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277 Cards in this Set

  • Front
  • Back
State anatomical organization/ major fxns  of the GI tract
State anatomical organization/ major fxns of the GI tract

DEFINE the enteric nervous system and STATE its importance.
Myenteric- between muscle layers (MOVEMENT)
Submucosal plexeus- (SECRETION)
Myenteric- between muscle layers (MOVEMENT)
Submucosal plexeus- (SECRETION)
What are the functions of the GI tract?
Digestion
Elimination
Endocrine
Protection
Motility
Absorption
Secretion
Storage
Digestion
Elimination
Endocrine
Protection
Motility
Absorption
Secretion
Storage
What is the first pass effect?

How is the GI tract regulated

During the interdigestive (fasting) state, you may think nothing is happening, but actually...

The MIGRATING MYOELECTERIC COMPLEX is active.
What is it useful for? Which hormones are secreted by M cells (lymph cells) in small intestine? How long does PHASE III of MMC last?

How are contractions generated? Why are SLOW WAVES (Basic Electrical Rhythm) BER not the same thing as ACTION POTENTIAL ("SPIKE" potential)  in the small intestine?
How are contractions generated? Why are SLOW WAVES (Basic Electrical Rhythm) BER not the same thing as ACTION POTENTIAL ("SPIKE" potential) in the small intestine?
BER: 
sets max possible rate of propulsion down GI tract
Always present (RMP)
Variations of activity of Na/ K ATPase pump

AP:
CONTRACTIONS= AP on the PEAKS of the slow waves
BER:
sets max possible rate of propulsion down GI tract
Always present (RMP)
Variations of activity of Na/ K ATPase pump

AP:
CONTRACTIONS= AP on the PEAKS of the slow waves
What sets the MAXIMAL POSSIBLE RATE of GI propulsion?
THE BER
THE BER
What mediates the RECEPTIVE RELAXATION RESPONSE? What if you don't have it?
Receptive relaxation occurs in the body of the stomach, and in the small intestine; this action helps accommodate the influx of material.  The response is vagally-mediated, through the release of vasoactive intestinal peptide (VIP).  If you don’t have rec
Receptive relaxation occurs in the body of the stomach, and in the small intestine; this action helps accommodate the influx of material. The response is vagally-mediated, through the release of vasoactive intestinal peptide (VIP). If you don’t have receptive relaxation in the stomach, you will feel “full” very fast, and will not be able to eat as much…there is literally less room to store food. This is the principle behind bariatric surgery for morbidly obese patients.
What types of food get out of the stomach quickly? Which takes longest to empty?

What is peristalsis? What happens at the front of the food we are squishing down? What happens in the back?

What is segmentation? How is it different from peristalsis?

What is a nicer way to call "pooping"? Which reflexes are involved?
RECTOSPHINCTERIC REFLEX
RECTOSPHINCTERIC REFLEX
Where is the Spincter of oddi located? What is its role?

Contraction of what forms these ringlets? What are these called?
Contraction of what forms these ringlets? What are these called?

Why is this a medical emergency?
Why is this a medical emergency?
Pneumoperitoneum is air or gas in the abdominal (peritoneal) cavity. 

The most common cause is a perforated abdominal viscus, generally a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trau
Pneumoperitoneum is air or gas in the abdominal (peritoneal) cavity.

The most common cause is a perforated abdominal viscus, generally a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma.
What is this?
What is this?
Achalasia

In the Esophagus (primary and secondary esophageal peristalsis) and stomach (MMC, receptive relaxation)

The lower esophageal sphincter (LES) relaxes when bolus arrives, unless there is smooth muscle disorder such as achalasia
What should you expect when you see this?
What should you expect when you see this?
Esophageal tumor
Esophageal tumor
In the small intestine, how can you tell the difference between Jejunum and Illium?
In the small intestine, how can you tell the difference between Jejunum and Illium?
Jejunum= Longer vasa rectae, fewer arcades
Jejunum= Longer vasa rectae, fewer arcades
In this CT, where/ where is this huge mass located?  How is this possible
In this CT, where/ where is this huge mass located? How is this possible
Trichobezoar
Stomach can distend and accomidate lots of room
Trichobezoar
Stomach can distend and accomidate lots of room
What the hell is this?
What the hell is this?
Colon- patient lying on his left side
Colon- patient lying on his left side
What is the difference between intraperitoneal vs. the retroperitoneal organs?
(Intra)Peritoneal - mobility vs malposition
Retroperitoneal - stability vs squash factor
(Intra)Peritoneal - mobility vs malposition
Retroperitoneal - stability vs squash factor
How can you tell the difference between a direct and indirect hernia?
How can you tell the difference between a direct and indirect hernia?
The inguinal triangle is the site for direct inguinal hernias. It is defined medially by the lateral border of rectus abdominus, inferiorly by the inguinal ligament, and superiorly by the inferior epigastric artery.

Remember--direct inguinal hernias protrude through the weak fascia of the abdominal wall, medial to the inferior epigastric vessels. Indirect inguinal hernias (which can also be called congenital inguinal hernias) occur lateral to the inferior epigastric vessels--they protrude through the deep inguinal ring.
















ID the following slide
ID the following slide

Describe all 9 layers of the abdominal wall!
Describe all 9 layers of the abdominal wall!

How can we divide up the abdomen in to 9 anatomical surface areas. What are all the different name
How can we divide up the abdomen in to 9 anatomical surface areas. What are all the different name

What happens when we have a remnant of the yolk sac?
What happens when we have a remnant of the yolk sac?
Meckel’s diverticulum
Meckel’s diverticulum
Which area, when stimulated by PNS secretes? What about motility
Which area, when stimulated by PNS secretes? What about motility



What type of hernia is this?
What type of hernia is this?
Indirect inguinal hernia  (through the deep inguinal ring) Passes lateral to the epigastric vessels
Indirect inguinal hernia (through the deep inguinal ring) Passes lateral to the epigastric vessels
Which type of hernia is this?
Which type of hernia is this?
Direct inguinal hernia (medial to the inferior epigastric vessels)

 (The bulging occurs medial to the inferior epigastric vessels in the inguinal triangle (Hesselbach's triangle), which is bounded:
laterally by the inferior epigastric artery;
mediall
Direct inguinal hernia (medial to the inferior epigastric vessels)

(The bulging occurs medial to the inferior epigastric vessels in the inguinal triangle (Hesselbach's triangle), which is bounded:
laterally by the inferior epigastric artery;
medially by the rectus abdominis muscle; and
inferiorly by the inguinal ligament
What four areas make up the inguinal canal and where are they located? Muscles? Aponerosis? Ligatments? Tendons?
What four areas make up the inguinal canal and where are they located? Muscles? Aponerosis? Ligatments? Tendons?







What can cause this to happen?
What can cause this to happen?
Hirshsprung’s Disease = megacolon, another smooth muscle disorder involving loss of enteric nerves in the distal portion of the colon. Includes loss of internal anal sphincter control.
What is going on here?
What is going on here?
Cholelithiasis (AKA Gallstones)
Cholelithiasis (AKA Gallstones)
What is happening here that is no bueno?
What is happening here that is no bueno?

Where would you need to be stabbed in order to be hit through the spleen?

Where would you need to shoot someone in order to hit them in the Gall bladder? What else would it hit around it?

Describe some of all the dieseases of things that can go wrong with the GI tract?
Describe some of all the dieseases of things that can go wrong with the GI tract?
Thoracic, retroperitoneal, systemic and abdominal wall etiologies must also be considered during
assessment of patients with acute abdomen 

Referred pain from various visceral structures is
common until the disease involves the parietal peritoneum or
Thoracic, retroperitoneal, systemic and abdominal wall etiologies must also be considered during
assessment of patients with acute abdomen

Referred pain from various visceral structures is
common until the disease involves the parietal peritoneum or somatically innervated body wall.
Name the Retroperitoneal structures
SAD PUCKER:
Suprarenal glands
Aorta & IVC
Duodenum (half)
Pancreas
Ureters
Colon (ascending & descending)
Kidneys
Esophagus (anterior & left covered)
Rectum
Identify the Arcuate line here. What happens here?
Identify the Arcuate line here. What happens here?
arcuate line is the point at which the posterior lamina of the rectus sheath ends and transversalis fascia lines the inner surface of the rectus abdominis m.

1/2 between pubic symphysis and unmbilicus
arcuate line is the point at which the posterior lamina of the rectus sheath ends and transversalis fascia lines the inner surface of the rectus abdominis m.

1/2 between pubic symphysis and unmbilicus
What is the name of the area 1/2 way between the pubic symphysis and umbilicus where this transition changes? Which area one is above this halfway point? Which one is below?
What is the name of the area 1/2 way between the pubic symphysis and umbilicus where this transition changes? Which area one is above this halfway point? Which one is below?
Top=  Upper three quarters of rectus sheath
Botton= lower quarter of rectus sheath
Top= Upper three quarters of rectus sheath
Botton= lower quarter of rectus sheath
Which is hepatic Vein? Which is Hepatic Artery?
Which is hepatic Vein? Which is Hepatic Artery?

Which one is:
 Saliva?
Gastric Juice? 
Pancreatic Juice?
Bile Juice?

How can you tell?
Which one is:
Saliva?
Gastric Juice?
Pancreatic Juice?
Bile Juice?

How can you tell?

What is the difference between ulcerative colitis and crohn's disease?

Where are the different openings of the diaphram located?
Where are the different openings of the diaphram located?

Describe the location of the different digestive enzymes

What happens when you are climbing up a ladder and you hear something splatter?
Diarrhea
*clap* clap *clap*
Diarrhea
*clap* clap *clap*
What does the vagus stimulate, and more importantly WHICH ACTIONS ARE NOT, I REPEAT , NOT STIMULATED BY the vagus?

DESCRIBE the regulation of gastric acid secretion

EXPLAIN the consequences of enhanced gastric acid production on intestinal function.

DEFINE steatorrhea. DESCRIBE the mechanisms for intestinal fat digestion and absorption.
Steatorrhea is fat in the stool.

We need BILE to facilitate fat absorption. When we are operating on lower levels of BILE (like when some of it is precipitated by low pH levels), we aren’t able to properly absorb fat.
DEFINE borborygmi. DESCRIBE the production of intestinal gas

EXPLAIN the consequences of lactose intolerance.

LIST the types of fluids entering the lumen of the GI tract.

DEFINE the enteric nervous system and STATE its importance.

STATE the importance of chemo-, osmo-, and mechanoreceptors in regulating GI function, and how they influence GI function.PREDICT the effects of loss of these receptors on enteric nerve function.

LIST possible neurotransmitters used in the GI tract.

STATE the primary vessels supplying the GI tract.

DESCRIBE the role of the blood flow in aiding GI function.

PREDICT the effects of autonomic nerve stimulation on secretion and propulsion in the GI tract





Which organs does the the superior mesinteric artery supply blood too? What does Inferior mesinteric artery supply blood to?

Name Orgin, insertion, and action of anterior abdominal muscles
Name Orgin, insertion, and action of anterior abdominal muscles

Name Orgin, insertion, and action of posterior abdominal muscles
Name Orgin, insertion, and action of posterior abdominal muscles

Where is the blood supply for the adrenal glands assymeteric?

