Esophagus - Liver Flashcards Preview

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Flashcards in Esophagus - Liver Deck (92):
1

What are the parts of the esophagus?

How long is each part?

What are their boundaries?

What is their course?

  • pars cervicalis:
    • 5 - 8 cm
    • cartilago cricoidea C6/7 - T4
    • btw vertebral column + trachea
  • pars thoracica:
    • ​16 cm
    • T4 - hiatus oesophagus T11
    • parallel to trachea until bifurcatio trachae, then behind left atrium 
  • pars abdominalis: 
    • 1 - 4 cm
    • hiatus oesophageus of diaphragm → ostium cardiacum of stomach
    • intraperitoneal

2

At what level are the esophageal constrictions?

They are caused by... ?

constrictio cricoidea

  • C6 - behind cricoid cartilage
  • caused by circ. fibers of esophageal sphincter m.

constrictio bronchoaorticea

  • T4 
  • caused by aorta laterally on left side

constrictio phrenica

  • T10 - hiatus oesophageus
  • caused by lig. phrenico-oesophageale
     

3

What is the angle of HIS?

 

The angle of HIS is an acute angle (< 80°) created between the cardia at the entrance to the stomach, and the esophagus by the collar sling fibres.

It forms a valve, preventing reflux of duodenal bile, enzymes and stomach acid from entering the esophagus, where they can cause inflammation.

BUT:

loss of tension → increased angle → reflux of HCl into esophagus

4

Which vessels supply/drain the esophagus?

Innervation?

 

 

supply:

  • cervical part: a. thyroidea
  • thoracic part: rr. of aorta + aa. intercostales
  • abdominal part: a. gastrica sin./a. phrenica inf. sin.

drainage:

  • cervical part: v. azygos/v. hemiazygos
  • thoracic part: v. thryoidea inf.
  • abdominal part: vv. oesophageales (anastomosis w/ v. gastrica sin.)

innervation:

  • n. vagus (X)

 

5

Where is the stomach located?

What shape does it have?

How much can it store?

  • crescent-shape
  • behind left dome of diaphragm, partially behind left costal angle, extends until L2/3
  • can store up to 1,500 ml

6

What attaches at the greater and lesser curvature of the stomach?

  • curvatura gastrica minor : omentum minus (to be precise: lig. hepatogastricum) 
  • curvatura gastrica major: omentum majus
    to be precise:
    • lig. gastrocolicum
    • lig. gastrophrenicum
    • lig. gastrosplenicum

7

Where do the walls of the stomach attach to?

  • paries anterior → abdominal wall
  • paries posterior → bursa omentalis + pancreas

8

Which structures in the stomach increase the surface?

  • large gastric folds (plicae gastricae) w/ areae gastricae 
  • gastric pits (foveolae gastricae) w/ gastric glands (visible on histological specimen)

 

additionally: in curvatura gastrica minor: gastric canal

 

9

Which muscles are responsible for vomiting?

diaphragm + abdominal mm.

10

What happens if there's a disproportion btw mucous and gastric acid in the stomach?

What is the most common reason for such a disproportion?

can lead to ulcer in the stomach/duodenum,

(in 80% of the cases caused by helicobacter pylori)

11

#1 - 5

Q image thumb

1) truncus coeliacus

2) a. hepatica communis

3) a. hepatica propria

4) - r. sinister

5) - r. dexter

 

12

#6 - 10

Q image thumb

6) v. portae hepatis

7) a. gastrica dextra

8) a. gastroduodenalis

9) a. mesenterica sup.

10) a. gastroomentalis dex.

13

#11 - 16

Q image thumb

11) a. gastroomentalis sin.

12) a. splenica

13) a. gastrica sin.

14) aa. gastricae breves

15) a. cystica

16) a. prancreaticoduodenalis sup.

14

A - E

Why is B) im important?

Q image thumb

A) esophagus

B) incisura cardiaca → angle of HIS, closes esophagus

C) cardia

D) fundus gastricus

E) corpus gastricum

15

F - J

Q image thumb

F) curvatura gastrica minor

G) curvatura gastrica major

H) incisura angularis

I) antrum pyloricum

J) canalis pyloris + ostium pylorum

16

K - L

Q image thumb

K) duodenum

L) ostium cardiacum

17

Differentiate btw the pathway of the vv. of the stomach in the greater and lesser curvature.

