Flashcards in Abdomen #2 (starting w/ portal vein; lecture 30B) Deck (112)
Where does the SMV meet the splenic vein? What do they form?
Posterior to the neck of the pancreas to form the portal vein.
List the tributaries of the splenic vein (4; and secondary tributaries if applicable)
1.) Inferior mesenteric vein (IMV) and its tributaries:
a.) Left colic
c.) Superior rectal
2.) Pancreatic veins
3.) Left gastroepiploic vein
4.) Short gastric veins
-approx. p.250 Moore
List the tributaries of the SMV
1.) Inferior pancreaticoduodenal vein
2.) Right gastroepiploic vein
3.) Right colic vein
4.) Ileocolic vein
5.) Jejunal veins
6.) Ileal veins
What are the three most important/clinically relevant portosystemic anastomoses, where do they occur, and what is their relevant pathology (e.g. esophageal varices)?
*Know clinical significance and anastomosing veins!*
1.) Lower esophagus
Portal: Oesophageal branches of left gastric veins
Systemic: Azygous veins
--> Esophageal varoces: Torrential bleeding from the mouth
2.) Upper anal canal
Portal: Superior rectal vein
Systemic: Middle/inferior rectal veins
--> If these veins become engorged, you get HEMORRHOIDS
Portal: Veins of ligamentum teres
Systemic: Superior/inferior epigastric veins
--> "Caput medusae" (p.280 Moore): Engorged dilated veins radiating around belly button can be caused by cirrhosis of the liver in alcoholics.
Where do the portosystemic anastomoses occur (6)?
Upper anal canal
Bare area of liver
Patent ductus venosus (rare)
When can a portal vein become blocked?
Cirrhosis of the liver (from alcohol)
1.) Where does the common bile duct open to?
2.) Where is it in relation to the first part of the duodenum on its way to the second?
1.) Medial side of the second part of the duodenum
2.) *Posterior to the first part of the duodenum* <-- Know this, according to Dr. Rich!
What is the blood supply for the gallbladder?
The CYSTIC ARTERY which is a branch of the RIGHT HEPATIC ARTERY.
What is Calot's Triangle? Borders?
Lateral: Inferior border of the liver
Medial: Cystic duct
Superior: Cystic artery
Where does the gallbladder receive innervation from? i.e. sensory, parasympathetic, sympathetic.
Sensory from RIGHT PHRENIC NERVE
Sympathetic: Celiac plexus
What lymph node becomes enlarged when there is inflammation of the gallbladder?
Mascagni's/Lund's lymph node
When performing surgery around Calot's Triangle (e.g. laproscopic cholecystectomy), what structures should be secured first in order to avoid injury?
Cystic duct and common hepatic duct
-19:00 Lecture 30B
The tail of the pancreas lies inside of what structure?
Lienorenal (literally, "Spleen Kidney") ligament
Where does the spleen lie in relation to the ribs?
Ribs # 9, 10, and 11. Thus, rib injuries can injure the spleen.
What structures form the cystohepatic triangle?
Cystic duct, common hepatic duct, and the liver margin.
-19:16, Lecture 30B
What provides sensory innervation for the gallbladder?
Right phrenic nerve
What are the main risk factors for developing gall stones (4)?
*The four F's*
Fat, female, forty, fertile
1.) Describe the location of the pancreas?
2.) Where does it refer pain to?
1.) Retroperitoneally and transversely across the posterior abdominal wall.
2.) To the back
What structure(s) is/are at risk when surgically removing the spleen?
The lienorenal ligament (attaches the hilum of the spleen to the kidney) and/or tail of the pancreas that lies within it
What lies behind the neck of the pancreas in situ?
Portal vein (where the SMV and splenic vein unite to form the portal vein).
What is a possible consequence of cancer in the head of the spleen?
It compresses the common bile duct and prevents bile from entering the second part of the duodenum and bile subsequently enters the bloodstream. THIS CAUSES JAUNDICE.
Which blood vessels does the head of the pancreas lie over?
IVC, left and right renal veins, and right renal artery.
What is the uncinate process?
A projection from the inferior part of the head of the pancreas that extends TO THE LEFT (it is at the bottom of the head after it forms a "C").
Where does the neck of the pancreas lie in relation to the pylorus and superior mesenteric vessels?
It overlies the superior mesenteric vessels and is ADJACENT to the pylorus.
Where does the body of the pancreas lie in relation to vertebrae, aorta, and omental bursa?
It crosses the body of L2 and aorta, and lies in the floor of the omental bursa.
What blood vessels is the body of the pancreas in contact with (5)?
Posteriorly, it is in contact with the aorta, SMA, left suprarenal, left kidney, and related vessels.
Where does the main pancreatic duct begin and run towards?