Spermatic cord contents "Piles Don't Contribute To A Good Sex Life"
Pampiniform plexus
Ductus deferens
Cremasteric artery
Testicular artery
Artery of the ductus deferens
Genital branch of the genitofemoral nerve
Sympathetic nerve fibers
Lymphatic vessels
Descending abdominal aorta: seven divisions "Sometimes Intestines Get Really Stretched Causing Leakage"
Suprarenals [paired]
Inferior mesenteric
Gonadal [paired]
Renals [paired]
Superior mesenteric
Celiac
Lumbar [paired]
Portal-systemic anastomoses: main 2 places that retroperitoneals connect into systemic
RetroPeritoneals hook up with Renal and Paravertebral veins.
Scrotum layers "Some Days Eddie Can Irritate People Very Thourougly"
Skin
Dartos layer
External spermatic fascia
Cremaster muscle
Internal spermatic fascia
Parietal tunica vaginalis
Visceral tunica vaginalis
Tunica albuginea
Inferior vena cava tributaries "I Like To Rise So High"
Illiacs
Lumbar
Testicular
Renal
Suprarenal
Hepatic vein.
Liver: side with ligamentum venosum/ caudate lobe vs. side with quadrate lobe/ ligamentum teres "VC goes with VC":
The Venosum and Caudate is on same side as Vena Cava [posterior]. Therefore, quadrate and teres must be on anterior by default.
· See inferior-view diagram
Descending abdominal aorta branches from diaphragm to iliacs "Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin"
Descending abdominal aorta branches from diaphragm to iliacs "Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin"
Phrenic [inferior]
Celiac
Superior mesenteric
Suprarenal [middle]
Renal
Testicular ["in men" only]
Lumbars
Inferior mesenteric
Sacral
Phrenic [inferior]
Celiac
Superior mesenteric
Suprarenal [middle]
Renal
Testicular ["in men" only]
Lumbars
Inferior mesenteric
Sacral
Spermatic cord contents "3 arteries, 3 nerves, 3 other things"
3 arteries: testicular, ductus deferens, cremasteric.
3 nerves: genital branch of the genitofemoral, cremasteric, autonomics.
3 other things: ductus deferens, pampiniform plexus, lymphatics.
· Note some argument about this: Moore doesn't put in cremasteric nerve, Lumley puts in inguinal...
Which blood vessels in this picture supply blood to the deep abdominal wall? 

Which vessels supply blood superficially to ab wall (5), and which ones are deeper(6)?
Which blood vessels in this picture supply blood to the deep abdominal wall?

Which vessels supply blood superficially to ab wall (5), and which ones are deeper(6)?
Superficial:
1. MUSCULOPHRENIC artery
2. INTERNAL THORACIC artery
3. SUPERFICIAL EPIGASTRIC ARTERY (medially)
4. SUPERFICIAL CIRCUMFLEX ARTERY(laterally)
5. FEMORAL artery

At a deeper level:
1. SUPERIOR EPIGASTRIC artery, 
2. INTERNAL THROACIC
Superficial:
1. MUSCULOPHRENIC artery
2. INTERNAL THORACIC artery
3. SUPERFICIAL EPIGASTRIC ARTERY (medially)
4. SUPERFICIAL CIRCUMFLEX ARTERY(laterally)
5. FEMORAL artery

At a deeper level:
1. SUPERIOR EPIGASTRIC artery,
2. INTERNAL THROACIC
3. TENTH and 11TH INTERCOSTAL ARTERIES (laterally)
4. SUBCOSTAL artery
5. INFERIOR EPIGASTRIC artery (medially )
6. DEEP CIRCUMFLEX ILIAC artery (laterally)
7. EXTERNAL ILIAC artery
Which one has obstructive liver diesease
Which one has obstructive liver diesease
White areas= scarring
decreased blood flow
obstructive disease
White areas= scarring
decreased blood flow
obstructive disease
How does this form?
How does this form?
Acities

Blood flow to the liver is crucial!! Obstruction can lead to acites, hepatomegaly, jaundice
Acities

Blood flow to the liver is crucial!! Obstruction can lead to acites, hepatomegaly, jaundice
The structures in the spermatic cord include:
The structures in the spermatic cord include:
A. ductus deferens/ VAS DEFRENS & artery (inferior vesical artery);
B. testicular artery (from the abdominal aorta);
C. pampiniform plexus of veins (testicular veins);
D. coverings of spermatic chord:
1. external spermatic fascia
2. cremasteric muscle and fascia
3. internal spermatic fascia

Other stuff:
the cremasteric artery and vein (small vessels associated with the cremasteric fascia);
the genital branch of the genitofemoral nerve (innervation to the cremasteric muscle);
sympathetic and visceral afferent nerve fibers;
lymphatics; and
remnants of the processus vaginalis
Which hernia passes MEDIAL to the inferior epigastric vessels?
Direct hernia


**indirect hernia passes LATERALLY and enters via DEEP INGUINAL RING
Which membrane of peritonium is innervated by ANS? Which area of organs is sensitive to well localized pain?
Which membrane of peritonium is innervated by ANS? Which area of organs is sensitive to well localized pain?





Where do we draw the line for the foregut, midgut, and hindgut?
the celiac trunk supplies the lower esophagus, stomach, and the proximal half of the descending part of the duodenum;
the superior mesenteric artery supplies the rest of the duodenum, the jejunum, the ileum, the ascending colon, and the proximal two-thirds of the transverse colon; and
the inferior mesenteric artery supplies the rest of the transverse colon, the descending colon, the sigmoid colon, and most of the rectum.


Which area of duodenum do most ulcers occur? What is around the area should an ulcer occur?
The first part!!

Ampulla/ duodenal cap
The first part!!

Ampulla/ duodenal cap




Describe formation of the Pleuropericardial Membrane
Describe formation of the Pleuropericardial Membrane
Remember the anterior and posterior cardinal veins come from the body wall, into the common cardinal vein, which connects them to the heart.  Some sort of mesenchymal sheet covers all of the veins. Remember the concept of intussusception: things being abs
Remember the anterior and posterior cardinal veins come from the body wall, into the common cardinal vein, which connects them to the heart. Some sort of mesenchymal sheet covers all of the veins. Remember the concept of intussusception: things being absorbed. Before we talk about the formation of the pleuropericardial membrane, let's work on a visual aid: Imagine a curtain is attached to the floor and the roof. You stand on a chair and grab the curtain. You represent the heart; your arm is the common cardinal vein; and the curtain is the mesentery ensheathing the anterior and posterior cardinal veins. As the common cardinal vein (your arm) starts to be absorbed into the heart (your body), the membrane (the curtain) starts to bow out because of its attachment to the body wall. The membrane is pulled right across the opening dividing the pleural cavity from the pericardial cavity.

FYI: Duct of Cuvier is another name for the common cardinal vein. Both names could be used in the test.
Where does the foregut, mid gut, and hind gut end respectively?
Where does the foregut, mid gut, and hind gut end respectively?
Forgut: first 2/4 of duodeunum
Midgut: Proximal half of transverse colon
hindgut: proximal 2/3 of rectum
Forgut: first 2/4 of duodeunum
Midgut: Proximal half of transverse colon
hindgut: proximal 2/3 of rectum
How are the intestines formed?
How are the intestines formed?
270 counter clockwise rotation 

The Gut Tube: Formation of Intestines
•	The endodermal gut tube grows very quickly - faster than the peritoneal cavity. 
•	It bulges ventrally -and is forced into the body stalk for five weeks (physiological umbilical
270 counter clockwise rotation

The Gut Tube: Formation of Intestines
• The endodermal gut tube grows very quickly - faster than the peritoneal cavity.
• It bulges ventrally -and is forced into the body stalk for five weeks (physiological umbilical hernia)
• Then as the mesonephroi regress and there is more room in the peritoneal cavity, it is pulled back in
• As the gut tube comes back into the abdominal cavity, it undergoes a 270° counterclockwise rotation around the axis formed by the vitelline duct and superior mesenteric artery (failure of the vitelline duct to fully regress results in Meckel's diverticulum).
• This rotation brings the cecum, ascending colon, transverse colon, and descending colon into their final anterior position framing the small intestines
• If this rotation occurs in the reverse direction, the individual will be fine if he presents with complete situs inversus, where everything is reversed. However, if all other organs are correctly situated and the reverse rotation occurs, major problems will ensue
Describe, in general, what the pair dorsal, lateral, and ventral segmental arteries. Which types supply the gut tube, and eventually become the celiac, SMA and IMA arteries?
Abdominal Blood Supply
-The dorsal mesentery connects the gut tube to the aorta
Three pairs of arteries come off the aorta at each level near the somites; the general name for these is “segmental arteries” even though the dorsal arteries are located between the somites and, therefore are actually between two adjacent ”segments.”
A.) Paired DORSAL intersegmental arteries- supply the somites and muscle mass; lie right beneath the nerves; give rise to posterior intercostal arteries
B.) Paired LATERAL segmental arteries-supply the mesonephric kidneys; eventually give rise to renal arteries
C.) Paired VENTRAL segmental arteries-supply the gut tube; however, the pair either fuses or one drops out so you are left with an unpaired ventral segmental artery
**Most of the ventral segmental arteries drop out, but three remain
1. Celiac Artery- servicing the abdominal foregut
2. Superior Mesenteric Artery- servicing the midgut
3. Inferior Mesenteric Artery- servicing the hindgut
(Note: these sets of embryonic arteries are not named arteries; some books identify the 3 pairs as lateral, intermediate and ventral arteries. You need to look at diagrams to ensure you understand the concepts.)
What is a coelom? 
How does it develop?
What is a coelom?
How does it develop?
The space between the two layers of mesoderm is the coelom. The coelom, by definition, is a space that is lined by an epithelium derived from mesenchyme.


Note: The blood vessels associated with the anterior and posterior body wall are the cardinal veins. They connect into the heart by means of the common cardinal vein, which drains into sinus venosus. In this way, the heart and the body wall are connected. This will be important at the end of the lecture.
What four components make up the Development of the Muscular Diaphragm
A region of mesenchyme which is anterior to the developing heart, the septum transversum, will form a large part of the diaphragm. As the septum transversum folds, it comes into contact with structures that are in the way of its eventual contact with the
Thus, the
diaphragm is made up of:
 Septum transversum (in the middle)
 Esophageal mesentery
 Pleuroperitoneal membrane
(associated with the
mesonephric kidneys)
 Posterior body wall
Note that the pleuroperitoneal canals
are the most common areas for
herniation, especially on the left side,
where the spleen and intestine may
be sucked into the thorax.

A region of mesenchyme which is anterior to the developing heart, the septum transversum, will form a large part of the diaphragm. As the septum transversum folds, it comes into contact with structures that are in the way of its eventual contact with the dorsal body wall: the gut tube, the kidneys and the posterior body wall itself. So the diaphragm is made up of four things:
1) The septum transversum in the middle.
2) The mesentery of the esophagus. As the septum transversum folds, it runs into the gut, which is connected to the body wall by the mesentery. Remember that the esophagus is the part of the gut that runs through the diaphragm before it connects to the stomach.
3) The pleuroperitoneal membrane associated with mesonephric kidneys. The mesonephric kidneys are the second in a series of three kidneys. They are covered by the surface that gives the lining to the coelom. When the developing septum transversum runs into the mesonephric kidneys, and the two mesonephroi disappear, the capsule on top of them gets incorporated into the diaphragm. This piece of diaphragm is named by the two cavities that it separates: it is the pleuroperitoneal membrane that separates the peritoneum from the pleural cavity.
4) Contributions from the posterior body wall.
The Greater omentum comes from the _________ (dorsal / ventral) mesentary.
The Greater omentum comes from the _________ (dorsal / ventral) mesentary.
DORSAL mesentary
DORSAL mesentary
Why are there 4, and not TWO layers of the greater omentum?
Why are there 4, and not TWO layers of the greater omentum?





