llist the two systems to describe the location of structures in the planes of the abdomen
- “Nine Region System”
- -Transtubercular plane (level of iliac tubercle and L5) & subcostal plane are horizontal planes (inferior 10th costal cartilage)
- -R midclavicular plane & L midclavicular plane are two vertical planes - “Quadrant system”
- -transumbilical plane (umbilicus level and L3/4) is the horizontal plane
- -median plane is the vertical plane
describe the nine region system
center column: epigastric, umbilical, hypogastric
lateral columns R/L: hypochondriac, lumbar, inguinal
transtubercular plane, subcostal plane, R/L midclavicular planes
describe the quadrant system
RUQ = liver, gallbladder, pylorus of stomach, duodenoum, ascending LI and R half of transverse LI, R kidney
LUQ = L lobe of liver, jejunum, proximal ileum, descending LI, L half of transverse LI, spleen, L kidney
RLQ= cecum, inferior ascending LI, appendix, R ureter, bladder, R ovary, uterine tube, uterus, spermatic cord abdominal part
LLQ = sigmoid colon, inferior descending LI, L ureter, bladder, L ovary, uterine tube, uterus, spermatic cord abdominal part
divisions of the abdominal wall
technical: 1. anterior, 2. lateral/flank, 3. posterior
for descriptive and function purpose: 1. anterolateral wall, 2. posterior abdominal wall
describe te anatomy of the anterolateral wall
multilayered wall
skin:superficial fascia (camper’s, scarpa’s): deep fascia: muscles of abdominal wall (external internal transversus oblique)–linea alba: extraperitoneal fat: Parietal layer of peritoneum, Visceral layer of peritoneum
campers fascia = fatty layer
scarpas fascia = membranous inner layer that has no fat, and is continuous with other fascia layers in the perineum and reproductive organs (penis, clit, scrotum)
deep fascia - invests the muscles of the wall
transverse fascia lines the inner portion of the transverse abdominal muscle and is continuous with the linea alba
peritoneum layers are serous membrane that invests the abdominal structures
parietal = lines wall of abdominopelvic cavity
visceral = covers the gi structures
List the muscles of the abdominal wall
Anterolateral: external oblique internal oblique transverse abdominal rectus abdominis pyramidalis -((small inner bottom of rectus abdominus)
OINA external oblique
O: ribs 5-12
I: linea alb [pubic tubercle, anterior half of iliac crest]
N: thoracic nerves
A: flex and rotate trunk, compress viscera (helps with expiration), supports viscera/spine
inferior aponeuroses folds back on itself to form the INGUINAL LIGAMENT
OINA internal oblique
O: thoracolumbar fascia [anterior 2/3 iliac crest, lateral half of inguinal ligament
I: ribs 10-12, linea alba, pectin pubis
N: thoracic nerve and first lumbar nerve
A: flex and rotate trunk, compress viscera on expiration, support viscera/spine (same as external oblique)
OINA transverse abdominal
O: costal cartilge of ribs 7-12 [thoracolumbar fascia, iliac crest, lateral 1/3 inguinal ligament]
I: Linea alba, pectin pubis, pubic crest
N: thoracic nerves and first lumbar nerve
A: compress viscera on expiration, support viscera/spine
OINA rectus abdominus:
O: costal cartilage of ribs 5-7, xiphoid process
I: pubic symphysis and pubic crest
N: Thoracic nerves
A: flexes trunk, compress viscera on expiration, support viscera / spine
describe the rectus sheath
formed by aponeuroses of external oblique, internal oblique, transverse abdominus
Encloses the rectus abdominus
ARCUATE LINE (btwn the level of umbilicus and pubic symphysis
- above this line the rectus sheath encompasses it all the way around “posterior portion of rectus sheath covers the rectus abdominus”
- below this line it is just infront! “ rectus sheath travels ansterior to rectus abdominus”
describe the linea alba
fibrous bnd of CT btwn the R and L rectus abdominis muscles
attachment for the oblique and transverse abdominal muscles!