Clinical relevance?

vv. parallel to aa., BUT:

  • in greater curvature: indirectly into v. portae via v. mesenterica sup./v. splenica (cf. vessel flashcards for more information)

  • in lesser curvature: v. gastrica dextra + v. prepylorica form v. coronaria ventriculi
    directly into v. portae + connection to vv. oesophageales (portocaval anastomosis)

 ⇒ portal reflux, e.g. in case of liver cirrhosis or thrombosis in v. splenic, can cause esophageal varices

18

Which nerves innervate the stomach para- / sympathetically? 

Effects?

symp. plexus coeliacus

parasymp.: truncus vagalis ant./post. (branches of n. vagus)

  • dilated blood vessels → incr. circulation
  • increased secretion of gastric juice + HCl
  • incr. stomach movements

19

How heavy is the pancreas?

Where does its body start?

Where does it attach to?

What is its function?

  • 40 - 120g, usually 70g
  • corpus starts at L1/2
  • facies posterior → post. abdominal wall
    facies anterior → covered by peritoneum

= most important digestive gland: 1.5 - 2l secretion/d → stored as zymogens (inactive precursors)

20

#1 - 5

Q image thumb

1) truncus coeliacus

2) a. gastrica sin.

3) a. splenica

4) a. hepatica communis

5) a. hepatica propria

21

#6 - 10

Q image thumb

6) a. gastroduodenalis

7) a. pancreaticoduodenalis sup.

8) a. gastroomentalis dex.

9) a. pancreaticoduodenalis sup. post.

10) a. pancreaticoduodenalis sup. ant.

22

#11 - 15

Q image thumb

11) a. pancreaticoduodenalis inf. ant.

12) a. pancreaticoduodenalis inf. post.

13) a. pancreaticoduodenalis inf.

14) a. mesenterica sup.

15) - r. duodenojejunalis

 

23

#16 - 18

Q image thumb

16) a. pancreatica dorsalis

17) a. pancreatica inf.

18) rr. pancreatici

24

Common features of the 3 parts of the small intestine?

drainage:

  • v. mesenterica sup. → v. portae

innervation:

  • symph: 3 nn. splanchnici T5-12 via plexus coeliacus/mesentericus sup.
  • parasymp: n. vagus (X)

25

What is the function of the small intestine?

  • digestion via enzymes + resorption via bile acids
  • endocrine cells regulate secretion ofpancreatic/gall bladder

26

How long is the duodenum?

List its parts and give their peritoneal relation.

duodenum = 12 finger → 25 - 30 cm

  • pars superior: intraperitoneal
  • pars descendens: retroperitoneal
  • pars horizontalis: retroperitoneal
  • pars ascendens: retroperitoneal

27

#1 - 5

Q image thumb

1) a. gastrica sin.

2) a. splenica

3) a. hepatica communis

4) a. hepatica propria

5) a. gastroomentalis dex.

28

#6 - 10

Q image thumb

6) a. pancreaticoduodenalis sup. ant.

7) a. pancreaticoduodenalis inf.

8) a. + v. mesenterica sup.

9) a. gastroduodenalis

10) pars superior duodeni

29

#11 - 15

Q image thumb

11) pars descendens duodeni

12) pars horizontalis duodeni

13) pars ascendens duodeni

14) flexura duodeni superior

15) flexura duodeni inferior

30

#16 - 20

 

#17 is part of.. ?

 

 

Q image thumb

16) flexura duodenojejunalis

17) lig. hepatoduodenale (1 of 3 parts of omentum min.)

18) Treitz-muscle 

19) v. portae hepatis

20) a. hepatica propria

 

31

#21 - 26

 

Give 2 names for #21, 22, 23, 24/26

 

Q image thumb

21) ductus choledochus (= common bile duct)

22) papilla dudodeni minor (=SANTORINI's)

23) papilla duodeni major (=VATERI's)

24+26) ductus pancreaticus (=WIRSUNG's)

25) ductus pancreaticus accessorius

32

#27 - 28

Q image thumb

27) ductus cysticus

28) gall bladder

33

What can happen in case of an inflammation of the superior part of the duodenum?

adherence to gall ballder → rupture → bilestones/pus into duodenum → can cause a duodenal obstruction

34

Where does the Treitz-muscle attach?