Where do intraembryonic and extraembryonic coeloms connect??? What causes them to connect?
INTRAEMBRYONIC and EXTRAEMBRYONIC COELOMS are connected in areas where there  are SOMITES!!! This occurs because the growing intraembryonic coelom between the two layers of the  lateral plate mesoderm eventually “ruptures,” spilling the intraembyronic coe
INTRAEMBRYONIC and EXTRAEMBRYONIC COELOMS are connected in areas where there are SOMITES!!! This occurs because the growing intraembryonic coelom between the two layers of the lateral plate mesoderm eventually “ruptures,” spilling the intraembyronic coelom out to connect with the extraembryonic coelom. Remember, where there are no somites, these two coeloms are not continuous and connected. In the anterior region of the embryo, the intraembryonic coelom exists on its own, running anterior to the oropharyngeal membrane like a U-shaped tunnel. This anterior part of the intraembryonic coelom will become the presumptive pericardial cavity.
How does the division between the lungs and the heart (PLEUROPERICARDIAL MEMBRANE)
How does the division between the lungs and the heart (PLEUROPERICARDIAL MEMBRANE)
Dr DeSesso emphasized that oxygenated blood comes through the umbilical veins, and there are also the 
vitelline veins from the yolk sac, and the cardinal veins from the body walls. 
The cardinal veins are important because they drain into the common ca
Dr DeSesso emphasized that oxygenated blood comes through the umbilical veins, and there are also the
vitelline veins from the yolk sac, and the cardinal veins from the body walls.
The cardinal veins are important because they drain into the common cardinal vein (aka Duct of Cuvier),
which connects the blood supply in the body walls to the heart. A sheet of mesenchyme covers all of these veins.
When the cardinal veins are intususscepted (absorbed) into the heart, the membrane (attached to the body wall) is pulled with them, and divides the pleural from the pericardial cavity – thereby forming the pleuropericardial cavity, and relocating the phrenic nerves to the anterior portion of the thorax (from their previous posterior position).
Think about the functions of the glorious liver... What happens as the liver stops working? What might you see?
Think about the functions of the glorious liver... What happens as the liver stops working? What might you see?

The liver is a sponge.... How much blood flow does this sponge get?
The liver is a sponge.... How much blood flow does this sponge get?
Portal vein= 1L/min
Hepatic vein = 4500ml/min

1.5L/min of blood flow ~ 30% of CO
How might congestive heart failure (on R side of heart) lead to poor liver function?
Increase in resistance/ pressure of inferior vena cava
--> increasing pressure hepatic vein feels
Increase in resistance/ pressure of inferior vena cava
--> increasing pressure hepatic vein feels
There are two types of jaundice (increased bilrubin in blood): Obstructive and Hemolytic...

Which type could still occur even with a perfectly functional liver?
HEMOLYTIC JAUNDICE= abnormal destruction of RBC

OBSTRUCTIVE JAUNDICE= stopped flow of bile/ back-up
HEMOLYTIC JAUNDICE= abnormal destruction of RBC

OBSTRUCTIVE JAUNDICE= stopped flow of bile/ back-up
VERY IMPORTANT::: What type of INSULIN-independent transporters are in the liver? How does this relate to the liver's fxn?
GLUT 2 TRANSPORTERS (ie. brain, liver, pancreas... etc)
GLUT 2 TRANSPORTERS (ie. brain, liver, pancreas... etc)
WHAT IS THE ONLY WAY WE CAN ABSORB SUGAR?!?!??!? 
Why does the liver help with this?
WHAT IS THE ONLY WAY WE CAN ABSORB SUGAR?!?!??!?
Why does the liver help with this?
MONOSACCHARIDES!!! 
liver can help store monosaccharides (glucose, galactose & fructose) as glycogen

LIVER IS THE GATEWAY!!! W/o liver... it would be 3x as high.
MONOSACCHARIDES!!!
liver can help store monosaccharides (glucose, galactose & fructose) as glycogen

LIVER IS THE GATEWAY!!! W/o liver... it would be 3x as high.
VERY IMPORTANT ENZYME:: What does HMG coA reductase build and which organ is it found in?
HMG CoA reductase= produces endogenous cholesterol
HMG CoA reductase= produces endogenous cholesterol
When we eat meat, we increase acid pool in our body. Why is the liver super duper important for PROTEIN metabolism? Why are we in big trouble if our liver doesn't work?
When we eat meat, we increase acid pool in our body. Why is the liver super duper important for PROTEIN metabolism? Why are we in big trouble if our liver doesn't work?
THE LIVER= DETOX ACIDS AND MAKE UREA!!

also... synthesis of plasma proteins and transamination... 

without liver= Acid /base problems (acidosis) AND toxic levels of NH3 (amonnia)

Also balance of oncotic pressure( makes plasma proteins)
THE LIVER= DETOX ACIDS AND MAKE UREA!!

also... synthesis of plasma proteins and transamination...

without liver= Acid /base problems (acidosis) AND toxic levels of NH3 (amonnia)

Also balance of oncotic pressure( makes plasma proteins)
How would our liver metabolize our meal at the heart attack grill?
How would our liver metabolize our meal at the heart attack grill?

Where is primary bile made? Where is it recycled?

AND how is it released?
CCK contracts gallbladder & relax the sphincter of Oddi
CCK contracts gallbladder & relax the sphincter of Oddi

terminal illium recycles bile back to liver via portal tract. (can recylce 4-6 times for every meal)
Why do we lose cholesterol in our poop?
Why do we lose cholesterol in our poop?
10% loss (bile made from cholesterol via diet/ or synthesized + glycerine/ taurine)
10% loss (bile made from cholesterol via diet/ or synthesized + glycerine/ taurine)
Why is it not a problem for us to remove the gall bladder in an emergency?
Why is it not a problem for us to remove the gall bladder in an emergency?
initial secretion of bile from gallbladder/ CCK not vital since fat is usually the last part of chyme to leave the stomach
Why do we need bile?
to get through the unstirred water layer in the small intestine. (taxi lipids through to enterocytes)

BILE = OSMOTIC AGENT 
= draws h20 and electrolytes and buffers
to get through the unstirred water layer in the small intestine. (taxi lipids through to enterocytes)

BILE = OSMOTIC AGENT
= draws h20 and electrolytes and buffers
Where is the subphrenic recess and the hepatorenal recess located? Where would we see the air on an xray?

Which area of liver sits on diaphram directly?
LIVER= INTRAPERITONEAL ORGAN EVEN THOUGH IT DOESN'T HAVE A MESENTARY

bare area= directly on diaphram... no peritonium
LIVER= INTRAPERITONEAL ORGAN EVEN THOUGH IT DOESN'T HAVE A MESENTARY

bare area= directly on diaphram... no peritonium
What is the key difference between the FUNCTIONAL liver, and the ANATOMICAL liver?
Anatomical= separated by faliciform ligament
functional= divided by right and left HEPATIC ARTERY
Anatomical= separated by faliciform ligament
functional= divided by right and left HEPATIC ARTERY
What are the three structures in the HEPATODUODENAL LIGAMENT of the lesser omentum?

What is the other ligament of the lesser omentum?
bile duct, hepatic artery, portal vein

PORTAL VEIN IS THE LARGEST!
bile duct, hepatic artery, portal vein

PORTAL VEIN IS THE LARGEST!
What are all the veins that drain in to the hepatic portal vein?
What are all the veins that drain in to the hepatic portal vein?
Look at the picture, you moron.
IMV, SMV, Splenic vein

(liver capillaries very sensitive to increases in pressure. Think of it as a sponge) Portal hypertension= bad
Match the portal/ systemic anastomosis with the veins? Which one is the most fatal?
Match the portal/ systemic anastomosis with the veins? Which one is the most fatal?
MOST FATAL: azygous & left gastric vein (esophogeal varices) *CAN BLEED LITERS IN GI TRACT

superior rectal & middle+inferior rectal vein (internal hemmoroids

paraumbilical & superficial veins of anterior abdominal wall (caput medusa)

colic & post
MOST FATAL: azygous & left gastric vein (esophogeal varices) *CAN BLEED LITERS IN GI TRACT

superior rectal & middle+inferior rectal vein (internal hemmoroids

paraumbilical & superficial veins of anterior abdominal wall (caput medusa)

colic & posterior abdominal wall (retroperitoneal anastomoses) *IN WALL... NOT A LOT OF SPACE TO BLEED

venous backpressure= bypass liver, veins can rupture easily
What is the best way to visualize gallbladder stones? (cholelithstasis)
MR or ultrasound= density of stones + bile easeir to differ

(CT= contrast needed, xray= not very radioopaque)
MR or ultrasound= density of stones + bile easeir to differ

(CT= contrast needed, xray= not very radioopaque)
Where else might you see gallbladder stones (via a direct fistula)? aka... what else is in close proximity to it?
duodenum or transverse colon
duodenum or transverse colon
Is the pain felt in these areas visceral or parietal? Why?
Is the pain felt in these areas visceral or parietal? Why?
ANS, Visceral, poorly localized

*DONT FORGET PHRENIC PAIN (c3,4,5) FROM THE DIAPHRAM= SHOULDER PAIN FOR GALLSTONE
What else is behind stomach and pancreas? 

How does the superior mesentaric artery come inbetween the two pieces of the pancreas?
What else is behind stomach and pancreas?

How does the superior mesentaric artery come inbetween the two pieces of the pancreas?
The lesser sac
The lesser sac
What is the one foregut organ that "cheats" and gets blood from both the celiac artery and SMA?

Where a GALLSTONE is located may have different presentations clinically.... blockage of the hepatopancreatic ampulla might give you what?
Where a GALLSTONE is located may have different presentations clinically.... blockage of the hepatopancreatic ampulla might give you what?
PANCREATISIS= enzymes chewing up the organ itself
PANCREATISIS= enzymes chewing up the organ itself
Is this a gallstone?
Is this a gallstone?
NO!! this is in the shape of a pancreas! = chronic pancreatitis
Why is pancreatic cancer so difficult to treat?
Dont come until big enough to block bile duct/ obstructive jaundice= by then too late!
already surrounded/ blocking aorta/ SMA. Very difficult to remove.
don't respond to chemo as well either.
Dont come until big enough to block bile duct/ obstructive jaundice= by then too late!
already surrounded/ blocking aorta/ SMA. Very difficult to remove.
don't respond to chemo as well either.
Which two ligaments hold the spleen together, and what arteries pass through each one?

hint= splenorenal ligament & gastroplenic ligament

What does the splenic artery supply blood to?

HIGH YIELD SWAREZ QUESTION: Why is it that if you have a penetrating injury to spleen (lots of bleeding in the peritoneum) that you may also have a PNEOMOTHROAX as well?
might puncture through pleural space as well!=  collapsed lung
might puncture through pleural space as well!= collapsed lung
During a paracentesis, think of exactly all the layers you would stab through.

HISTOLOGICALLY, how can you tell the difference between Large intestine an small intestine

THE ARE NO _________ IN THE STOMACH SUBMUCOSA.
NONE!
THE ARE NO _________ IN THE STOMACH SUBMUCOSA.
NONE!
Oh there are submucosal GLANDS in the ESOPHAGUS, but you don't wan't the esophagus. You want the stomach.... and there are NO GLANDS in the STOMACH submucosa!!
Oh there are submucosal GLANDS in the ESOPHAGUS, but you don't wan't the esophagus. You want the stomach.... and there are NO GLANDS in the STOMACH submucosa!!
How can you tell the difference between the cardiac region and the pyloric region of the gut?

How can you tell the difference among the duodenum, jejunum, and illium histologically?

What is something only found in illium? What about duodenum?
How can you tell the difference among the duodenum, jejunum, and illium histologically?

What is something only found in illium? What about duodenum?

What happens to the number of goblet cells as you go down the tract of the small intestine?  What else changes as you move along?
What happens to the number of goblet cells as you go down the tract of the small intestine? What else changes as you move along?

