ABDOMEN - Team Motivation › onlinetest › backend › source › Anat4... · 2018-09-06 ·...
Transcript of ABDOMEN - Team Motivation › onlinetest › backend › source › Anat4... · 2018-09-06 ·...
ABDOMEN
Boundries of abdomen
• Roof
• Floor
• Anterior wall
• Posterior wall
Content: • Rectus abdominis & pyramidalis • Superior & inferior epigastric vessels • Lower 5 intercostal & subcostal nerves
Rectus sheath
INGUINAL CANAL
• Musculo-apponeurotic tunnel
• About 4 cm in length
• Extends from deep inguinal ring
to superficial inguinal ring
Inlet (Deep Inguinal Ring)
Outlet (Superficial Inguinal Ring)
Anterior wall
Posterior wall
Floor – Poupart’s ligament
Roof
INGUINAL HERNIA
An abdominal content covered by peritoneum enter the
inguinal canal
Content of hernial sac vary from a piece of omentum to small
or large intestine
When Meckel’s diverticulum enter - Littre’ s hernia
Two types:
• Indirect /oblique
• Direct
Defensive mechanism of inguinal canal (or Shutter mechanism)
Falp valve mechanism – In increased IAP the posterior wallof canal is
pushed forward & come in contact with anterior wall obliterating the
canal
Ball valve mechanism – In increased IAP the cremaster muscle in
male contract & pull the testes towards the superficial ring thus the
outlet of the canal is closed like a plug (cremasteric plug)
At the 4th month of foetal life testis appears in iliac fossa
at 7th month it reaches deep inguinal ring
During 8th month it travels the inguinal canal
finally reaches srotum at or slightly after birth
Descent of Testis
Abdominal aorta
Celiac Artery
Superior mesenteric Artery
Inferior mesenteric Artery
Abdominal aorta
Inferior vena cava
HEPATIC PORTAL VEIN
Valveless Drain • Abdominal part of GIT (from lower third of oesophagus to halfway down the analcanal) • Spleen • Pancreas • Gallbladder
Length : 5 cm
sometimes the trunk of vein presents a dilatation, portal sinus, just before its division
Porta-caval anastomosis
At lower end of oesophagus
At the umblicus spokes of
wheel (Caput Medusae)
At lower end of rectum and
anal canal
THE PERITONEUM
Largest serous sac in to which organs are pressed from outside
Consist of
• Parietal peritoneum
• Visceral peritoneum
Peritoneal cavity
• Male - closed sac
• Female - open sac
• Present two inter communicating sac – (Epiploic foramen / foramen of winslow- T12, 3 cm)
Greater sac
Lesser sac (omental bursa)
Primary retroperitoneal organ: Suprarenal gland
Urinary : kidney
ureter
bladder
Circulatory : aorta
Inferior Vena Cava (IVC)
Digestive : rectum (part, lower 1/3rd extraperitoneal)
Secondry retroperitoneal organ: Head,neck & body of pancreas (tail-peritoneal)
Duodenum (except proximal first segment- peritoneal)
Ascending & descending colon
Peritoneal folds
Omenta : connect stomach with other abdominal organs
• Lesser omentum : stomach liver
• Greater omentum : stomach transverse colon
(abdominal police gaurd)
Mesentry : connect gut from posterior abdominal wall
• The mesentry – connected with jejunum & ileum
• Transverse mesocolon – with transverse colon
• Sigmoid mesocolon – with sigmoid colon
Gastrointestinal Tract (GIT)
STOMACH
Most dialated part of GIT
Capacity:
• 30-50 ml- newborn
• 1000 ml- puberty
• 1500 ml- adult
Shape : J shape (in living)
sickle shaped (in cadaver)
Clinaclly 3 types
• Sthenic normal type
• Hypersthenic steer horn stomach
• Hyposthenic (Asthenic)
Gastric triangle
• Area of stomach in contact with anterior abdominal wall • Boundries: Right side - lower border of liver Left side - left costal margin Below - transverse colon • In complete esophageal obstruction, a tube is introduced in stomach through gastric triangle for feeding the patient
Stomach Bed
• Left crus of diaphragm
• Left suprarenal gland
• Anterior surface of left kidney
• Splenic artery
• Anterior surface of pancreas
• Anterior layer of transverse mesocolon &
sometimes left colic flexure
• Spleen – when stomach is distended
GIT histology
• Submucosal plexus (of Meissner)- in
submucosa
• Myentric plexus (of Auerbach)-
between CML & LML
Gastric glands
Cardiac gland – mucus secreting cells
Pyloric gland – mucus secreting cells &
neuroendocrine cells
Principle gland – most highly specialized
• in body & fundus
• Cell types :
Chief (peptic) cells - pepsin & lipase
Parietal (oxyntic) cells – gastric acid, intrinsic factor
(necessory for absorption of vit. B12)
Mucous neck cells
Stem cells
Neuroendocrine (enteroendocrine)cells
G cell -> gastrin
D cell -> somatostatin
Enterochromaffin like cell -> histamin
Isthmus : dividing and undifferentiated
cells
Neck : mucous neck cells, parietal cells, &
enteroendocrine cells including APUD cells
Fundus/basal : mainly chief cells, some
parietal cells, and several types of
enteroendocrine cells.