Why is it clinically relevant?

Give other names, too.

= m. suspensorius duodeni, sometimes also called suspensory lig. of the duodenum (but actually additional coll. fibers that are clearly differentiable from Treitz-muscle itself)

  • from pars ascendens → aortic origin of a. mesenterica sup.
  • defines clinically border btw upper/lower gastrointestinal bleeding

35

Which aa. supply the duodenum?

a. pancreaticoduodenalis sup./inf. ant./post.

→ anastomosis btw truncus coeliacus & a. mesenterica sup.

36

Where do the jejunum and ileum start and end?

Peritoneal relation?

  • lie in pars infracolica
  • flexura duodenojejunalis (L2) → valva ileocaecalis (Bauhin-valve): first 2/5 jejunum, last 3/5 ileum
  • intraperitoneal

37

What is a Meckel's diverticulum?

Why can it be clinically relevant?

= remnant of vitelline duct in 3% of population, approx. 50 - 120 cm above Bauhin-valve

 ⇒ if inflammed often mistaken with appendicitis

38

How do you call a mirrored arrangement of the abdominal viscera?

situs inversus

39

Which aa. supply jejunum + ileum?

What do they form?

a. mesenterica superior

  • 4-5 aa. jejunales 
  • 12 aa. ileales

 ⇒ form arterial arcades

40

What are the parts of the large intestine?

Peritoneal relations?

What is its overall lengh?

  • 1.5 m

intraperitoneal: (~ all horizontal parts)

  • cecum + appendix 
  • colon transversum
  • colon sigmoideum

sec. retroperitoneal: (~ all vertical parts)

  • colon ascendens
  • colon descendens
  • rectum

subperitoneal

  • canalis analis

41

What is the function of the large intestine?

  • reabsorption (~ 1.5l/d) of H20 from chymus
  • indeg. contents broken down by bacteria

 

42

 In what way is the colon different from the previous segments of the gastrointestinal tract?

  • taeniae
  • haustrae/plicea semilunares (produced by muscular contractions)
  • appendices epiploicae (fatty appendages)

43

What are the different taeniae of the colon?

  • taenia libera = visible
  • taenia omentalis = inserts in omentum majus
  • taenia mesocolica = inserts in mesocolon

44

Where is the cecum located?

How big is it?

Where does it start and end?

  • 6 - 8 cm in fossa iliaca dextra
  • Bauhin-valve → appendix vermiformis

45

Explain the variations of cecum's peritoneal relation.

  • caecum mobile: completely covered by peritoneum (→ intraperitoneal) 
  • caecum liberum: own mesocaecum (→ intraperitoneal)
  • caecum fixum: fixed to post. abdominal wall (→ sec. retroperitoneal)

 ⇒ most commonly intraperitoneal

46

What is the function of the appendix?

How big is it (also diameter)?

Where is it located (most common variations)? 

What is its peritoneal relation?

  • part of immune system (abundant lymph follicles)
  • 8 - 10 cm long, 6 mm diameter
  • 65% retrocecal
    31% subcecal
  • intraperitoneal, sometimes own mesoappendix

47

#1 - 4

 

Where is #3 and #4. Why are they clinically important?

Q image thumb

1) colon ascendens

2) cecum

3) McBurney point:
 → opening to appendix, right 1/3 on line btw navel and r. S.I.A.S. ⇒ physical examination of appendicitis

4) Lanz point:

 → projection of tip of appendix if subcecal variation, right 1/3 on line btw 2 S.I.A.S. 

48

#1 - 5

Q image thumb

1) a. ileocolica

2) - r. colicus

3) - r. ilealis

4) a. caecalis ant.

5) a. ceacalis post.

49

#6 - 10

 

Another name for #10.

Q image thumb

6) a. appendicularis

7) colon ascendens

8) cecum

9) ostium appendicis vermiformis

10) valva ileocaecalis (=Bauhin-valve)

50

#11 - 15

Q image thumb

11) papilla ilealis

12) labium ileocolicum

13) labium ileocaecale

14) frenulum ostii ilealis

15) appendix vermiformis

51

What are the parts of the colon?

What are their peritoneal relations?