How does the composition of saliva change as the flow of saliva increases?
How does the composition of saliva change as the flow of saliva increases?
During salivary secretion, blood flow to the acini is increased by parasympathetic stimulation, and ultrafiltrate from plasma (mostly serous fluid) enters the acini. Filtrate from the cells enters the lumen of the acinar cells, mixing with secreted mucus
During salivary secretion, blood flow to the acini is increased by parasympathetic stimulation, and ultrafiltrate from plasma (mostly serous fluid) enters the acini. Filtrate from the cells enters the lumen of the acinar cells, mixing with secreted mucus and α-amylase, creating the primary secretion. This secretion is modified as it passes through the ducts into the mouth. Lingual lipase (secreted from the Von Ebner's glands of the tongue) is added to the saliva in the mouth. The graph illustrates the effect of increasing salivary secretion on composition of saliva. The changes are due to the reduced modification of saliva through the ducts as flow increases.
What do the Cardiac, Fundic/ gastric, and Pyloric glands secrete in to the stomach, and what do they do?
What do the Cardiac, Fundic/ gastric, and Pyloric glands secrete in to the stomach, and what do they do?
* HCl: Digests food, kills ingested bacteria, converts inactive pepsinogens to pepsins.
* Intrinsic factor: Essential gastric secretion required for B12 absorption in the terminal ileum.
* Pepsinogens: The inactive form of pepsins, which are proteases that are activated in the acid environment. Thus, protein digestion begins in the stomach.
* Gastrin: A gut hormone secreted from G-cells located in the antrum of the stomach and the duodenum. Gastrin stimulates HCl secretion and gastric motility (mixing), as well as lower GI motility (mass movements).
* Lipase (gastric lipase): Continues process of lipid digestion.
* Mucus: Thick mucus is secreted with HCO3-. The HCO3- remains trapped in the mucus layer at the epithelial cell surface, effectively buffering the cells from the acid environment in the lumen (Fig. 23.5).
* Other factors: Somatostatin (SS) inhibits HCl secretion; histamine stimulates HCl secretion.
Name the 5 hormones of the GI tract!

Which one INCREASES Gastric emptying? Which hormone increases movement of food during the fasting stage (MMC)?

What does the illieum do? What kind of problems would you have if you needed to remove it?
Surgical removal of the terminal ileum causes multiple problems, including loss of both bile recycling and vitamin B12 absorption. In this circumstance, bile production by the liver is upregulated, but production is not sufficient for absorption of fat contained in a normal meal, and some steatorrhea may result. To treat vitamin B12 deficiency, injections are administered every few months (infrequent injections are sufficient because excess B12 will be stored in the liver).
Name what the products are for when we drink milk. Which enzymes do we use?
Carbohydrate digestion STARTS in the mouth with salivary amylase, but we need to break down sugar to monosaccarides since that is the only way we can absorb cards in the enterocytes. What brush border enzymes help do this?
Note: another name for isomaltase is alpha-dextrinase
Pancreatic lipase is secreted in active form, but it doesn't work with bile. What else needs to be secreted in order for pancreatic lipase to work??

[linguinal and gastric lipase don't need this]
Pancreatic lipase is secreted in active form, but it doesn't work with bile. What else needs to be secreted in order for pancreatic lipase to work??

[linguinal and gastric lipase don't need this]
Pancreatic lipase is different from lingual and gastric lipases, in that it requires a co-lipase to work.  The pancreatic lipase is secreted in active form, but is inactive in the presence of bile salts and acids because the bile binds to the surface of T
Pancreatic lipase is different from lingual and gastric lipases, in that it requires a co-lipase to work. The pancreatic lipase is secreted in active form, but is inactive in the presence of bile salts and acids because the bile binds to the surface of TG oil drops to form an emulsion (remember, there is going to be lots of bile secreted in response to the same CCK that is simulating enzyme release from the pancreas!). Co-lipase secreted from the pancreas is activated in the duodenum by trypsin, and binds to bile salts by the oil drops, then one lipase molecule forms a complex with one co-lipase molecule. This process “opens a door” for the pancreatic lipase to access the lipids. This is critical to the formation of micelles.
Why do we care about the pancreatic trypsin inhibitor? Why might it come in handy?
Why do we care about the pancreatic trypsin inhibitor? Why might it come in handy?
In the stomach: HCl digests proteins and anything else it can; HCl (and gastric and intestinal hormones) stimulates secretion of pepsinogens which are cleaved to pepsins by the acidic environment; pepsins aid specific protein digestion, and are effectively inactivated in higher pH.
The pancreas: proteases are secreted as zymogens through the hepatic duct into the duodenum. “Fire extinguisher” for trypsin: trypsin inhibitor in the intralobular and main ducts
Compare the relative importance of the various lipases in digestion of fat
Pancreatic lipase/co-lipase accounts for the majority of fat digestion (70-80%). However lingual and gastric lipases become important if there is a problem with the pancreatic lipase working.
State the function of enterokinase (aka enteropeptidase) Where can you find it?
State the function of enterokinase (aka enteropeptidase) Where can you find it?
Enteropeptidase (also called enterokinase) is an enzyme produced by cells of the duodenum and involved in human digestion. It is secreted from intestinal glands (the crypts of Lieberkühn) following the entry of ingested food passing from the stomach. Enteropeptidase converts trypsinogen (a zymogen) into its active form trypsin, resulting in the subsequent activation of pancreatic digestive enzymes.

In the small intestine: activation of pancreatic proteases by intestinal enterokinase; optimal pH (why is this important?); proteins are digested into smaller peptides Pancreas also secretes nucleases which break nucleic acids into purine and pyrimidine bases.
Whats the biggest problem with lipid absorption? How do we overcome this?
Whats the biggest problem with lipid absorption? How do we overcome this?
They’re hydrophobic!! 


The upper half of the villi is the site of membrane-bound enzymes (brush border enzymes) for final digestion of carbohydrates and proteins. This is also the site of absorption. The bottom part of the villi form the crypts of Li
They’re hydrophobic!!


The upper half of the villi is the site of membrane-bound enzymes (brush border enzymes) for final digestion of carbohydrates and proteins. This is also the site of absorption. The bottom part of the villi form the crypts of Lieberkühn, from which buffers and mucus are secreted, as previously discussed in Chapter 23. Finally, because there is laminar flow through the lumen, the slowest movement is near the enterocytes, and this is slowed even further because of the mucus secreted to protect the cells. This creates an unstirred water layer that molecules must pass through to access the enterocytes. This is no problem for movement of most nutrients but creates a problem for hydrophobic, lipid-based molecules.

The are hydrophobic! And although that’s just fine for getting into the enterocyte, they’ve got to get through the unstirred water layer that lines the lumen of the gut. So the bile salts are necessary for the formation of amphipathic micelles which can traverse the barrier (review digestion section on micelle formation).

Why is the unstrirred water layer there, anyway? Protects enterocytes, rate limiting step for lipid absorption.

Lipids enter the cells by diffusion:
Fatty acids; 2-monoglycerides; cholesterol; lysolecithin; fat-soluble vitamins (ADEK): most of the bile salts remain in the lumen of the intestine.
This beta- lipoprotein coat so critical for absorption of lipids. What do we need it for and  what could happen if you don't have it?

 abetalipoproteinemia! Say that 10x fast!
This beta- lipoprotein coat so critical for absorption of lipids. What do we need it for and what could happen if you don't have it?

abetalipoproteinemia! Say that 10x fast!
β-Lipoprotein is critical for chylomicron formation. When it is absent, lipids will not be able to exit the intestinal cells and enter the lymph. Fat builds up in the enterocytes. As the villous cells are replaced and sloughed off into the lumen, the lipid is excreted. This condition of abetalipoproteinemia results in the inability to absorb lipids.

Inside the enterocytes, the lipids are re-esterified with free fatty acids in the smooth endoplasmic reticulum to form TGs, cholesterol esters, and phospholipids.

These lipids then get a -lipoprotein coat (Apo B), which helps them exocytose: they are now called chylomicrons, and are primary made of TG’s (95%), PL’s (4%), and cholesterol (1%). These molecules are TOO BIG to get directly into capillaries, so they diffuse into the lacteals, circulate through the lymph and into the larger vessels in the venous circulation.

The -lipoprotein is very important, and lack of circulating Apo B (abetalipoproteinemia) is associated with massive lipid accumulation in the ER of the enterocytes. It is synthesized in cells of the small intestine and the liver.
Which area of small intestine is most active for fat absorption? What about vitamin absorption? Why is vitamin B12 special?
Duodenum & jejunum. The duodenum and jejunum are most active in fat absorption: most ingested fat is absorbed by mid-jejunum, although some small chain FA cand diffuse into the portal blood. Fat in stools is from colonic bacteria, and desquamated intestin
Duodenum & jejunum. The duodenum and jejunum are most active in fat absorption: most ingested fat is absorbed by mid-jejunum, although some small chain FA cand diffuse into the portal blood. Fat in stools is from colonic bacteria, and desquamated intestinal cells, unless there is malabsorption.

WHY IS VIT B12 SO SPESHUL?
B12 (cobalamin): essential vitamin for maturation of RBC; needs R binders and intrinsic factor to keep from being digested, and facilitate absorption, respectively. Lack of B12 causes pernicious anemia.
In saliva and gastric juice, B12 is bound to R binders (aka R protiens) (glycoproteins), which protect it from the pepsins: most of the B12 is bound to R binders in the stomach. In the duodenum, trypsin degrades the R binders, and the B12 forms a complex with intrinsic factor (glycoprotein secreted by gastric parietal cells): this complex is resistant to pancreatic proteases. The B12/intrinsic factor complex is absorbed in the terminal ileum.
B12/IF complexes dimerize, and bind to a receptor in the terminal ileum. B12 enters the cell and probably is stored in the mitochondria until it exits the basolateral side (mechanism unknown). In the plasma B12 is bound to TRANSCOBLAMIN II.
What happens to bile acids?  What form is the majority of bile in (conjugated or unconjugated)?  Is the co-transported or simple diffusion?

What form of bile is most frequently lost/ difficult to revocer??
What happens to bile acids? What form is the majority of bile in (conjugated or unconjugated)? Is the co-transported or simple diffusion?

What form of bile is most frequently lost/ difficult to revocer??
Primary recovery is through active and passive absorption in the terminal ileum:

Conjugated bile acids (conjugated with glycine or taurine) are polar, and are co-transported with sodium, down the sodium gradient: they natrually form salts with the sodi
Primary recovery is through active and passive absorption in the terminal ileum:

Conjugated bile acids (conjugated with glycine or taurine) are polar, and are co-transported with sodium, down the sodium gradient: they natrually form salts with the sodium. The majority of bile is in conjugated form.
Unconjugated bile acids are less polar, and are absorbed by simple diffusion. This can occur anywhere down the tract, but most still occurs in the ileum. This represents a small percent of the reclaimed bile.
Primary bile acids are conjugated and hydroxylated in the liver; secondary bile acids have been deconjugated and dehydroxylated by intestinal bacteria, so they are less polar.
Once absorbed into the cell, they diffuse into the portal blood and return to the liver. The liver extracts the bile acids in one pass, and reconjugates the secondary bile acids.

unconjugated bile acid is most frequently lost.
Free iron is toxic to the cells! SO how the heck do we absorb it ? What form do we usually abosrb it in and why?
Free iron is toxic to the cells! SO how the heck do we absorb it ? What form do we usually abosrb it in and why?

Why do we lose iron everyday, if our body stores it as ferritin?
Free iron is toxic to the cells, so to get into the enterocyte (from duodenum and jejunum), iron needs a carrier protein (DMT1)to cross the membrane and enter cell.
THE EASIEST TO ABSORB IS THE REDUCED STATE (Fe2+)

Stored as FERRITIN
Go out basallateral transporter--> in blood and immidiately bound to TRANSFERRIN

Iron is lost when these enterocytes (only live a few days...) and sloughed off in the GI tract.

Free iron is toxic to the cells, so to get into the enterocyte (from duodenum and jejunum), iron needs a carrier protein (DMT1)to cross the membrane and enter cell.