Begins in the tail and runs towards the head.
1.) Where does the common bile duct open into the duodenum?
2.) What is the structure called?
1.) It opens into the major duodenal papilla in the DESCENDING portion (2nd part) of the duodenum.
2.) Hepatopancreatic AMPULLA OF VATER
What is the name of the structure that surrounds the major duodenal papilla?
Sphincter of Oddi (smooth muscle)
1.) Where does the accessory pancreatic duct open into?
2.) Where does the ampulla of Vater open into?
1.) Minor duodenal papilla
2.) Major duodenal papilla
1.) What is the largest lymphatic organ and where is it located?
2.) Where does it lie in relation to the ribs?
1.) The spleen, located in the LUQ
2.) Related posteriorly with ribs 9-11
Which structures are related to the spleen in the following ways:
4.) At splenic hilum
2.) Splenic flexure of colon
3.) Left kidney (via splenorenal ligament)
4.) Tail of pancreas extends to hilum
1.) What provides parasympathetic innervation to the spleen?
2.) Greater splanchnic
When observing a person posteriorly, approximately where does the spleen refer pain?
In the left border of the mid-back
1.) Is the descending colon intra or retroperitoneal?
2.) Sigmoid colon?
2.) Intra (covered on all sides by peritoneum)
What are the 3 key features that distinguish the large intestine from the small intestine?
1.) Tenia coli (longitudinal muscle band)
2.) Haustra (dilated intestine formed by tenia coli)
3.) Appendices epiploicae
1.) The appendix is _____-peritoneal.
2.) The ascending colon is _____-peritoneal
3.) The transverse colon is _____-peritoneal
4.) The descending colon is _____-peritoneal
What is the cecum?
A dilated portion of the ascending colon
What is the appendix attached to?
What attaches the transverse colon to the posterior abdominal wall?
The sigmoid colon is covered on all sides by ______ called ______.
Peritoneum called SIGMOID MESOCOLON.
What does the ileocecal valve NOT prevent?
1.) Where does the appendix typically arise from?
2.) Where does it get blood supply from *and what is it a branch of* <-- EXAM QUESTION!
3.) What provides parasympathetic innervation to the appendix
1.) The posteromedial side of the cecum
2.) Appendicular artery -- Branch of the ILEOCOLIC ARTERY
Where is the ascending colon in relation to the abdominal wall?
On the right side of the posterior abdominal wall
What is the vascular supply for the ascending colon (2)?
1.) Ileocolic artery and vein
2.) Right colic artery and vein.
Where do ascending colon lymphatics drain?
Epicolic (upon) and paracolic (to either side) nodes
Where does the transverse colon receive blood supply from (3)?
1.) Left colic artery (IMA) and vein
2.) Right colic artery (SMA) and vein
3.) Middle colic artery (SMA) and vein
1.) What provides parasympathetic innervation to the descending colon?
1.) Pelvic splanchnics
2.) Lumbar sympathetic trunk, superior hypogastric plexus
What provides blood supply to the sigmoid colon (2)?
1.) Left colic artery and vein
2.) Superior sigmoid artery and vein
What provides sympathetic and parasympathetic innervation to the sigmoid colon?
Sympathetic: Lumbar sympathetic trunk, superior hypogastric plexus
Parasympathetic: Pelvic splanchnic nerves
At what vertebral level does the rectum begin?
Anterior to the body of S3
At what vertebral level does the IMA arise?
Arises in front of L2-L3
What does the Arc of Riolan (aka meandering artery) do?
Not present in all people. It provides alternate anastomoses between IMA (left colic) and SMA (middle colic)
1.) What supplies sympathetic innervation to the large intestine?
1.) It is derived from spinal cord segment T10-L2
2.) Vagus and pelvic splanchnics
*Dr. Rich said PLEASE KNOW THIS***
What is McBurney's point?
*A way to find the appendix* --> Approximately 1/3 of the distance along a line drawn from the ASIS to the umbilicus
1.) What is diverticulosis? How to treat?
2.) Diverticulitis? How to treat?
1.) Outpocketings of the intestinal mucosa into submucosa and muscular layer. Feces can become stuck and cause infections. *Treat with fiber to keep feces moving*
2.) Diverticulitis is inflammation and infection, usually as a result of diverticulosis. *Treat with NPO (nothing eaten orally)*
What is a volvulus?
Twisting of the descending colon
1.) What is megacolon?
2.) What are secondary symptoms?
3.) Can it be caused by infection? by what?
1.) Megacolon is an abnormally dilated colon. It is often accompanied by a paralysis of the peristaltic movements of the bowel --
2.) This can cause FECOLOMAS (large collections of feces stuck in the colon).
3.) Yes; Clostridium Difficile
Where does the liver lie?