Where do they start and end?

 

  1. colon ascendens
    cecum → flexura colica dextra 
    - sec. retroperitoneal
  2. colon transversum
    → flexura colica sinistra
    - intraperitoneal
  3. colon descendens
    → fossa iliaca sin.
    - sec. retroperitoneal
  4. colon sigmoideum
     rectum (at L2/3)
    intraperitoneal

52

Which structures attach at the different parts of the colon?

colon transversum

  • mesocolon transversum
  • lig. hepatocolicum (ext. of lig. hepatoduodenum)
  • lig. gastrocolicum
  • lig. phrenicocolicum (flexura colica sinistra)

colon sigmoideum

  • mesocolon sigmoideum which continues as recessus intersigmoideus

53

Which structure forms the splenic nest?

 

lig. phrenicocolicum

flexura coli sinistra → post. abdominal wall

54

Which aa. supply the different parts of the colon?

a. mesenterica inf.

colon ascendens + transversum

  • a. colica dex. (anastomosis w/ r. colicus from a. ileocolica, w/ a. colica med.)
  • a. colica med. (anastomosis w/ a. ascendens from a. colica sin. = greater Riolan's anastomosis)

colon descendens + sigmoideum

  • a. colica sin.
  • a. sigmoidea (anastomosis w/ a. rectalis sup. = Sudeck's anastomosis)
  • a. rectalis sup. (s.a.)

55

Which nerves innervate the colon?

Any special features?

symp: plexus mesentericus sup./inf.

parasymp: 

  • n. vagus (X) → Cannon-Böhm point (end of vagus innervation)
  • after Cannon-Böhm point: nn. from sacral spinal cord S2-4/5

56

From where to where does the rectum extend to?

How long is it?

What can you say about its shape?

​from colon sigmoideum (S2/3) → canalis analis
∽ 12cm

flexures:

  • 1st flexure: flexura sacralis (dorsal)
  • 2nd flexure: flexura perinealis (ventral)
  • + lateral flexures

 

57

Which special structures can you find in flexura perinealis?

plicae transversae recti (2 left, 1 right)

→ the right one is the biggest, ∽6-7 cm above anus = Kohlrausch-fold: defines opening to ampulla recti

58

#1 - 5

 

What is special abt #3?

Are the mm. shown here striated (= voluntary contraction) or smooth (= involuntary contraction)?

Q image thumb

1) ampulla recti

2) m. levator ani = striated

3) m. puborectalis = striated (= part of m. levator ani) 

4) m. corrugator ani = smooth

5) m. sphincter ani inf. = smooth

59

#6 - 10

 

What are the parts of #6?

Is it striated (= voluntary contraction) or smooth (= involuntary contraction) muscle?

What is #7 responsible for?

 

Q image thumb

6) m. sphincter ani externus = striated

→ pars profunda, pars superficialis, pars subcutanea

7) corpus cavernosum recti → produces columnae anales

8) plexus venosus rectalis ext.

9) zona cutanea 

10) linea anocutanea

60

#11 - 15

 

Another name for #11. In what way is it different from the overlying structure?

What is special abt #14?

Give 3 names for #15.

Q image thumb

11) pecten analis (= zona alba), here: change of simp. colum. to str. squ. non-ker. ep.

12) valvae anales

13) junctio anorectalis

14) sinus anales (origin of gll. anales)

15) columnae anales (columns of Morgagni, zona columnalis)

61

#16 - 18

 

Another name for #17 and #18.

Why is #18 clinically important?

Q image thumb

16) prostate gland

17) linea pectinata (= linea dentata)

18) gll. anales (= proctodeal glands, site for anal fistulas)

62

What is special abt the blood supply/drainage around the canalis analis?

 

blood supply differs in 2 areas (zona columnaris, zona alba & cutanea), demarcated by linea dentata

  • blood supply ABOVE linea dentata:
    a. mesenterica sup. → a. rectalis sup. → v. rectalis sup. → portal venous system
  • blood supply BELOW linea dentata:
    a. iliaca int. → a. rectalis inf./med. → v. rectalis inf./med. → systemic circulation

​ ⇒ anastomosis btw portal & caval system

63

Analogous to the pathway of blood vessels in the rectum there is also a seperation of lymph vessels.

Explain.