Blood Supply
INTESTINE
Small intestine : ( 6.5 m = 21’)
• Duodenum – 25 cm (5,8 10, 2.5)
(Do-deca dactulos)
• Jejunum – 2.5 m
• Ileum- 3.7 m
Large intestine : (1.5 m = 6’)
• Caecum - 6-7 cm
• Colon - 1.3 m (15, 50, 25, 40 cm)
• Rectum – 12 cm
• Anal canal – 3.8 cm
Taeniae coli
Sacculation / Haustration
Appendices Epiploicae
Small Intestine
Diagramatic sketch of Villous structure
Epithelium
Arteriole Venule Lymphatic (lacteal)
Capillary network
45
Small intestine 1: Duodenum V- vill, G-glands in submucosa
Small intestine Large intestine
(Valve of Kerking)
Vermiform Appendix
Narrow worm like tubular diverticulation from postero- medial wall of caecum 2 cm below ileocaecal junction
Length : 2-20 cm (9 cm) Parts :
• Base • Body • Tip : variable in position:
retro-caecal (12 o’clock) : 60 % pelvic (4 o’clock) : 30 % pre-ilial (2 o’clock) : most dangerous (b/c
inflammation from appendix spreads to general peritoneal cavity)
Mc Burney’s point : maximum tenderness in appendicitis Arterial supply : appendicular artery, a branch of iliocolic artery
Psoas sign
The Mesentry
Free border- 20 feet long
Vertebral border (root) -15 cm long
• Extends from left side of L2 vertebra at
duodeno-jejunal flexure to right sacro-iliac
joint at ilio-caecal junction
• Structures crossed by the root (from above
downwards)
3rd part of duodenum
Abdominal aorta
IVC
Right gonadal vessels
Right ureter
Right psoas
Right genito-femoral nerve
Right sacro-iliac joint
Anal canal
Anal columns (column of Morgagni): 6-10
Anal valve (valve of Ball)- crescentric mucous folds
connecting lower ends of anal columns
Anal papillae : epithilial processes from free margin of
anal valves, remnant of anal membrane
Anal sinus
LIVER Largest gland of body
Colour : reddish brown
Shape : wedge shape, broad base
towards right
Absolute weight :
• At birth : 150 gms
• Adult male : 1.4-1.8 kg
• Adult female : 1.2- 1.4 kg
Proportional Weight :
• In new born : 1/18th of body weight
• In adult : 1/36th of body weight
Situation : whole right hypochondrium,
upper part of epigastrium
• Occupies 2/5th of abdomen Riedel’s lobe
Lobes of the Liver • Right lobe - 5/6th • Left lobe - 1/6th
Surfaces of liver • Parietal surface –
Anterior Posterior Superior Right lateral – biopsy through
9th/10th ISC during forced expiration • Visceral / inferior o Porta Hepatis – not a true gateway Structure at porta hepatis – before backward : (DAV) R&L hepatic duct R&L branch of hepatic artery R&L branch of portal vein
Segmental Anatomy of Liver– Couinaud Segments
LIGAMENTS OF LIVER
Peritoneal folds/ False ligament
True ligaments
• Ligementum teres hepatis
– Remnant of obliterated left umbilical vein
– Extends from umbilicus to left branch of portal vein at porta hepatis
– Pass along free border of Falciform ligament & floor of the fissure for ligamentum teres
– In foetal life- Left umblical vein conveys oxygenated blood from placenta to fetus
• Ligamentum venosum
– Remnant of obliterated ducts venoces which is foetal ife connect left branch of portal vein with IVC (or upper hepatic vein)
– In foetal life- most of blood of left umbilical vein shunts to IVC via ductus venosus after bypassing hepatic circulation
Blood Supply to Liver
• Hepatic artery (20%)
• Portal vein (80%)
Hepatic vein
Structural Organization of the Liver
Parenchyma
Connective tissue stroma
continuous with fibrous capsule
of Glisson
Sinusoidal capillaries (sinusoids)
Perisinusoidal spaces (spaces of
Disse)
Micro-structure of Liver
Classical lobule
Portal lobule
Hepatic acinus
Space of Disse (perisinusoidal space) Space of Moll (periportal space) Kupffer cell : belong to mononuclear phagocytotic system
Hepatic stelate cell (ito cells) : • Filled with cytoplasmic vacuoles containing vit. A • In certain pathologic conditions, these cells lose their storage vacuoles and differentiate
into myofibroblasts that produce collagen fibers, leading to liver fibrosis
1. Periportal zone 2. Transitional zone 3. Pericentral / centrilobularzone
Gall Bladder
Shape : pear shaped
Colour : grey blue
Capacity : 30-50 ml
Length : 7-10 cm
Partts :