In the right hypochondrium (RUQ)
Which lobe of the liver is bigger? What separates the two lobes?
Right lobe is bigger. Separated by the Falciform ligament.
What connects the anterior surface of the liver to the anterior abdominal wall?
What contains the obliterated umbilical vein?
Ligamentum Teres, aka Round Ligament (of the liver)
What structures does the liver lie in relation to (5)?
1.) Right side of anterior stomach
2.) First part of duodenum (superior part)
4.) Right colic flexure and transverse colon
5.) Right kidney and suprarenal glands
What organ lies on the right inferior border of the liver?
What makes up the H-shaped fissure of the liver?
-Fissure of the ligamentum venosum
-Fossa for gallbladder
-Fissure for IVC
-Central portion formed by the hilum of the liver
What are the two most important recesses of the liver and what is their clinical significance?
1.) Subphrenic recess: Between liver and diaphragm; lung infections can invade the subphrenic space through the diaphragm.
2.) Hepatorenal recess (Morrison's recess): Where fluid collects when person is lying down because it is the most dependent part of the abdomen.
The ligamentum venosum is the leftover portion of what embryonic structure?
Where does the liver receive its blood supply (2)?
Portal vein (70%), Hepatic artery (30%)
Kidneys are _____-peritoneal
The _____ kidney is slightly higher than the ______ kidney. Give vertebral levels
Left kidney (T11-L2) is slightly higher than the right kidney (T12-L3)
Posteriorly, the superior parts of the kidneys lies deep to the _____ and _____ ribs.
11th and 12th
What is the name of the fat that lies outside of the renal fascia?
What encloses the adrenal gland?
Renal fascia (Gerota's Fascia)
What are the order of the vessels to the kidney, anterior to posterior?
Renal VEIN, renal ARTERY, URETER
What renal substructures are located within the following:
1.) Cortex (4)
2.) Medulla (3)
1.) Glomerulus, renal corpuscle, proximal and distal convoluted tubules, proximal collecting ducts.
2.) Thick and thin limbs of loop of Henle, distal parts of proximal and distal convoluted tubules, distal collecting ducts.
-14:05 Lecture 31A
What structures are related to the right kidney anteriorly (5)?
Superior: Suprarenal gland
-15:23 Lecture 31a
What structures are related to the right kidney posteriorly (5)?
12th rib, diaphragm, transversus abdominis, psoas major, QL
-15:23 Lecture 31a
What structures are related to the left kidney anteriorly (6)?
Spleen, suprarenal gland, stomach, pancreas, colon, jejunum
What structures are related to the left kidney posteriorly (6)?
11th and 12th ribs, diaphragm, QL, transversus abdominis, psoas major
What are the two places where fluid can collect in a supine individual?
Hepatorenal recess, rectovesical/rectouterine pouch (aka Pouch of Douglass)
What supplies blood to the kidneys? Branches of?
Renal arteries, directs branches of the abdominal aorta.
What structure does the right renal artery pass on the way to the kidney? In what manner does it pass?
It passes POSTERIOR to the IVC
What veins does the left renal vein receive (2)?
1.) Left suprarenal vein
2.) Left gonadal vein
The left renal vein passes deep/posterior to what important artery?
The ureter is _____-peritoneal
The beginning of the ureter is associated with what vertebral level? Ending associated with what bony landmark?
The ureter is crossed by what artery near the bladder? Clinical significance?
Uterine artery. During hysterectomy, it is possible to knick the ureter.
*Water under the bridge*
What are the sites of the three clinically significant constrictions of the ureters?
1.) Junction of the ureter and renal pelvis
2.) As they cross the pelvic brim or external iliac artery
3.) In the wall of the urinary bladder
In both males and females, where does uretric pain radiate?
Into the lower quadrant of the anterior abdominal wall (i.e. groin) -- associated with nausea and vomiting.
With kidney stones, due to close relation of kidneys to the ______ muscle, extension of the _____ causes pain in the pararenal region.
PSOAS MUSCLE, HIP JOINTS
How can you distinguish between the right and left suprarenal glands by virtue of their shape? Which structures are each spatially related to?
Right = triangular --> Contacts IVC and liver.
Left = Semilunar --> Related to spleen, stomach, and left crus of diaphragm.
What provides blood supply to the kidneys (3)? Where are each from?
1.) Superior suprarenal arteries (from inferior phrenic artery)
2.) Middle suprarenal artery (from aorta)
3.) Inferior suprarenal artery (from renal artery)
What is the venous drainage for the adrenal glands?
Drains into single, large SUPRARENAL VEIN --> drains into left renal vein on the LEFT, and the IVC on the RIGHT.