Kids and menstrating women need the most iron
What effect would prolonged diarrhea have on the acid base chemistry of the body? More acidic or less acidic? Why??
Diarrhea reduces K+ absorption, since the rapid flow disperses concentration gradient for movement into the cells. This can contribute to the development of metabolic acidosis during prolonged diarrhea.


Potassium

• Passively absorbed in jejunum and ileum: concentration gradient increases as water is absorbed--has to have high concentration in the lumen to move, since intracellular K+ is high!
• Primarily secreted in the colon, but can be absorbed if lumenal concentration is high (over 25mM)


Aldosterone increases K+ secretion in colon, in exchange for sodium
how are farts made?
how are farts made?
Gas formation: bacterial metabolism of carbohydrates; stomach (O2, N2), duodenum (CO2), ileum and colon (CO2, H2, CH3, H2S, NH3); polyamines (putrescine, spermine); flatulence
What are the main electrolytes found in Mr. Hankey (the christmas poo)?
What are the main electrolytes found in Mr. Hankey (the christmas poo)?
Potassium and bicarbonate

Slow movement (haustrations): facilitates absorption in the absence of villi
Colonic salvage is the final absorption of sodium and water –aldosterone effect
 “Fecal” production begins in late transverse colon.
Main electrol
Potassium and bicarbonate

Slow movement (haustrations): facilitates absorption in the absence of villi
Colonic salvage is the final absorption of sodium and water –aldosterone effect
“Fecal” production begins in late transverse colon.
Main electrolytes in feces: potassium and bicarbonate
Why is fiber so good for digestion?
carbs, cellulose, fiber, bile= all osmotic agents...
draw more water in to lumen
cause more stretching of mechanoreceptors--> stronger stretch--> stronger contractions larger bulk of mass movements in colon. Food moves a little bit faster

So fiber= more regular bowel movements
Where does most of the sodium come from for 2* active transport of glucose????
Where does most of the sodium come from for 2* active transport of glucose????
Comes from the digective secretions (aka buffers, saliva, etc.)

So a low sodium diet is no big deal.
Would you get hyper or hypo kalemic with vomiting? Would your acid base balance go up or down?

What about with chronic diahhrea
Chronic vomiting= hypokalemic
Alkalemic= loss of H+ in gut

In chronic diarrhea--> hypokalemic and ACIDONIC--> lose a lot of bicarbonate &
Chronic vomiting= hypokalemic
Metabolic alkalosis= loss of H+ in gut

In chronic diarrhea--> hypokalemic and metabolic ACIDOSIS--> lose a lot of bicarbonate & K+
" a very beautiful and efficient system..."

VERY IMPORTANT HORMONE:: Which hormone (secreted by the DUODENUM & jejunum)  prepares the liver for incoming sugar by stimulating the  pancreatic to secrete INSULIN in to the blood.???

Hint: it also decrea
" a very beautiful and efficient system..."

VERY IMPORTANT HORMONE:: Which hormone (secreted by the DUODENUM & jejunum) prepares the liver for incoming sugar by stimulating the pancreatic to secrete INSULIN in to the blood.???

Hint: it also decreases H+ secretion by parietal cells in stomach and decreases gastric emptying??
GASTRIC INHIBITORY PEPTIDE/ GLUCOSE INSOLINOTROPIC PEPTIDE
GASTRIC INHIBITORY PEPTIDE/ GLUCOSE INSOLINOTROPIC PEPTIDE
Why do Olestra potato chips, and those fake sugar substitutes cause cramping?
Why do Olestra potato chips, and those fake sugar substitutes cause cramping?
It is an SUCROSE polyester (undigestable carbohydrate) 
it is OSMOTIC 
digested by bacteria
It is an SUCROSE polyester (undigestable carbohydrate)
it is OSMOTIC
digested by bacteria
"Which hormone is going to stimulate the pancreatic ACINAR cells to secrete enzymes?"  What stimulates secretion of the hormone? Which organ secretes it?
"Which hormone is going to stimulate the pancreatic ACINAR cells to secrete enzymes?" What stimulates secretion of the hormone? Which organ secretes it?
CCK!

Fat & meats
SI senses small peptides/ amino acids and FATS
CCK!

Fat & meats
SI senses small peptides/ amino acids and FATS
MAS IMPORTANTE:::: Trypsin helps digest proteins, but WE are made of proteins... so wtf is the clever little mechanisim the body uses to make sure we don't eat ourselves?

Aka how can we make sure that these proteases are ONLY ACTIVE IN THE LUMEN of the gut????
ENTEROKINASES IN THE LUMEN of the small intestine (AND ONLY FOUND IN THE LUMEN) help activate trypsinogen -->  trypsin so it is only active in the lumen!!
ENTEROKINASES IN THE LUMEN of the small intestine (AND ONLY FOUND IN THE LUMEN) help activate trypsinogen --> trypsin so it is only active in the lumen!!

The pancreas also secretes trypsin inhibitor along with trypsinogen so it doesn't digest itself either (acute pancreatitis.)

PROTIP: CO-LIPASE (for fat digestion along with bile salts) is also secreted in zymogen form. It is activated by trypsin. Lipids are super high maintenance, but we need them!
Why do nurses tell us to fast before getting blood work done?
Why do nurses tell us to fast before getting blood work done?
Because when we eat, fat enters through the systemic circulation first. It bypasses the liver!!! So if we get blood work done and hour or so after we eat, we are going to get this gross layer of fat.

You see the chylomicrons before they go back to the liver for processing
What effect would more fiber or more bile have on the amount of water that is excreted? What about more water?
What effect would more fiber or more bile have on the amount of water that is excreted? What about more water?
increase in fiber or bile would INCREASE the amount of fluid in the excrement. They are both OSMOTIC agents.

But WATER, on the other hand, will be absorbed more by the small intestine so... "YOU WILL NOT GET MORE DIARRHEA IF YOU DRINK MORE WATER"
Come hell or high water, we are going to get the sodium electrolytes back in to the extracellular fluid (via co-transporters with nutirents, or antiporters if nutrients are not present). What else will follow in to the extracellular fluid?

How?
Chloride and water
Chloride and water
How does vitamin D help with calcium absorption?
More vitamin D in the blood= Increases the Ca transporters on apical surface of cell and increases the calbindin proteins

**** Hold up... why does Ca need to be bound to something in cells if it isn't toxic like iron is? Cause if unbound, the increase
More vitamin D in the blood= Increases the Ca transporters on apical surface of cell and increases the calbindin proteins

**** Hold up... why does Ca need to be bound to something in cells if it isn't toxic like iron is? Cause if unbound, the increase in Ca concentration can seriously mess up the intracellular messaging systems . for reals... Doesn't have to be bound in the blood.
The journey of Vitamin B12

eat--> bound by R proteins in mouth--> R proteins destoryed by tripsin in stomach--> intrinsic factor protects B12 in stomach and protects it from pancreatic proteases--> Which cells produce intrinsic factor (binds to B12) th
The journey of Vitamin B12

eat--> bound by R proteins in mouth--> R proteins destoryed by tripsin in stomach--> intrinsic factor protects B12 in stomach and protects it from pancreatic proteases--> Which cells produce intrinsic factor (binds to B12) that comes out of in the stomach?
PARIETAL CELLS! (SAME CELLS THAT SECRET HCl)

**similar to lipids... you can see that vitamin B12 is also very high matinance/ aka very complicated to absorb. Very important for maturation of RBC
VERY IMPORTANT::: The primary movement in the colon is...
SEGMENTAL PROPULSION!!!
SEGMENTAL PROPULSION!!!
VERY IMPORTANT:: The primary movement in the small intestine is...
SEGMENTATION
MASS IMPORTANTE::: What two things will stimulate mass movements?
Neuronal: The Vagus (maybe a little of the lower lumbard plexus)
Hormonal: And Gastrin (maybe a little CCK)

aka. once we know we just got some food... out with the old and in with the new!

mass movement = pushing the poop along
We get rectal stretch--> rectosphincteric reflex tells us it is time to poop soon.

The reason we don't poop ourselves every time we eat is because we get RELAXATION of the internal anal sphinter to accomodate.
ENTERIC NERVOUS SYSTEM IS KEY!!
True or false. The kidneys are located in the peritoneal cavity? 

If you were going to harvest someone's organs (aka their kidneys) which fascia would you have to cut through? Are the kidneys surrounded by fat in the PERInephric space or the PARAnephri
True or false. The kidneys are located in the peritoneal cavity?

If you were going to harvest someone's organs (aka their kidneys) which fascia would you have to cut through? Are the kidneys surrounded by fat in the PERInephric space or the PARAnephric space?
False! They are RETROPERITONEAL. 

You will have to cut through GEROTA's FASCIA (aka renal fascia) if you are going to remove someones kidney.

Kidneys have fat in the PERINEPHRIC space.
False! They are RETROPERITONEAL.

You will have to cut through GEROTA's FASCIA (aka renal fascia) if you are going to remove someones kidney.

Kidneys have fat in the PERINEPHRIC space.
Which vein is in the "nutcraker" angle? Where is it coming from and what is it draining in to?
Which vein is in the "nutcraker" angle? Where is it coming from and what is it draining in to?
L renal kidney running right underneath the SMA
L renal kidney running right underneath the SMA
What is this?
What is this?
Congenital diaphragmatic hernia
Which kidney is more protected by bone? Which kidney is more likely to be injured by penetrating injury?

Which kidney could cause a pneumothroax if you are trying to remove a kidney stone from it? Hint** remember the spleen***
The Left kidney is more protected since Left kidney is up higher in the abdomen.

BUT... if you are trying to steal someone's Left kidney,  be careful because the PLEURAL SPACE could be there as well!

ALSO keep in mind... You might see only see a sli
The Left kidney is more protected since Left kidney is up higher in the abdomen.

BUT... if you are trying to steal someone's Left kidney, be careful because the PLEURAL SPACE could be there as well!

ALSO keep in mind... You might see only see a slice of one kidney on CT since one may be a little higher or lower
The renal veins and arteries are ginourmous since they do a lot of filtering. (25% of CO)

Which renal vein is shorter? Which renal artery is shorter? Why?!
The renal veins and arteries are ginourmous since they do a lot of filtering. (25% of CO)

Which renal vein is shorter? Which renal artery is shorter? Why?!
R renal vein shorter since it is closer to IVC
L Renal vein short since closer to aorta

L adrenal vein and left gonadal vein both drain in long R renal vein.

On the right side, they R gonad anf right adrenal both drain directly to IVC
R renal vein shorter since it is closer to IVC
L Renal vein short since closer to aorta

L adrenal vein and left gonadal vein both drain in long R renal vein.

On the right side, they R gonad anf right adrenal both drain directly to IVC
Find the AORTA, SMA and the IVC? What is in between aorta and SMA?

What is wrong here? What is it normally supposed to look like?
Find the AORTA, SMA and the IVC? What is in between aorta and SMA?

What is wrong here? What is it normally supposed to look like?
THE L RENAL VEIN.

May cause L adrenal vein dialation or L gonadal/ ovarian vein dialation. 


This is the "Nutcraker angle" if it is too sharp, can cause kidney problems.
THE L RENAL VEIN.

May cause L adrenal vein dialation or L gonadal/ ovarian vein dialation.


This is the "Nutcraker angle" if it is too sharp, can cause kidney problems.
If you need to find the ureter on an Xray, where would you look for them?
If you need to find the ureter on an Xray, where would you look for them?
They line up with the lumbar transverse process
They line up with the lumbar transverse process
Where are the most likely locations for kidney stones?
Where are the most likely locations for kidney stones?
At three points along their course the ureters are constricted :
1.) at the ureteropelvic junction;
2.) where the ureters cross the common iliac vessels at the pelvic brim;
3.) where the ureters enter the wall of the bladder.
How do you tell the difference between pain coming from an appendix vs. a right sided kidney stone?
How do you tell the difference between pain coming from an appendix vs. a right sided kidney stone?
(+) Pain on rebound=  friction between visceral and parietal peritoneum makes it worse.= appendicitis

with kidneystone--> we can press in all we want... pain will be the same (entire kidney is retropertioneal) peritoneum is not involved.

parietal pe
(+) Pain on rebound= friction between visceral and parietal peritoneum makes it worse.= appendicitis

with kidneystone--> we can press in all we want... pain will be the same (entire kidney is retropertioneal) peritoneum is not involved.

parietal peritonium is fine= kicking and screaming
Parietal peritonium in pain... walk very slowly to not disturb the peritonium= "GUARDING"= APPENDICITIS?

