenal veins
V. Ileocolic vein
VI. Right colic vein
VII. Middle colic vein

4. Right and left gastric veins
5. Cystic vein
6. Prepyloric vein
7. Paraumbilical veins
(Run with round ligament of the liver and communicate with the subcutaneous veins of the abdominal wall)

(Thieme)

Front 51

The liver
a. List the pathway of bile, according to which are intrahepatic and extrahepatic
b. Histology of the extrahepatic bile ducts

Back 51

a. Bile pathway
Intrahepatic
1. Hepatocytes ->
2. Bile canaliculi ->
(between hepatocytes)
3.Short canals of Hering ->
(Canal of Hering\Cholangiole - a ductule occurring between a bile canaliculus and an interlobular bile duct)
5. Interlobular bile ducts ->
6. Larger bile ducts ->
7. Right and left hepatic ducts
(Receive a right duct of caudate lobe and a left duct of caudate respectively)

Extrahepatic bile ducts
6. Common hepatic duct ->
(4-6 cm, hepatoduodenal ligament)
7. + Cystic duct = Bile duct
(6-8 cm, sphincter of bile duct before it joins the pancreatic duct)
8. + Pancreatic duct = Major duodenal papilla ->
9. Hepatopancreatic ampulla
(Sphincter of Oddi\Sphincter of ampulla)

b. Extrahepatic bile ducts
I. Columnar epithelium with lamina propria
II. Muscular layer - thin
III. Adventitia
(Contains the glands of bile duct)

(Thieme)

Front 52

The gallbladder
a. Size, max volume
b. Parts
c. Microanatomy and mucosal characteristics
d. Arterial supply
e. Venous drainage
f. Sensory innervation
g. Lymphatic drainage

Back 52

a. 8-12 cm long, 4-5 cm wide. Can accommodate 30-50 mL of fluid max.

b. Fundus (extend past the inferior border of the liver), body, neck.

c. Histology
I. Mucosa form ridgelike mucosal folds
(Allow expansion)
II. Columnar epithelium with goblet cells
III. Subepithelial connective tissue
IV. Muscular layer - spiral arrangement
V. Serous coat

d. Arterial supply - cystic artery (<- right branch of hepatic artery proper)

e. Venous drainage - cystic veins (-> hepatic portal vein)

f.. sensory innervation - right phrenic nerve

g. Hepatic nodes.

Front 53

The pancreas
a. Size
b. Vertebral level
c. Parts
d. Relation to peritoneum

Back 53

a. 13-15 cm long

b. L1-L2.

c. Parts
1. Head of pancreas
(In duodenal loop)
I. Uncinate process
(Surround inferior mesenteric vein in pancreatic notch)

2. Body of pancreas
(The omental tuberosity extends into the omental bursa)

3. Tail of pancreas

d. Retroperitoneal.
(The transverse mesocolon arise from it -> anterosuperior and anteroinferior surface)

(Thieme)

Front 54

The pancreas
a. Describe the exocrine secretory units and the pancreatic duct system
b. Arterial supply
c. Lymphatic drainage

Back 54

a. Exocrine pancreas
1. Acini - serous secretory units ->
(Polarized epithelial cells)
2. Intercalated ducts ->
(Centroacinar cells)
3. Excretory ducts ->
4. Pancreatic duct ->
5. + Bile duct = Hepatopancreatic papilla -> hepatopancreatic ampulla\Vater Ampulla with sphincter of Oddi\Sphincter of hepatopancreatic ampulla

b. Arterial supply
1. Head - anterior and posterior superior pancreaticoduodenal arteries (<- gastroduodenal artery <- common hepatic artery)
2. Head - inferior pancreaticoduodenal artery (<- superior mesenteric artery)
3. Body and tail - pancreatic branches of splenic artery
(Venous drainage are equivalent)

c. Lymphatic drainage
1. Head of pancreas -> pancreaticoduodenal nodes -> hepatic nodes
2. Body and tail of pancreas -> pancreatic nodes (along the superior and inferior borders of the pancreas) -> celiac nodes

(Thieme)

Front 55

The omental bursa
a. Anterior and posterior borders
b. Entrance - name, where
c. Parts

Back 55

a. Borders
I. Anterior - the stomach
II. Posterior - parietal peritoneum-covered pancreas

b. Omental\Epiploic foramen\Foramen of Winslow
Bounded anteriorly by the hepatoduodenal ligament (containing the hepatic portal vein, hepatic artery proper, and bile duct) and posteriorly by the peritoneal fold over the IVC.
(Visible after cutting the lesser omentum, gastrocolic ligament, or transverse mesocolon)

c. Parts
I. Vestibule of omental bursa
(Bounded by lesser omentum and parietal peritoneum. The papillary process of the caudate lobe of the liver project into it. the gastropancreatic fold divide it from the main cavity.)