Why is it clinically relevant?

lymph flow differs in 2 areas (zona columnaris, zona alba & cutanea), demarcated by linea dentata

  • lymph flow ABOVE linea dentata:
    → lnn. rectalis sup. → lnn. mesenterici inf., iliaci int. (in lumbar area)
  • lymph flow BELOW linea dentata:
    lnn. inguinales sup. (in pelvic area) 

 ⇒ metastasis of rectal carcinomas in various directions

 → sup. carcinomas: painless (arise from col. ep.)
 → inf. carcinomas: painful (arise from strat. squ. ep.)

64

What is a reason for hemorrhoids?

portal hypertension (e.g. in case of liver cirrhosis) → enlargement of rectal portocaval anastomosis in corpus cavernosum of anus (= v. rectalis sup. + med./inf.)

65

Why is rectal administration of drugs (= suppositories) so effective?

drugs get in rectal portocaval anastomosis via v. rectalis med./inf. (→ v. iliaca int. → v. cava inf.) into systemic circulation

66

Which structures are part of the organ of continence?

What is the "normal" situation?

organ of continence:

  • rectum
  • anal sphincter mm.
  • corpus cavernosum recti

 ⇒ sustained tonic contraction of sphincter mm.

 ⇒ sling formed by m. puborectalis closes anus

 ⇒ supported by corpus cavernosum recti

67

What happens in the process of defecation?

  1. content of colon → increases wall tension of ampulla recti
  2. reflexive relaxation of m. sphincter ani int. + contraction of rectum/colon sigmoideum 
  3. voluntary relaxation of m. sphincter ani ext. (n. pudendus)

68

Where is the liver located?

What is its peritoneal relation?

How heavy is it?

How do you call its main surfaces?

  • located under right costal dome
  • intraperitoneal, except:
    • area nuda (attaches to diaphragm)
    • porta hepatis
    • fossa vesicae biliaris
    • sulcus v. cavae
  • 1,200 - 1,800g 
  • facies visceralis (= back), facies diaphragmatica (= top)

69

What attaches to the liver and where?

  • lig. hepatoduodenale (part of omentum minus)
    on tuber omentale → duodenum
  • lig. hepatogastricum 
    in sulcus lig. venosi → curvatura gastrica minor
  • lig. falciforme 
    front → parietal peritoneum

70

What are the functions of the liver?

  • metabolism: produces proteins for blood clotting, cholesterol, storage of glycogen
  • detoxication
  • exocrine gland: produces bile
  • storage of lipid soluble vitamins (esp. vit A)
  • immune defense: produces Kupffer-cells, plasmaproteins
  • during fetal period: hematopoiesis

71

Which structures divide the liver into functional liver parts (= partes hepatis dextra/sinistra)?

Which segments belong to each part?

Why is it segmented?

A - I.

Q image thumb

sagittal plane through gall bladder + v. cava inf. 

  • segments I-IV: left lobe
  • segments V-VIII: right lobe

​segmented accordingly to pathways of Glisson's triad (v. portae, a. hepatica, bile ducts + vv. hepaticae)

⇒ important for liver resection to ensure as little blood loss as possible

A = VII
B = V
C = III
D = IVa
E = VI
F = VIII
G = IVb
H = II
I = I = lobus caudatus

 

72

#1 - 5

Q image thumb

1) vesica biliaris

2) lobus quadratus

3) lig. teres hepatis

4) incisura lig. teretis

5) fissura lig. teretis

 

73

#6 - 10

 

What attaches to #6?

Q image thumb

6) margo inf.

7) porta hepatis

8) lobus hepatis sin.

9) impressio gastrica

10) tuber omentale → omentum minus

74

#11 - 15

Q image thumb

11) impressio oesophagea

12) appendix fibrosa hepatis

13) lobus caudatus

14) v. cava inferior

15) lig. venae cavae

75

#16 - 20

Q image thumb

16) area nuda

17) impressio suprarenalis

18) lig. coronarium

19) v. porta hepatis

20) impressio renalis

76

#21 - 25

Q image thumb

21) impressio duodenalis

22) a. cystica

23) impressio colica

24) lobus hepatis dex.