"
Ureteric innervation is from the renal, aortic, superior hypogastric, and inferior hypogastric plexuses through nerves that follow the blood vessels.
Visceral efferent fibers come from both sympathetic and parasympathetic sources, whereas visceral afferent fibers return to T11 to L2 spinal cord levels. Ureteric pain, which is usually related to distention of the ureter, is therefore referred to cutaneous areas supplied by T11 to L2 spinal cord levels. These areas would most likely include the posterior and lateral abdominal wall below the ribs and above the iliac crest, the pubic region, the scrotum in males, the labia majora in females, and the proximal anterior aspect of the thigh."
How many arteries are there for the adrenal glands? How many veins? Are they the same on eat side?

What is super cool about how the adrenal glands are innervated?

Which back muscle, that runs from posterior to anterior might indicate an infection in the peritoneal space?? Why might it be confused for a femoral hernia?
Which back muscle, that runs from posterior to anterior might indicate an infection in the peritoneal space?? Why might it be confused for a femoral hernia?
Psoas Major muscle

pus may drain all the way down to femoral region. Ginourmous muscle. could be confused for femoral hernia or lymph swelling
Psoas Major muscle

pus may drain all the way down to femoral region. Ginourmous muscle. could be confused for femoral hernia or lymph swelling
What is directly under the medial arcute ligament of the diaphram?
What is directly under the medial arcute ligament of the diaphram?
median= the aorta
medial= psoas major
lateral= quadratous luborum
median= the aorta
medial= psoas major
lateral= quadratous luborum
What is the one obvious easy to identify nerve? which nerve goes directly through the psoas major muscle?

Which one can be pinched by the inguinal tendon?

Where are all these nerves coming from!?!
What is the one obvious easy to identify nerve? which nerve goes directly through the psoas major muscle?

Which one can be pinched by the inguinal tendon?

Where are all these nerves coming from!?!
The gentiofemoral nerve goes through psoas
FEMORAL nerve goes through that corner

all coming from LUMBAR PLEXUS
The gentiofemoral nerve goes through psoas
FEMORAL nerve goes through that corner

all coming from LUMBAR PLEXUS
Your guts are pretty flexible... Which organs in the pelvic cavity can go up? Which ones in the Abdominal cavity can go down?

Lineorenal ligament is the same thing as
splenorenal ligament
Extensions of cortex in to the medulla are called?
Extensions of cortex in to the medulla are called?

What structures would you hit if you were to remove someones kidneys from the posterior. What muscles are directly posterior to it?
What structures would you hit if you were to remove someones kidneys from the posterior. What muscles are directly posterior to it?
Remember we are looking at taking their kidneys from behind...

Left kidney is more superior.

WATCH OUT FOR PNEUMOTHORAX. Kidneys go all the way up into the diaphram.

"An ideal place to situate the transplant kidney is in the left or the right ili
Remember we are looking at taking their kidneys from behind...

Left kidney is more superior.

WATCH OUT FOR PNEUMOTHORAX. Kidneys go all the way up into the diaphram.

"An ideal place to situate the transplant kidney is in the left or the right iliac fossa (Fig. 4.146). A curvilinear incision is made paralleling the iliac crest and pubic symphysis. The external oblique muscle, internal oblique muscle, transverse abdominis muscle, and transversalis fascia are divided. The surgeon identifies the parietal peritoneum but does not enter the peritoneal cavity. The parietal peritoneum is medially retracted to reveal the external iliac artery, external iliac vein, and the bladder. In some instances the internal iliac artery of the recipient is mobilized and anastomosed directly as an end-to-end procedure onto the renal artery of the donor kidney. Similarly the internal iliac vein is anastomosed to the donor vein. In the presence of a small aortic cuff of tissue the donor artery is anastomosed to the recipient external iliac artery and similarly for the venous anastomosis. The ureter is easily tunneled obliquely through the bladder wall with a straightforward anastomosis.
The left and right iliac fossae are ideal locations for the transplant kidney, because a new space can be created without compromise to other structures. The great advantage of this procedure is the proximity to the anterior abdominal wall, which permits easy ultrasound visualization of the kidney and permits Doppler vascular assessment. Furthermore, in this position biopsies are easily obtained. The extraperitoneal approach enables patients to make a swift recovery."




Which artery goes all the way into the villitine cord during development of the MID-GUT?

When you have a LOCALIZED PAIN in the abdomen,  what  definitely  is involved?
When you have a LOCALIZED PAIN in the abdomen, what definitely is involved?
PARIETAL PERITONIUM


Referred pain from various visceral structures is
common until the disease involves the parietal peritoneum or somatically innervated body wall.
Localized pain because the nerves serving the abdominal wall recieve general somati
PARIETAL PERITONIUM


Referred pain from various visceral structures is
common until the disease involves the parietal peritoneum or somatically innervated body wall.
Localized pain because the nerves serving the abdominal wall recieve general somatic sensation from the patrietal peritonium to the skin.
Describe adventages & disadvantages of cuts to the thorax. Which one do you really need to watch out for certain nerves?
Describe adventages & disadvantages of cuts to the thorax. Which one do you really need to watch out for certain nerves?
(1) Median incisions
1. Can be made rapidly w/o cutting muscle, major blood vessels, or nerves.
2. Are made through linea alba, superior and inferior to umbilicus.
3. Relatively bloodless, except in cases of excess fat.
4. Because of poor vascularization, may undergo necrosis unless cut edges properly re-aligned
during closure.
5. Good for exploratory procedures. Below umbilicus, frequently used for reaching female pelvic
viscera.

(2) Paramedian incisions
1. Made in sagittal plane, may extend from costal margin to pubic hairline.
2. Incision goes through anterior layer of rectus sheath, muscle retracted laterally to avoid injuring
vessels and nerves.
3. Posterior rectus sheath and peritoneum is then incised to enter peritoneum.

(3) Gridiron (muscle-splitting) incisions
1. Often used for an appendectomy. McBurney incision is approximately 2.5 cm superomedial to
ASIS.
2. Ext. oblique aponeurosis is incised inferomedially in direction of fibers and retracted.
3. Musculoaponeuroses of int. oblique and transversus are then split along the course of the fibers
and retracted.
4. Iliohypogastric nerve is identified and preserved. ****
5. When incision is small and done carefully, healing is excellent.

(4) Transverse incision
1. Are made through anterior rectus sheath and rectus abdominis.
2. Provide good access and limit damage to nerve supply.
3. When muscle segments are rejoined and heal, they are similar to a new intersection.
4. The incisions are not made at tendinous intersections; cutaneous nerves and branches of sup.
epigastric vessels pierce fibrous regions of the muscles here.
5. Incisions are most useful above umbilicus, and can be extended laterally.
6. Are not good for exploratory procedures because superior and inferior extension is difficult.

(5) Pfannenstiel (suprapubic) incision
1. Incisions are made horizontally with slight convexity.
2. Used for most gynecological and obstetrical operations.
3. Linea alba and anterior rectus sheath transected and resected superiorly.
4. Rectus muscle retracted laterally or divided through their tendinous parts.
5. Iliohypogastric and ilioinguinal nerves are identified and preserved.****

(6) Subcostal incisions
1. Provide access to gallbladder and biliary tract on right side and spleen on left.
2. Incisions are made parallel, but at least 2.5 cm inferior to costal margin to avoid 7th and 8th thoracic spinal nerves.****
What sorts of pathologies can create this potential space between the stomach and pancreas (aka the lesser sac/ omental bursa)
What sorts of pathologies can create this potential space between the stomach and pancreas (aka the lesser sac/ omental bursa)
Pathologies (ulcers, pancreatitis) can create an actual space, visible with imaging.

posterior ulcer= Juices from the stomach will enter the lesser sac.

In the supine position, stomach acids can erode the pancreas (pain reffered to back)
What lymph tissue would you remove for someone with stomach cancer/ carcinoma?
What lymph tissue would you remove for someone with stomach cancer/ carcinoma?
patrial gastroctomy with removal of all CELIAC NODES and often the organs that drain in to them (duodenum, jejunum, lower esophagus)
During a hemicolectomy, or a nephrectomy, which organ near both of those has great potential to be damaged?
2nd part of duodenum due to close proximity to colon and kidney
What is the distal colon innnervated by? What is the proximal colon innervated by?
From a clinical and surgical standpoints, the large intestine is thought of as being two “organs,” a
proximal (or right) colon and a distal (or left) colon (table 2). The proximal colon serves to absorb
water and electrolytes, while the distal colon sto
From a clinical and surgical standpoints, the large intestine is thought of as being two “organs,” a
proximal (or right) colon and a distal (or left) colon (table 2). The proximal colon serves to absorb
water and electrolytes, while the distal colon stores feces. Even the neurovascular supply of these
organs changes where the proximal colon ends and the distal colon begins; i.e. the proximal colon is
supplied by the Superior Mesenteric Artery and innervated by the Vagus Nerve (10th cranial nerve), while
the distal colon is supplied by the Inferior Mesenteric Artery and innervated by the Pelvic Nerves
(S2,S3,S4).
Why you are trying to remove part of the colon, which areas are most useful to help you reattatch the colon?
Sigmoid, transverse, and cecum have a mesentery and thus they are mobile, so are often used for colostomy.
• Surgical approaches must preserve the blood supply to the unresected bowels so that intestinal arterial
continuity can be restored by anastomoses after the bowel is reconnected
Where are the weakest parts of the MARGINAL ARTERY OF DRUMMOND?
Typically, the branches of arteries supplying the colon (i.e., right, middle, and left colic arteries)
anastomose as they approach the colon, forming a continuous anastomotic channel. This is called
the marginal artery of Drummond. Surgeons must be cautious, since the anastomoses are weak
at the splenic flexure and recto-sigmoid junction.
How can you tell if someone has an appendicitis? What makes it feel better? Worse?

Which aretery could clot?

Rupture of the appendix could cause infection of what membrane? Why would a patient have abdominal rigidity?
Appendicitis
• Appendicitis is rare in the very young and elderly
• The base of the appendix lies deep to a point that is one third of the way along the oblique line
joining the ASIS to the umbilicus (McBurney’s point) (Fig. 85, #3)
• Its position varies and is responsible for the symptoms and the site of muscular spasms and
tenderness when the appendix is inflamed. The variable position of the appendix can make it
difficult to diagnose appendicitis. For example, appendicitis can be mistaken for ovarian pain if it
hangs low enough in the pelvis. Before CT use, 15% unnecessary surgeries were performed – this
figure is now down to 5%.
• Pain of appendicitis usually begins as vague pain the periumbilical area – afferent nerve fibers enter
spinal cord at T10, same area served by the umbilicus. Thus, this is an example of referred pain
• Later, severe pain results in the lower right quadrant from irritation of the parietal peritoneum
• Extending thigh at hip joint, elicits pain (a positive psoas sign)
• Acute infection of the appendix may result in thrombosis (clotting of blood) of the single
appendicular artery from the ileocolic artery.
• Thrombosis will result in ischemia, gangrene, and perforation of the inflamed appendix
• Rupture of the appendix results in peritonitis, increased abdominal pain, nausea and/or vomiting
and abdominal rigidity
• Flexion of the right thigh ameliorates pain because it causes relaxation of the right psoas muscle
Bleeding/ fluid in this area of females is usually a dead giveaway for ectopic pregnancy.
The RECTOUTERINE POUCH (pouch of douglas)
What are the three major ways we can have portal hypertension?