What is a tumor of the adrenal gland called? Describe
Pheochromocytoma: Tumor arising from the adrenal medulla. Adrenal gland secretes catecholamines (peripheral vasoconstriction, coronary vessel dilation). Thus, tumor cyclically secretes catecholamines and elicits sympathetic responses (transient intermittent HTN, sweating, anxiety, nausea, tremor, palpitation, chest pain, headache, etc.).
Describe the medial arcuate ligament
It is a superior thickening of the psoas sheath fascia -- It becomes the site of origin of the muscle of the diaphragm.
Name the 5 muscles of the posterior abdominal wall
Diaphragm, QL, psoas major, psoas minor, and iliacus.
1.) Describe the diaphragm, i.e. composition and general locations.
2.) Describe the two domes of the diaphragm
1.) Musculotendinous partition separating the thoracic and abdominal cavities.
-Muscular part is to the periphery
-Central tendon is towards the middle.
2.) Right dome is higher than the left, ascends to 5th rib on the right, and the 5th intercostal space on the left during expiration.
Describe the origins of the diaphragm (4)
1.) Sternal part: Inner surface of xiphoid process
2.) Costal part: Costal cartilage and lower 6 ribs.
3.) Lumbar part: Medial and lateral arcuate ligaments.
4.) Crura: Musculotendinous bundles from the bodies of L1-L3, right and left.
What is the insertion of the diaphragm?
At what vertebral level does the aorta pierce the diaphragm and enter the abdomen? What is this spot called?
T12 --> Aortic Hiatus
At what vertebral level does the esophagus enter the abdominal cavity?
What muscle does the median arcuate ligament lie on?
Describe the diaphragmatic apertures (i.e. where they are, what they transmit, and any clinical significance)
1.) Caval opening: At T8 to the right of the midline. Transmits branches of the right phrenic nerve, few lymphatics, and the IVC. *When diaphragm CONTRACTS during INSPIRATION, it widens the opening and dilates the IVS and facilitates blood flow.
2.) Esophageal Hiatus: At level of T10 in the right crus. Transmits the esophagus, anterior and posterior vagal trunks, and esophageal branches of the left gastric vessels.
3.) Aortic Hiatus: At T12 between the crura and posterior to the median arcuate ligament. Transmits the aorta, thoracic duct, and sometime azygous and hemiazygous veins.
What is the mnemonic for the diaphragmatic apertures?
I (IVC) ate (T8) ten (T10) eggs (esophagus) at (aorta) twelve (T12)
What is the origin and insertion of the QL and its innervation
Origin: 12 rib and tips of lumbar TPs.
Insertion: Iliac crest
Innervation: T12, L1-L4
What are the vertebral levels marking the beginning and end of the abdominal aorta?
Begins anterior to the body of T12 and ends at the bifurcation of the common iliac arteries at L4.
Where does IVC begin, ascend, and enter thorax?
-Begins at L5, right of the median plane, inferior to aortic bifurcation and posterior to right common iliac artery.
-Ascends on right psoas muscle, right to bodies of L3-L5.
-Enters thorax at T8 (caval opening) by PIERCING THE CENTRAL TENDON!
Give the IVC tributaries and vertebral levels (7)
1.) Hepatic veins, T8
2.) Inferior phrenic veins, T8
3.) Suprarenal vein, L1
4.) Renal veins, L1
5.) Gonadal vein, L2
6.) Lumbar veins, L1-L5
7.) Common iliac veins, L5
-23:20, Lecture 31b
Give the nerve roots and names of the lumbar plexus (7)
*Composed of anterior rami of L1-L4 nerves*
1.) Femoral nerve (L2-L4)
2.) Obturator nerve (L2-L4)
3.) Lumbosacral trunk (L4, L5)
4.) Ilioinguinal and iliohypogastric nerves (L1) arise from anterior ramus of L1
5.) Genitofemoral nerve [cremasteric reflex] (L1, L2)
6.) Lateral cutaneous nerve of the thigh, or lateral femoral cutaneous nerve (L2, L3)
7.) An accessory obturator nerve (L3, L4) is present almost 29% of the time
-Schematic 35:47, Lecture 31b
How to memorize LUMBAR PLEXUS
Break the nerves up into ones that are:
-Lateral to psoas major: subcostal, iliohypogastric, ilioinguinal, LFC, femoral.
-Anterior to psoas major: GF--> genital and femoral branch (cremasteric reflex)
-Medial to psoas major: Obturator, lumbosacral trunk, 1/2 L4, all of L5
28:30 or *30:30* Lecture 31b
What are the two types of lymphatic in the posterior abdominal wall and what do they drain?
1.) Preaortic nodes (celiac, superior mesenteric, inferior mesenteric): GI tract and accessory digestive organs.
2.) Paraaortic nodes (lumbar or lateral aortic): Renal system