describe the inguinal ligament
extends btwn ASIS and pubic tubercle
formed by the folded aponeurosis of external oblique*
describe the inguinal canal
Male: spermatic cord/vas deferns, ilioinguinal nerve
Female: round ligament, ilioinguinal nerve
canal formed by the CT of the anterior abdominal wall
- anterior: aponeruosis of external and internal oblique
- floor/inferior: inguinal ligament formed by the inferior fold of the external oblique
((he said we dont have to worry about these but just incase:
posterior: transverse fascia
superior: fibers of the transverse abdominal and internal oblique arch))
TWO openings:
Superficial (External) Ring- formed by an arch in the external oblique aponeurosis
Deep (internal) Ring- formed by transverse fascia
Clinical: indirect and direct inguinal hernias (see another slide)
describe inguinal hernias
indirect: bowel protrudes thru deep ring and descents thru canal– exits LATERALLY to inferior epigastric vessels
- -most common is congenital weakness
Direct: bowel protrudes thru defect in anterior (mc) Hesselbach’s triangle [lateral border of rectus abdominus, inguinal ligament, inferior epigastric artery and vein] *exits MEDIALLY to epigastric vessels
list content of peritoneum
serous membrane lining the abdominal cavity and visceral organs of the abdomen (as fetus developes the viscera ivaginate into peritoneum creating 2 layers) 1. parietal layer 2. viscerl layer 3. mesentary 4. greater omentum 5. lesser omentum 6. peritoneal cavity 7. retroperitoneal/intraperitoneal space
describe the parietal layer and visceral layer of peritoneu,
parietal- lines internal walls of abdominopelvic cavity
visceral - lines abdominal viscer
describe mesentary of peritoneum
mechanical anchoring and blood supply!
double layered fold of peritoneum from the organ invaginating on the peritoneum
“suspends” or connects the organ to the POSTERIOR wall of abdomin
contains BVs, lymph vessels, nerves
describe the greater and lesser omentum
greater : peritoneal folds that hangs down from the greater curvature of the abdomen and loops back up to attach to the transverse colon
Lesser: double layer of peritoneum that attaches to the stomach and proximal duodenum and then attaches to liver
describe the peritoneal ligament
double layer of peritoneum that attaches an organ to the abdominal wall or another organ:
- -> FALCIFORM LIGAMENT-attaches the liver to the anterior abdominal wall
- -> GASTROSPLENIC LIGAMENT- attaches the spleen to the stomach
describe the peritoneal cavity
thin potential space btwn visceral and parietal pericardium
*peritoneal cavity is NOT the same as the abdominal cavity– can fill with fluid or gas from pathology
describe the retroperitoneal vs intraperitoneal space
retro: organs are suspended and coverd anteriorly and posteriorly by the peritoneum
-they didnt invaginate into the peritoneum during development
Intra: organs are covered anteriorly by one layer of the peritoneum
-they did not invaginate into the peritoneum
list structures in the retro peritoneal space
"vertical GI" abdominal aorta IVC pancreas duodenum kidneys adrenal glands ureter ascending and descending colon rectum
list structures in the intraperitoneal space
liver gallbladder stomach spleen pancreas tail, duodenum, jejunum, ileum transverse colon sigmoid colon
list the structures of the abdominal viscera
- Divisions: foregut, midgut, hindgut
- esophagus
- stomach
- SI
- LI
- Spleen
- pancreas
- Liver
- Hepatic portal system
- gallbladder
describe the divisions of the abdominal viscera (embryo origin)
- foregut –> oropharynx to hepatopancreatic ampulla (in the duodenum)
- supplied by the celiac trunk - Midgut–>hepatopancreatic ampulla to distal (about 1/3 of transverse colon)
- supplied by superior mesenteric artery - Hindgut –> distal 1/3 of transverse colon to anus
- supplied by inferior mesenteric artery
describe the esophagus
muscular tube connects the pharynx to the stomach
descends in *superior and posterior mediastinum
passes thru diaphragm in esophageal hiatus**