Why is "steamroller" the most dangerous childhoodgame of all time?
Problems of the pancreas (cancer, pancreatitis) can be fatal.
• Acute pancreatitis has a 15% fatality rate.
• An enlarged tail may be the earliest sign of pancreatitis. To check for pancreatitis, you look for the
abnormal appearance of fat/cysts, which are early signs.
• The tail of the pancreas is located close to the spleen, so surgeons must be cautious not to damage
the tail during a splenectomy.
• Pancreatic cancer usually involves the head (Fig. 111). This frequently compresses the bile duct,
causing obstructive jaundice, retention of bile pigments, and enlargement of the gallbladder.
Tumors in the neck and body of the pancreas can obstruct the portal vein or IVC, which lie
posterior to the pancreas.
• The pancreas can be
crushed against the anvillike
vertebral column.
This is often due to
compression by a seatbelt
or steering wheel during
a car accident. It can also
occur when young
children walk on oneanother’s
bellies!
Rupture of the pancreas
often tears its ducts,
which allows pancreatic
juice to enter the
parenchyma of the gland
and neighboring tissues.
The pancreatic juice
digests these tissues,
which is quite painful.
What is happening at the L1 region?
The LI vertebral level is marked by the transpyloric plane, which cuts transversely through the body midway between the jugular notch and pubic symphysis, and through the ends of the ninth costal cartilages (Fig. 4.164). At this level are:
the beginning
The LI vertebral level is marked by the transpyloric plane, which cuts transversely through the body midway between the jugular notch and pubic symphysis, and through the ends of the ninth costal cartilages (Fig. 4.164). At this level are:
the beginning and upper limit of the end of the duodenum;
the hila of the kidneys;
the neck of the pancreas; and
the origin of the superior mesenteric artery from the aorta.
Each of the vertebral levels in the abdomen is related to the origin of major blood vessels

Where is the celiac trunk?
Which level does the trunk bifurcaite?
Where do you find the medial sacral artery?
Visualizing the position of major blood vessels

the celiac trunk originates from the aorta at the upper border of the LI vertebra;
the superior mesenteric artery originates at the lower border of the LI vertebra;
the renal arteries originate at appro
Visualizing the position of major blood vessels

the celiac trunk originates from the aorta at the upper border of the LI vertebra;
the superior mesenteric artery originates at the lower border of the LI vertebra;
the renal arteries originate at approximately the LII vertebra;
the inferior mesenteric artery originates at the LIII vertebra;
the aorta bifurcates into the right and left common iliac arteries at the level of the LIV vertebra;
the left and right common iliac veins join to form the inferior vena cava at the LV vertebral level.

Medial sacral artery is right inbetween that bifurcation
Which organs are in which quadrant? How do you find the appendix (usually)?

Where is the highest kidney you will see?
Where to find the kidneys
The kidneys project onto the back on either side of the midline and are related to the lower ribs (Fig. 4.168):
the left kidney is a little higher than the right and reaches as high as rib XI;
the superior pole of the right ki
Where to find the kidneys
The kidneys project onto the back on either side of the midline and are related to the lower ribs (Fig. 4.168):
the left kidney is a little higher than the right and reaches as high as rib XI;
the superior pole of the right kidney reaches only as high as rib XII.
The lower poles of the kidneys occur around the level of the disc between the LIII and LIV vertebrae. The hila of the kidneys and the beginnings of the ureters are at approximately the LI vertebra.
What three arteries feed the superadrenal glands and what three different areas do they come from?

WHAT IS A KEY DIFFERENCE BETWEEN THE L & R SUPRAADRENAL VEINS?
1. Phrenic artery--> superior surarenal artery
2. median surparenal artery
3. renal artery--> inferior suprarenal artery
1. Phrenic artery--> superior surarenal artery
2. median surparenal artery
3. renal artery--> inferior suprarenal artery
What are some important structures to keep in mind when you are removing the kidneys? What is around the left kidnet?

What about the right kidney???
What are some important structures to keep in mind when you are removing the kidneys? What is around the left kidnet?

What about the right kidney???

What is literally the MOST important thing to rememeber about the venous tributaries of the vena cava?
+ no gut tributaries (i.e. ALL hepatic portal)


Other details:
+ Bifurcates lower (L5)
+ starts earlier (comes through diaphram @ T8 vs. T12 for aorta
+ no gut tributaries (i.e. ALL hepatic portal)


Other details:
+ Bifurcates lower (L5)
+ starts earlier (comes through diaphram @ T8 vs. T12 for aorta
What do you have to worry about with aortic aneurisims?
Watch out for pinching of the L renal artery between superior mesentaeric artery and aorta.
Watch out for pinching of the L renal artery between superior mesentaeric artery and aorta.
Ureter is a long *ass tube. What are the different places where it can get its blood supply?

If you stabed me in the back, where there are no bones... what muscle might you hit?
this muscle helps stabilizes rib 12
this muscle helps stabilizes rib 12
if you are not careful with the femoral nerve, what action might you mess up for the patient?

Which hole does the thoracic duct go through?
Which hole does the thoracic duct go through?

HIGH YIELD SUAREZ Q: Where are the four possible referred pain pathways?
referred pain pathway
Where our AFFERENT pathways are coming from?
referred pain pathway
Where our AFFERENT pathways are coming from?
Which abdominal nerve is responsible for the CREMASTERIC REFLEX??
Which abdominal nerve is responsible for the CREMASTERIC REFLEX??
GENITOFEMERAL NERVE  (also goes through the inguinal canal)
GENITOFEMERAL NERVE (also goes through the inguinal canal)
For the LUMBAR PLEXI

Memorize the origin and action (both MOTOR and SENSORY) of all these nerves... GO!!!

ps. what is so special about the lateral cutaneous nerve of thigh??
For the LUMBAR PLEXI

Memorize the origin and action (both MOTOR and SENSORY) of all these nerves... GO!!!

ps. what is so special about the lateral cutaneous nerve of thigh??
No motor fxn
No motor fxn
What the hell is so important to know about these prevertebral plexi?
What the hell is so important to know about these prevertebral plexi?
Throughout its length, the abdominal prevertebral plexus is a conduit for:
preganglionic sympathetic and visceral afferent fibers from the thoracic and lumbar splanchnic nerves;
preganglionic parasympathetic and visceral afferent fibers from the vagus n
Throughout its length, the abdominal prevertebral plexus is a conduit for:
preganglionic sympathetic and visceral afferent fibers from the thoracic and lumbar splanchnic nerves;
preganglionic parasympathetic and visceral afferent fibers from the vagus nerves [X]; and
preganglionic parasympathetic fibers from the pelvic splanchnic nerves

READ THE SLIDE!!
READ THE SLIDE!!
Unlike birds that have a CLOACA, how do we as humans seperate our peepee and our caca (poop)?
Unlike birds that have a CLOACA, how do we as humans seperate our peepee and our caca (poop)?
The URORECTAL SEPTUM separates the anus and the urethrea. The septum comes from mesenchyme--> eventually becomes the peroneal septum (aka the gooch as seen on Jackass).

The pink part on the top = bladder & allantois
The URORECTAL SEPTUM separates the anus and the urethrea. The septum comes from mesenchyme--> eventually becomes the peroneal septum (aka the gooch as seen on Jackass).

The pink part on the top = bladder & allantois
How is development of the pancreas similar to the development of the lung buds?
How is development of the pancreas similar to the development of the lung buds?

What happens around the 8th or 9th week of gestation?
Why might this be important for gestational diabetes?
Epithelium defines what the tissue becomes
Mesenchyme = structural

•The pancreas starts out as dorsal and ventral pancreatic buds. 
•The dorsal pancreatic bud stays in place and the ventral pancreatic bud rotates around behind the presumptive duodenu
Epithelium defines what the tissue becomes
Mesenchyme = structural/ determines branching

•The pancreas starts out as dorsal and ventral pancreatic buds.
•The dorsal pancreatic bud stays in place and the ventral pancreatic bud rotates around behind the presumptive duodenum to join the dorsal pancreatic bud.
•Most of the pancreas is from the dorsal bud; however the pancreatic duct is formed from the duct of the ventral bud.
•Annular pancreas occurs when the pancreatic buds rotate in a manner to surround the gut tube, potentially strangling the small intestine.
•Exocrine pancreas (digestive enzymes) develops from Notch-sensitive endoderm; surrounding mesenchyme releases signal molecules (including Follistatin, FGFs) that activate the Notch pathway.
•Endocrine pancreas (Islets of Langerhans) develop from Notch insensitive endoderm. Signals from vasculature are needed. There are two lines of endocrine progenitor cells:
Pax-6 sensitive cells develop in weeks 8-9 (α and γ cells – glucagon and pancreatic polypeptide);
Pax-4 sensitive cells develop later (β and δ cells – insulin and somatostatin).

notch- inactivated= stimulated by VASCULATURE= VEGF= endocrine pancreas

PAX -6 = Alpha & delta
PAX- 4 = Beta & gamma
Describe the lymph drainage of the gastro intestinal system.

The lymph drainage flow in reverse direction of _______
What is so special about intestinal lymph?

VERY IMPORTANT HIGH YIELD SUAREZ QUESTION:::  compare and contrast MOTOR and SENSORY innervation of the GIT. When are they different?
VERY IMPORTANT HIGH YIELD SUAREZ QUESTION::: compare and contrast MOTOR and SENSORY innervation of the GIT. When are they different?


3 (Genitofemoral)
3 (Genitofemoral)
How can you tell the differnece between large vs small bowel on Xray
How can you tell the differnece between large vs small bowel on Xray

What two structures are found in the nutcracker angle?
Left renal vein and 3rd duodenum are the two structures that go between the Aorta and SMA
What are all of these ducts here called?
What are all of these ducts here called?

What is this?
What is this?
Main Point:
Pneumoperitoneum is gas between the visceral and parietal pleura. Allows discrete edges between adjacent structures to be seen.
Gas will go to the most non-dependant place in the abdomen (here it is under the right hemidiaphram because patient is upright)

Main Point: Not to remember riglers sign but to realize that when the patient is supine (on back) that the air will go to the center of the abdomen, as in this case, and separate loops of bowel.

Main Point: Another example of how air goes to the most non-dependant location.
What kind of bowel is indicated here?
What kind of bowel is indicated here?
Small bowel obstruction

Main Point: Bowel that is obstructed becomes dilated.  Small bowel can look as large as or larger than normal colon.  But, remember that small bowel the valvulae conniventes traverse the whole diameter of small bowel.  Helps dis
Small bowel obstruction

Main Point: Bowel that is obstructed becomes dilated. Small bowel can look as large as or larger than normal colon. But, remember that small bowel the valvulae conniventes traverse the whole diameter of small bowel. Helps distinguish.
Whats this?
Whats this?
Cholelithiasis

Main Point: remember the 5 radiographic densities.  If it looks like bone but is not a bone, it is a calcified structure.  Even though we can’t see the gall bladder on plain film, when there are stones  located In RUQ where we would expe
Cholelithiasis

Main Point: remember the 5 radiographic densities. If it looks like bone but is not a bone, it is a calcified structure. Even though we can’t see the gall bladder on plain film, when there are stones located In RUQ where we would expect the gall bladder to be we can make the diagnosis of gallstones.
WTF is this? A baby?!?!
WTF is this? A baby?!?!
GALLSTONES Main Point:  We have not looked a lot of US.  But the key to remember when looking at US is that the anatomy is exactly the same once you figure out your orientation.   

Here is another picture of it on an CT.
GALLSTONES Main Point: We have not looked a lot of US. But the key to remember when looking at US is that the anatomy is exactly the same once you figure out your orientation.