25) lig. venosum

77

#26 - 30

Q image thumb

26) fissura lig. venosi

27) fissura venae cavae

28) ductus choledochus

29) proc. caudatus

30) proc. papillaris

78

What are the 3 hepatic veins?

Variations?

  • v. hepatica dex.
  • v. hepatica sin. 
  • v. hepatica intermed.

BUT: in 2/3 v. hepatica sin. + intermed. form truncus hepaticus sin.

79

What are possible causes for portal hypertension?

Explain the process.

 

  1. a) alcoholism → can cause liver cirrhosis
    b) hepatitis B/C
  2. scar tissue in liver
  3. increased resistance to blood flow due to compression of vessels
  4. portal hypertension

 

80

What are possible effects of portal hypertension?

  • splenomegaly: 30-50% of all patients
  • Cruveillhier-Baumgarten murmur: loud venous murmur audible over upper abdomen
  • dilation of portocaval anastomoses
    • ​caput medusae syndrome: dilated vv. paraumbilicales + reopening of v. umbilicalis
    • esophageal varices: most common cause of death (bleeding)
    • in rectum
    • in stomach
    • in retroperitoneum
    • in spleen
    • in kidneys

81

Explain the blood flow in the liver.

  1. a) a. hepatica propria (= vas privatum) 
    b) v. portae hepatis (= vas publicum
  2. a) interlobular a.
    b) interlobular v.
  3. hepatic sinusoids
  4. hepatocytes
  5. central v.
  6. collecting v.
  7. vv. hepaticae

82

Where is the gall bladder located?

Describe its structure (incl. duct).

 

in fossa vesicae biliaris on liver → 1/2 covered by peritoneum

structure:

  • fundus
  • corpus
  • collum
  • ductus cysticus with plica spiralis (= Heister's), closes duct

 

83

How much bile can be stored in the gall bladder?

How does it get filled?

  • usually 40 - 70 ml, when dilated up to 200 ml
  • gets filled by reflux of bile when papilla is closed

84

Explain the intrahepatic bile flow.

synthesized by hepatocytes

  1. bile canaliculi btw hepatocytes
  2. canals of Hering
  3. interlobular bile ducts
  4. unite
  5. ductus hepaticus dex./sin.

85

Explain the extrahepatic bile flow.

  1. ductus hepaticus communis (4 - 6cm)
    ductus cysticus 
  2. ductus choledochus (6 - 8 cm long, 0.4 - 0.9 cm diameter)
  3. papilla duodeni major 

86

What are the parts of ductus choledochus?

  • pars supraduodenalis (in lig. hepaticoduodenale)
  • pars retroduodenalis
  • pars pancreatica (in head of pancreas)
  • pars intraduodenalis (to duodenum desc.)

87

Explain the most frequent variation of the structure of papilla duodeni major.

in 60% ampulla hepatopancreatica 2 sphincter mm.

  • m. sphincter ductus pancreatici
  • 2nd sphincter has 2 names
    • upper part = m. sphincter ductus choledochi
    • lower part = m. sphincter ampullae (= Oddi's)

 

88

Explain blood supply/drainage + innervation of the gall bladder.

  • blood supply:​ a. cystica (supplied by r. dex. of a. hepatica propria)
  • blood drainage: v. cystica → v. portae
  • innervation: 
    • symph./parasymph.: plexus hepaticus
    • sensory: n. phrenicus dex.

 

89

Which structures form trigonum cholecystohepaticum?

Give another name.

Explain its clinical relevance.

 = Calot's triangle: in 75% origin of a. cystica

  • ductus cysticus
  • ductus hepaticus communis
  • liver

 ⇒ a. cystica/ductus cysticus must be sealed before gall bladder can be removed

A image thumb
90

What are possible causes for obstructive jaundice?

chronic pancreatitis/pancreas carcinomas can cause reflux of bile (= cholestase) into ductus choledochus → deposit of bile pigments in skin → yellow

BUT: enlargement of ductus choledochus (> 1 cm) can also be caused by bile stones or inflammation

91

What could be a symptom of an inflammed gall bladder and why?

radiating pain in the right shoulder due to same sensory innervation (n. phrenicus)

92

What is a possible reason for an acute pancreatitis?

reflux of bile into pancreas due to bile stone stuck in ampulla

(lower risk if ductus choledochus + Wirsung's duct seperated → no common ampulla)