Gastroesophageal junction - where esophagus meets stomach
Upper esophageal sphincter (UES) -junction of pharynx and esophagus
-made of the inferior pharyngeal constrictor and cricopharyngeus muscles
Lower esophageal sphincter (LES) - junction of esophagus and stomach, smooth muscle hard to ID
*GERD
list the muscles of the upper esophageal sphincter
inferior pharyngeal constrictor
cricopharyngeus
describe the stomach
cardia (transition)
fundus
body (parietal and chief cells)
pylorus (stomach peristalsis)
greater curvature
less curvature
muscles of stomach wall:
oblique (Deepest)
circular
longitudinal (outermost)
rugae (gastric folds)- large longitudinal in mucosal folds of stomach, flatten with food
Pyloric sphincter-circular and connects the stomach to duodenum/si
*gastric ulcers
describe the small intestine
20 feet
mesentary of small intestine is anchor and lets in vessels, lymph, nerves and allows dynamics
with 3 divisions:
1. duodenum: 25 cm/10 in
proximal part has mesenteric attachments + intraperitoneal
duodenum becomes retroperitoneal
hepatopancreatic ampulla(of vater)= major landmark! [common bile duct and main pancreatic duct of wirsung enter the SI by this ampulla–enters the descending portion of the duodenum ?with the main duodenal ampulla? in the duodenal papilla
^^ anthing proximal to this hepatopancreatic ampulla is supplied by celiac trunk, anything distal to it is supplied by superior mesenteric artery
–pancreas secretes digestive enzymes
–gall bladder secretes bile
ligament of Treitz- loops over esophageal hiatus in diaphragm, peritoneal fold at junction of duodenum and jejunum (suspensory muscle of duodenum)
- Jejunum:
Loops tend to be found in the LUQ, shorter then ileum: 2/5th of the SI - Ileum **SPELL CHECK DO NOT WRITE ILIUM!!
- loops tend to be found in the RLQ, terminates at the ileocecal valve (connection to the large intestine cecum)
- site of VIT B 12 absorption!!
clincial: chrons dz, meckels diverticulum, duodenal ulcer
describe the large intestine
1.5 Meters (4-5 feet)
external wall made of
A. Taenia coli - 3 ands of longitudinal muscle converging at appendix
B. haustra - sacculations of the LI formed by contractions of the taenia coli
divisions of large intestine proximal to distal:
- appenxic (RLQ)
- McBurneys point (btwn asis and umbilicus)
- Cecum (junction of ileum and LI, ileocecal valve separates)
- Ascending colon (retro)
- Transverse colon (intra)
- Descending colon (retro)
- Sigmoid colon (intraperitoneal)
- -diverticula- abnormal sacs/pouches
- -diverticulitis- inflam or rupture or diverticula
- ->function is to store feces!!!! - rectum
Clinical: colon polyps, ulcerative colitis
supplied by sup and inf mesenteric arteries
describe the spleen
Intraperitoneal
in the LUQ, protected by ribs 9-12
hard to palpate if normal
attached to the stomach (via gastosplenic ligament) and left* kidney ( via splenorenal ligament)
located near the tail of the panceras
if enlarged u can palpate it with pt on their right lateral decubitus
Function: filter RBC, remove old/abnormal ones
store platelets/RBC
Lymphatic/immune fxns: produces lymphocytes/ antibodies to protect against infection, produce IgM
supplied by celiac trunk- the splenic artery!
describe the pancreas
only one with referred pain that crosses the midline
4 divisions: head neck body tail
mainly retro except the tail is intra
they cross the midline of abdomen
head is close to duodenum
Ducts:
- main pancreatic duct (of wirsung) - joins the bile duct to form the hepatopancreatic ampulla and opens into the descending portion of the duodenum via the major duodenal papilla
- acessory duct (of santorini) - also enters the duodenum
Function:
Endocrine- islets of langerhands release endocrine hormones (glucagon, insulin, somatostatin, pancreatic polypeptide)
Exocrine- digestive enzyme splits carbs fats and proteins in the duodenum- balances the acidic ph of the duodenum
supplied by the celiac trunk–branches come off both the splenic and common hepatic arteries!