Here is another picture of it on an CT.
Da faq are these?!?
Da faq are these?!?
Renal caliculi Rememerb
Renal caliculi

(kidney stones) note the renal pelvis outline
Da faq is going on here?
Da faq is going on here?
Pneumobilia

Main Point: Gas can get into the bile ducts and the potal veins.  By knowing the anatomy, you can identify those structures when this finding is present.
Pneumobilia- air in biliary system

Main Point: Gas can get into the bile ducts and the potal veins. By knowing the anatomy, you can identify those structures when this finding is present.
Why can we see contrast at both the fundus AND pylorus?
Why can we see contrast at both the fundus AND pylorus?
Main Points:
1. Angular notch separates pyloris from body
2. Explain that this is double contrast.  Mention why contrast is at the fundus and pyloris (because those areas are dependant – pt supine)
Main Points:
1. Angular notch separates pyloris from body
2. Explain that this is double contrast. Mention why contrast is at the fundus and pyloris (because those areas are dependant – pt supine)

small bowel= 3 cm

colon= 6 cm



L lateral decubitus Quiz Question to see if the students understand that fluid/contrast will be dependant even if film is turned upright to the viewer.
L lateral decubitus Quiz Question to see if the students understand that fluid/contrast will be dependant even if film is turned upright to the viewer.
Da faq is going on here? Gall stones? Kidney stones?
Da faq is going on here? Gall stones? Kidney stones?
Chronic pancreatitis
What is this arrow pointing to?
What is this arrow pointing to?
Main Point: Colon displaced from the properitoenal fat can indicated fluid/mass effect.
Main Point: Colon displaced from the properitoenal fat can indicated fluid/mass effect.
Name dem bones
Name dem bones

Where is the outline of the kidney
Where is the outline of the kidney

Find the outline of the psoas muscle. What else is located in this muscle?
Find the outline of the psoas muscle. What else is located in this muscle?

Where is the ligament of Terez?

How can you tell diff between jejunum and illieum on xray
How can you tell diff between jejunum and illieum on xray


Just look at the slides
Just look at the slides

That seems really uncomfortble
That seems really uncomfortble
How can you tell the difference between celiac vs SMA on CT cross section?
How can you tell the difference between celiac vs SMA on CT cross section?
Look @ the kidneys!!!
Look @ the kidneys!!!
How can you tell the difference between SMA and SMV?
How can you tell the difference between SMA and SMV?
vein to right
vein is larger
vein to right
vein is larger
how can we fin the hepatic artery?
how can we fin the hepatic artery?
Hepatic artery is anterior to portal vein.
Hepatic artery is anterior to portal vein.
How can you find ovary?
How can you find ovary?
find uterus, and ovary should be nearby
find uterus, and ovary should be nearby
How can you find the prostate?
How can you find the prostate?
Bowel posterior, urethra anterior 

Note:  contrast is in the bladder due to the timing of the scan after contrast.
Bowel posterior, urethra anterior

Note: contrast is in the bladder due to the timing of the scan after contrast.
Test question!!!! What is the difference between OSMOTIC diarrhea and secretory diarrhea?
In general, osmotic diarrhea is the most common type of diarrhea. It is caused by hypermotility, which forces the chyme/feces through the lower GI tract too rapidly for proper absorption of fluid and electrolytes. In contrast, secretory diarrhea is specif
In general, osmotic diarrhea is the most common type of diarrhea. It is caused by hypermotility, which forces the chyme/feces through the lower GI tract too rapidly for proper absorption of fluid and electrolytes. In contrast, secretory diarrhea is specifically caused by increased secretion of solutes into the lumen of the gut. The hallmark example of this occurs with cholera toxin.
What does CHOLERA do EXACTLY!?!??!
What does CHOLERA do EXACTLY!?!??!
Cholera is disease caused by the bacterium Vibrio cholerae, which is contracted in a fecal-oral manner, usually through ingestion of contaminated water. In the small intestine, the bacteria produce cholera toxin, which has devastating effects on the intestinal epithelium. The toxin modifies the G protein Gs, and as a result, GTPase activity is inhibited, causing prolonged activation of adenyl cyclase. The resulting high level of cAMP activates the CFTR (see "Cystic Fibrosis" Clinical Correlate in Chapter 2), which causes active Cl- secretion into the lumen of the small intestine. The Cl- efflux is accompanied by Na+ efflux (preserving electroneutrality), and water follows the electrolytes. This isotonic secretion of electrolytes and water depletes the vascular space while maintaining plasma osmolarity. In this manner, the vascular space is rapidly contracted, causing severe dehydration and shock. Antibiotic therapy and intravenous hydration is the most desirable therapy; otherwise, oral rehydration therapy (ORT, containing water, electrolytes, and glucose) from an uncontaminated source can be given. The glucose in the ORT promotes sodium and electrolyte absorption and actually draws more of the secreted Na+ and Cl- back into the vascular space, along with water. This is effective in reducing the diarrhea and maintaining hydration. Without antibiotics, and with availability of uncontaminated water, the bacteria will be cleared from the GI tract in 7 to 10 days, as the enterocytes slough off and are replaced by new cells.
YOU MUST HAVE THIS DOWN COLD!!!
For the following hormones, what secretes it and why? What does it do?
Gastrin
Secretin
CCK
GIP
Petide YY
Motilin
Ghrelin

As you can see by this chart here, the stomach secretes many different things (aka HIPGLOM) first and foremost is ACID.

What regulates gastric ACID secretions and WHICH ONES ACT DIRECTLY ON PARIETAL CELLS?!
As you can see by this chart here, the stomach secretes many different things (aka HIPGLOM) first and foremost is ACID.

What regulates gastric ACID secretions and WHICH ONES ACT DIRECTLY ON PARIETAL CELLS?!

Stretch of the ANTRUM of the stomach secretes what in to the blood??
GASTRIN from gastra G cells

GASTRIN will increase production of H+ from parietal cells

"then @ Parietal cells, we got somatostatin that says whoooooooaaaa... slow the eff down!! chill out parietal cell. Stop making so much acid."  GIP and Secretin r
GASTRIN from gastra G cells

GASTRIN will increase production of H+ from parietal cells

"then @ Parietal cells, we got somatostatin that says whoooooooaaaa... slow the eff down!! chill out parietal cell. Stop making so much acid." GIP and Secretin released from the duodenal cells also help slow gastrin down.
Describe what makes up the mucosa, submucosa and muscularis externa?
Describe what makes up the mucosa, submucosa and muscularis externa?

What are some of the consequences of overactive acid secretions? as seen in zollinger-emison syndrome
What are some of the consequences of overactive acid secretions? as seen in zollinger-emison syndrome
*Bile is going to be more clumpy (doesnt work as well in lower pH)
*bile that clumps can't be recycled-->
goes in to feces

Biles also causes SOLVENT DRAG. osmotic agent.
also COLON STRETCH and faster movement through tract (osmotic diarrhea)

steatorhhea (fatty poop)
PANCERATIC GASTRONOMA/ Zollinger-emison syndrome
CLINICAL CORRELATE
Zollinger-Ellison Syndrome
Gastrinomas are tumors (usually pancreatic) that secrete gastrin, but do not have any of the normal feedback systems that control gastrin release. These tumors cause Zollinger-Ellison syndrome, in which the constant secretion of gastrin causes uncontrolled, high levels of gastric HCl release and ulcerations of the stomach mucosa. In addition, the high acid secretion acidifies the duodenum and early jejunum, impeding the actions of digestive enzymes and precipitating bile. This especially affects lipid digestion and absorption, because the low duodenal pH denatures pancreatic lipase, significantly reducing lipid digestion. This results in steatorrhea and excess bile salts in the feces. Treatment is by removal of the tumor and the use of PPIs to further reduce acid secretion, allowing ulcerations to heal.

"Pathophysiology: Gastrin works on stomach parietal cells causing them to secrete more hydrogen ions into the stomach lumen. In addition, gastrin acts as a trophic factor for parietal cells, causing parietal cell hyperplasia. Thus there is an increase in the number of acid-secreting cells, and each of these cells produces acid at a higher rate. The increase in acidity contributes to the development of multiple peptic ulcers in the stomach and duodenum (small bowel)."- wiki
Where does ghrelin come from, and what does it do?

Salivary alpha-amylase is activated by what?
Chloride!!


Starch digestion begins in the mouth with salivary α-amylase. Digestion continues in the small intestine by pancreatic α-amylase, which hydrolyzes the starch molecules to maltose, maltotriose, and isomaltose. The amylase is activated by Cl-.
Glucokinase does what in the liver? phosphorylase does what in the liver?
Glucokinase does what in the liver? phosphorylase does what in the liver?
Remember: brush border also has glut 2 transporters. doesn't care about insulin. enterocytes goal is to get it inside.
Remember: brush border also has glut 2 transporters. doesn't care about insulin. enterocytes goal is to get it inside.
Out of HDL, VLDL, and LDL, which one has the most cheolesterol? The most protein?

What could INHIBIT gastric secretion? (4 things)
Several factors inhibit acid secretion:
1. Somatostatin (SS), released from endocrine cells in the gastric pit, acts in a paracrine manner on the parietal cells, as well as on G-cells to inhibit gastrin.
2. Glucose insulinotropic peptide or gastric inhibitory peptide (GIP), released from the duodenum and jejunum, acts directly on the parietal cells.
3. Secretin, released from the duodenum and jejunum, acts at the G-cells to suppress gastrin.
4. Peptide YY, released from various areas of the GI tract in response to fats, helps shut off acid and pancreatic secretions when chyme is leaving the upper GI tract. The effects on gastric acid may be through suppression of ACh release from cholinergic fibers, and/or stimulation of paracrine somatostatin.
EXTREMTLY IMPORTANT: What is the name of the GLUCOSE TRANSPORTER for enterocytes that makes oral rehydration therapy so effective for dehydration or enteric dieseases such as cholera?
SGLT-1 Transporters

the rapid absorption of glucose facilitates Na+ absorption, and hence Cl- and H2o absorption as well!
The spleen and liver usually have similar soft tissue composition on CT. Why is the liver darker?? What is the pathology here when the spleen and liver are two different colors?????
The spleen and liver usually have similar soft tissue composition on CT. Why is the liver darker?? What is the pathology here when the spleen and liver are two different colors?????
FATTY LIVER!! (more fat than normal soft tissue.)
Less dense

fat has less attenuation than soft tissue/ water, so more xrays can pass through--> darker on exam


Lead has most attenuation 
Air has least attenuation--> most exposure of xray film
FATTY LIVER!! (more fat than normal soft tissue.)
Less dense

fat has less attenuation than soft tissue/ water, so more xrays can pass through--> darker on exam


Lead has most attenuation
Air has least attenuation--> most exposure of xray film

When fat = 5-10% of total liver weight= FATTY LIVER

chronic STEATOHEPATITIS (inflammation from fat buildup) can lead to scarring (cirrhosis) and loss of liver fxn

When fat metabolisim is dysregulated--> we have (metabolic syndrome) fats accumulating in liver--> more alcohol can exacerbate this problem.

alcohol not always causitive, but usually related...
ALANINE TRANSAMINASE enzyme (ALT) levels in blood. 

What can they tell us versus the aspartate (AST) enzymes? Which is liver specific enzyme?
ALANINE TRANSAMINASE enzyme (ALT) levels in blood.

What can they tell us versus the aspartate (AST) enzymes? Which is liver specific enzyme?
(Rick) ALANine= SPECIFIC TO LIVER enzyme for protien metabolism

aspartate transaminase (general protein metabolism enzyme specific to liver)
(Rick) ALANine= SPECIFIC TO LIVER enzyme for protien metabolism

aspartate transaminase (general protein metabolism enzyme specific to liver)