II. The superior recess of omental bursa
(Between esophagus and IVC)

III. The splenic recess of omental bursa
(Between the splenic ligaments and stomach)

IV. The inferior recess of omental bursa
(Between stomach and transverse colon)

(Thieme)

Front 56

Eponyms
a. Major duodenal papilla
b. Sphincter of hepatopancreatic ampulla
c. Principal pancreatic duct
d. Accessory pancreatic duct
e. Prepyloric vein

Back 56

a. Papilla of Vater.

b. Sphincter of Oddi.

c. Principal pancreatic duct of Wirsung.

d. Accessory pancreatic duct of Santorini.

e. Mayo vein
(Tributary of right gastric vein)

(Netter)

Front 57

Eponyms
a. Ileocecal fold
b. Periportal space
c. Infundibulum of Gall bladder
d. Cystohepatic triangle
e. Marginal artery of colon

Back 57

a. Bloodless fold of Treves.

b. Periportal space of Mall
(A tissue space between the limiting lamina and the portal canal in the liver)

c. Hartman's pouch.

d. Calot triangle
(Area bounded by the cystic artery, cystic duct, and (common) hepatic duct—important structures to identify in performing a laparoscopic cholecystectomy.)
(Also - cystic lymphatic node = Calot node)

e. Marginal artery of colon\Artery of Drummond\Riolan arc
(Artery formed by anastomoses between the right and left colic arteries; it passes downward from the left colic flexure to the aboral end of the pelvic colon.)

(Netter)

Front 58

Sigmoid colon
a. Anatomical variations (4)
b. <-, ->

Back 58

a. Anatomical variations
1. Typical.
2. Short, straight, obliquely into the pelvis.
3. Looping to right side.
4. Ascending high into the abdomen.

b. Sigmoid colon
<- Pelvic brim\inlet - bounded by linea terminalis
-> S3 (ending of teniae coli, omental appendices, and haustra)

(Netter)

Front 59

Variations in colic arteries (5)

Back 59

Variations in colic arteries
1. Common trunk for right colic and middle colic artery.

2. Common trunk for right colic and ileocolic artery.

3. Absence of middle colic artery replaced by large branch from left colic artery.

4. Absence of right colic artery.

5. Arc of Riolan between middle colic and left colic arteries.

(Netter)

Front 60

Variations of hepatic portal vein (4)

Back 60

1. Left gastric vein enters junction of splenic and superior mesenteric vein.

2. Left gastric vein enter splenic vein.
(24%)

3. Inferior mesenteric vein enter junction between splenic and superior mesenteric vein.

4. Inferior mesenteric vein enter superior mesenteric vein.

(Netter)

Front 61

Lymphatic system
a. Lumbar lymphatic trunks - <-, ->
b. Intestinal lymphatic trunks - <-, ->

Back 61

a. Lumbar lymphatic trunks
<-
1. Lower limbs
2. Pelvic viscera and walls
3. Kidneys and adrenal glands
4. Large intestine

-> Cisterna chyli

b. Intestinal lymphatic trunks
<-
1. Lower part of liver
2. Stomach
3. Spleen
4. Pancreas
5. Small intestine

-> Cisterna chyli
(-> thoracic duct)
(Posterior to aorta, anterior to 1st and 2nd lumbar vertebrae)

(Stedman)

Front 62

Pelvis
a. Iliopectineal line - components
b. Linea terminalis - components
c. 'Function' of linea terminalis

Back 62

a. Iliopectineal line
I. Arcuate line of ilium
II. Pecten pubis\Pectineal line

b. Linea terminalis
I. Sacral promontory
II. Iliopectineal line

c. Forms the lower boundary of the iliac fossa (the area which gives attachment to iliacus) and separates the true\lesser from the false\greater pelvis.

(Netter, Stedman)

Front 63

Eponyms
a. Transverse folds of Rectum

Back 63

a. Valves of Houston - superior, middle, inferior
(5.5, 8.5, 12 cm from anus)

b.

Front 64

Back 64

(Instant anatomy)

Front 65

Transpyloric plane
a. Where is it found
b. Content (10)

Back 65

Front 66

Referred lower chest and abdominal pain - give the dermatome level and associated structures

Back 66

Front 67

Back 67

(Instantanatomy)