Describe the liver
intraperitoneal
anatomy: R lobe, L lobe separated by the FALCIFORM ligament(which attaches to the anterior abdominal wall)
Functional divisions: R lobe, Functional L lobe = (L lobe, caudate lobe, quadrate lobe) – divided by:
Cantlie’s Line which runs from gallbladder to IVC
-each division has its own blood supply, portal system, drainage system
RUQ and LUQ suspended by falciform ligament (peritoneal fold attaches to the anterior abdominal wall Lessor omentum (peritoneal folds attach to lesser curvature of the stomach) hepatic veins (Connect to ivc)
Surfaces:
- diaphragmatic surface - dome shape, anterior, superior, posterior
- visceral surface - primarily posterior and inferior (think SI, stomach, GB)
Function: filter circulating toxins, drugs, hormones, old blood cells active role in met of carbs protein fat endocrine functions role in activating vit d synthesis and secretion of bile
describe the hepatic portal system
“vein located btwn two capillary beds”- GI tract and Liver
-blood travels from heart to GI and exchanges o2 for nutrients then takes nutrients to the liver via PORTAL VEIN, then filters thru liver and leaves via HEPATIC vein and drains into IVC
Liver has direct artieral supply from heart–>Hepatic Artery
-30% of blood flow to liver, o2 rich direct supply
the remaining 70% is via oxygen poor blood from the portal vein
Porta hepatis- exit/entrance for portal vein, hepatic ducts, hepatic artery on the visceral surface of the liver
Portal hypertension:
-impaired blood flow thru the liver caused by pathologies and CIRRHOSIS: destruction of hepatocytes and replacement with fibrous tissue
blood flow reverses and flows into IVC via 3 anastomoses (esophagus, rectum, epigastric vein see other slide)
Ascites = accumulation of fluid within the peritoneal cavity from portal hypertension (increased resistance of venous system)
describe the 3 anastomoses in portal hypertension
- esophagus= forms esophageal varices –blood in vomit
- rectum =forms hemorrhoids
- epigastric veins in anterior abdominal wall forms “CAPUT MEDUSAE”
- -dilated superficial veins of abdomen
“gutt, butt, caputt”
describe the gall bladder
in the GB fossa of visceral surface of liver
close to the proximal duodenum
-Cystic duct leaves the GB carrying bile to and from the GB and merges with common hepatic duct to form common bile duct which merges with main pancreatic duct to form hepatopancreatic ampulla which opens into the descending duodenum via man duodenal papilla
–sphincter of the bile duct is at the distal end of bile duct
— if contracted, the bile backs up in the GB for storage
describe the blood supply to the viscera of the abdominal cavity (6)
OFF ABDOMINAL AORTA
- celiac trunk (foregut, stomach duodenum, spleen, liver, pancreas)
a. common hepatic artery
b. splenic artery
c. left gastric artery - Superior mesenteric Artery (midgut, duodenum, pancreas, 2/3 transverse colon)
- -via mesentery (which provides a route for artery, vein, nerves, lymphatics (lacteals drain ingested fats from SI)
- Inferior mesenteric artery (hindgut, last part of LI)
- R/L renal arteries - kidneys
- R/L gonadal arteries - supply testes or ovaries (passes thru inguinal canal with ductus deferens or round ligament)
- common iliac arteries (terminal branches of abdominal aorta) –BIFURICATE at L4!!