•Fundus- just below the tip
of 9th costal cartilage
•Body
•Neck cystic duct
Hartmann’s pouch- small
diverticulum from neck
Callot’s triangle :
content -cystic artery
Nerve supply
Parasympathetic
Motor to musculature of gall bladder & bile duct
Inhibitory to sphincter
Sympathetic (T7-T9)
Vasomotor
Motor to sphincter
A/A
• Inflammation of gall bladder- k/a cholecystitis is more frequent in (5 F) fair, fertile,
fatty, female & above forty years of age
PANCREAS
Mix gland
Exocrine part : enzymes
Endocrine part (islet of Langerhans):
hormones
• Alpha cells (20%) : glucagon
• Beta cells (68%) : insulin
• Delta cells (10%) : somatostatin
• PP cells (2%) : pancriatic polypeptide
hormone -> inhibit intestinal mobility
Parts : head, neck, body, tail
Duct :
• Main duct ( duct of Wirsung)
• Accessory duct (duct of Santorini)
Length 12-15cm
Breadth 3-4cm
Thickness 1.5-2cm
Weight 80-90gms
Annular pancrease : vetral pancreas splits & form a ring around the duodenum, occasionally resulting in duodenal stenosis
SPLEEN Largest lymphatic organ
Graveyard of rbc
In foetal life – manufacture Erythrocytes
After birth – manufacture lymphocyte
Measurements : Harris dictum: 1, 3, 5, 7, 9, 11
Weight - 7 oz (150 gm)
Ligaments of spleen
Gastro-splenic ligament : shotr gastric & left gastro-
epiploic vessels
Lieno-renal ligament : spleenic vessels
Phrenico-colic ligament (sustantaculum lienis)-
support the spleen from below
Lieno-phrenic ligament : Suspensory ligament of
spleen
White pulp (malpighian body) : consisting of lymphatic nodule
arranged around an ecentric arteriole
Red pulp : (75%) consist of
• Venous sinuses
• Splinic cord of Billroth :
KIDNEY Essential organ of excretion
Shape : bean shaped with hilum directed
medially
Situated retroperitoneally in posterior
abdominal wall by sides of vertebral
column
Extends from T12- L3 vertebra
Right kidney- slightly lower than left kidney
Left kidney-longer, narrower & more
nearer to vertebral column than right
Measurement: 11 X 6 X 3 cm
Weight : male 150-170 gms
Female 130-150 gms
Structures passing through hilum- from
before backwards (VAP)
Renal vein
Renal artery
Pelvis of ureter
As a rule, one branch of renal artery &
corresponding tributary of renal vein pass
behind the pelvis
In addition the hilum transmits renal
lymphatics, nerves & perinephric fat
Coverings of kidney
Fibrous capsule (true capsule)
Perinephric fat (adipose tissue)
Renal fascia (false capsule, fascia
of Gerota)
• Anterior layer- thin & k/a Fascia of Toldt
• Posterioe layer- thick & k/a fassi of Zuckerkendl
Paranephric fat
Renal angle
Outer : renal substance
• Cortex : renal columns
cortical arches- has
medullary ray
convoluted parts
• Medulla: 8-18 pyramids
Inner : renal sinus- has
Renal blood vessels
Perinephric fat
Minor calyces (7-13)
Major calyces (2-3)
Pelvis of ureter (5-7 ml)
Each papilla is perforated by 16-20 or more duct of
Billini & received by minor calyx.
As a rule, one minor calyx receives 1-3 renal papilla
Structure of Kidney
NEPHRON
Structural & functional unit of kidney
Number : about one million in each kidney
Length : 50-55 mm
Each nephron consist of :
• Malpighian (or Renal) capsules : for filteration &
consist of
o Bowman’s capsule - lined by Squamous epithelium
o Glomerulus - a network of blood capillaries
• Neck
• Tubules : for selective reabsorption of filtrate until
urine is formed & consist of
o Proximal convoluted tubule (PCT)
o Loop of Henle’s
Descending limb - thinner
Ascending limb - thicker
o Distal convoluted tubule
• Lobe of kidney- one pyramid capped with
adjoining cortex
• Lobule of kidney - an area of the cortical
arch bounded on each side by inter-
lobular blood vessel & presenting in the
central axis of single medullary ray
Arterial supply of kidney
Ureters
Thick- walled cylindrical tubs
25 cm long
3 mm in diameter
Consist of 3 parts
• Pelvis (5-7 ml)
• Abdominal part
• Pelvic part
Constrictions of uretor : 3, developmental
• At pelvi-uretric region
• At pelvic brim
• At the point where ureter pierces bladder
wall
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