clinical abdominal aneurysm
Describe the thoracic diaphragm
musculotendinous structure that forms “ roof” of abdominal cavity
dome shape, separates thoracic and abdominal cavities
on expiration it can get as high as the 5th rib
3 openings:
- caval foramen- most anterior, IVC passes thru, located in the central tendon**
- esophageal hiatus- middle of the 3, esophagus passes thru
- aortic hiatus- posterior of the 3, aorta passes thru
Central tendon- contains the caval foramen
muscular portion=peripheral region:
- sternal part (2 small sections of muscle attach to xiphoid process)
- costal part (inferior six costal cartilages and ribs
- lumbar part (from lateral and medial arcuate ligaments and from upper lumbar vertebra to form right and left crura)
ligaments
- lateral arcuate ligament (arches over quadratus lumborum)
- medial arcuate ligament (arches over psoas)
- right crus (forms esophageal hiatus and contributes to aortic hiatus
- left crus ( contributes to aortic hiatus)
describe the posterior abdominal wall
muscles: psoas major iliacus quadratus lumbroum *role in back pain* transverse adominis
Posterior portion of the diaphragm
NERVES:
- subcostal nerve
- lumbar plexus nerves:
a. ilioinguinal nerve (all the way down to testes thru canal)
b. femoral nerve (over iliacus)
c. obturator nerve (comes thru obturator canal?)
describe the nerves to the thoracic diaphragm
- R/L phrenic nerves – supply motor to diaphragm and sensory to CENTRAL diaphragm
- Intercoastal nerves – supply sensory to peripheral diaphragm
- subcostal nerves– supply sensory to peripheral diaphragm
OINA psoas major
O: lumbar vertebra
I: lesser trochanter
N: lumbar plexus
A: flex hip, ER femur, flex vertebral column
OINA Iliacus
O: iliac fossa
I: lesser trochanter
N: femoral
A: flex hip, ER hip, Stabilize hip
OINA: quadratus lumborum
O: 12th rib
I: iliolumbar ligament
A: extend and lateral flex vertebral column, fixes 12th rib on inspiration
no N?
and nothing for transverse abdominis
describe the suprarenal glands
top of kidneys
surrounded by fatty tissues
separated from kidney via RENAL FASCIA
1. suprarenal cortex (cortisol aldosterone androgens)
2. suprarenal medulla (neural tissue similar to cells of sympathetic nervous system -catecholamines - epi / ne)
describe the kidneys general
retroperitoneal
4inX2in and 1 in thick
has contact with diaphragm and posterior wall muscles
RIGHT kidney is inferior compared to left
R: upper pole anterior to 12th rib, “posterior” to ascending colon and liover, 1 finger width above iliac crest
L: upper pole anterior to 11 and 12th ribs, located “posterior” to stomach, spleen, pancreas, jejunum, descending colon
descend with inspiration about 1 inch (Can palpate the r with deep breath)
layers surrounding kidney:
- renal capsule
- perirenal fat
- renal fascia
- pararenal fat (collagen fibers run thru this to anchor kidney)
Renal hilum- indent on medial side of kidney that is the entrance for renal pelvis renal artery and vein
Internal features of the kidneys
2 layers:
- cortex (1-2 million nephrons-filter units)
- medulla (5-10 renal pyramids (the apex is the renal papilla)
arteries: renal-segmenal-interlobar-arcuate-radiate-afferent-glomerular capillaries (in bowmans capsule)-efferent (blood secrete waste products into tubule for excretion here)-vasa recta (removes excess concentration of na, cl, etc)-venous return to the IVC
collecting duct pathway:
nephrons-collecting tubules (in medulla )-minor calyces 5-10-major calyces 2-3-renal pelvis (funnel shaped duct continuous with ureter) - ureter-bladder
Describe the ureters
smooth muscular tube 25-30 cm long -fill up the bladder
descend ANTERIOR along psoas and ANTERIOR to internal iliac arteries**
3 regions of constriction (kidney stone can lodge here)
1. URETEROPELVIC junction junction of renal pelvis and ureter
2. ureter passing over pelvic brim
3. ureter enters bladder
list the location of the abdominal cavity
btw thoracic diaphragm and pelvic inlet
-the lower ribs, muscular abdominal wall and pelvis protect viscera of abdomen