Anatomy 4.2 GIT Gross_Elevazo
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Transcript of Anatomy 4.2 GIT Gross_Elevazo
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Anatomy 4.2 Nov.9, 2011
Upper and Lower GIT-Gross Dr. Elevazo
Group 4 | Baes, Ballero, Baluyot, Baas, Bandoma, Baranda, Borzaga, Bautista, C., Baustista, B. Page 1 of 17
OUTLINE
1. UPPER GASTROINTESTINAL TRACT I. Oral cavity
A. Lips B.Vestibule C. Mouth Proper D. Temporomandibular Joint (TMJ) E. Palate F. Palate G. Tongue H. Salivary Glands
II. Pharynx III. Esophagus IV. Gastroesophageal joint V. Stomach
2. LOWER GASTROINTESTINAL TRACT I. Small Intestine
A. Duodenum B. Jejenum C. Ileum
II. Large Intestine A. Cecum B. Appendix C. Acending Colon D. Transverse Colon E. Descending Colon F. Sigmoid Colon G. Rectum H. Anal Canal III. Blood Supply IV. Venous Drainage V. Lymphatic Drainage
UPPER GASTROINTESTINAL TRACT
I. ORAL CAVITY
Beginning or commencement of GIT The GIT communicates to the outside through the oral cavity
From the oral fissures to the oropharyngeal isthmus (entrance to
the pharynx; formed on each side by the palatoglossal fold)
Consists of the lips, teeth, tongue, glands and muscles of mastication
A.LIPS
2 fleshy folds that surround the oral orifice
Covered on the outside by skin and lined on the inside by mucous membrane
Substance is made up by the orbicularis oris ms & muscles that radiate from the lips into the face, and contains labial blood vessels and nerves, CT and salivary glands o philtrum Shallow vertical grove seen in the midline on the
outer surface of upper lip o labial frenula Median folds of mucous membrane that
connect inner surface of the lips to the gums; cause problems in the fitting of artificial dentures
Food is chewed by the teeth and saliva from salivary glands facilitates the formation of bolus o Deglutition (swallowing) is voluntarily initiated
Figure 1. Oral cavity, hard palate, etc
Divided into two by teeth and maxilla
B.VESTIBULE
A slit-like space that communicates with the exterior thru the oral fissure when mouth is open and communicates with mouth proper behind 3
rd molar on each side when jaws are closed
o Lies between lips and cheeks (externally) o Lies between gums and teeth (internally)
Limited above and below by the reflection of the mucous membrane from the lips and cheeks to the gums
Lateral wall: cheek made up by the buccinator muscle and is lined with mucous membrane o Duct of the parotid salivary gland opens on a small papilla into
the vestibule opposite the upper 2nd molar tooth
C.MOUTH PROPER
When mouth is open you see the following: o Teeth o Palate o Tongue
Space posterior and medial to the upper and lower dental arches in front of the oropharyngeal isthmus
Borders: o Roof: hard palate (anterior) & soft palate (behind) o Floor: anterior 2/3 of the tongue and the reflection of the
mucous membrane from the sides of the tongue to the gum of the mandible (snell)
o Posterior/side: sublingual caruncle o Apex: opening of whartons duct o Posterior/lateral: sublingual fold o Laterally and anteriorly bounded by the maxillary and
mandibular alveolar arches housing the teeth Ducts of the submandibular and sublingual glands open onto
the floor of the mouth on either side of the frenulum
Muscles on the floor of the mouth
Table1. Muscles on the floor of the mouth
MUSCLE NERVE SUPPLY
Infrahyoids depresses the mandible
Geniohyoid C1 and C2 (ansa cervicalis)
mylohyoid, (R) & (L) Inferior Alveolar nerve (branch of mandibular division of trigeminal n.)
digastric, anterior belly mylohyoid branch of mandibular division of trigeminal n.
digastric, posterior belly facial nerve
Suprahyoid elevates the mandible
Stylohyoid facial nerve
Note: Action of muscle is always towards the origin of the muscle
Figure2. TMJ and its parts
The vestibule and oral cavity proper are separated by teeth and alveolar processes of mandible and maxilla
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Group 4 |Baes, Ballero, Baluyot, Banas, Bandoma, Baranda, Borzaga, Bautista, C., Baustista, B. Page 2 of 17
D. TEMPOROMANDIBULAR JOINT (TMJ)
Lower oral cavity
Modified hinge type of synovial joint
Divided into upper and lower cavities by the articular disc o Composed of/articulation of the articular tubercle &
mandibular fossa of the temporal bone and the head or condyloid process of the mandible
o Upper joint is for gliding movements (retraction and protraction)
o Lower joint is for hinge movement (elevation, and depression) Mandible
- U-shaped with flat ramus (R & L) - Transmits vessels (arteries, veins and nerves) - Not fused in children 2 y/o - Mandibular foramen (inner) found in medial aspect which
contains inferior alveolar vessels and nerve to exit the mental foramen as mental vessels and nerves (anterior/outer)
o Covered with fibrocartilage o Nerve supply: auricular temporal and masseteric branches of
mandibular nerve o Movements that occur at the tmj: Retraction and protrusion (gliding joint):superior
compartment Elevation and depression (hinge joint): inferior compartment
LIGAMENTS OF THE TEMPOROMANDIBULAR JOINT o Lateral temporomandibular ligament Thickening of fibrous capsule Prevents TMJ from extending posteriorly
(normal: expect an anterior movement) o Sphenomandibular ligament Medial side of TMJ; primary passive support of tonus Provides primary support to TMJ Prevent jaws from falling down
o Stylomandibular ligament Behind and medial to TMJ; does not strengthen joint Thickening of fibrous capsule of parotid gland
Lateral temporomandibular ligament is intrinsic ligament, while the latter two, sphenomandibular and stylomandibular, are extrinsic ligaments
Muscles of Mastication o All are innervated by mandibular branch of CNV and all crosses
the TMJ Temporalis Elevates (anterior fibers) & retracts (posterior
fibers) mandible Masseter Elevates mandible Medial pterygoid Elevates mandible Lateral pterygoid Depresses and protracts mandible
o Buccinator muscle is an accessory muscle of mastication o Muscles that protract the mandible: Pterygoids (internal and external) Masseter Temporalis (anterior fibers)
o Muscles that retract the mandible: Temporalis (posterior fibers)
CLINICAL CORRELATON Excessive contraction of lateral pterygoid muscles can
dislocate the jaw anteriorly (most of the time, because head is in front of anterior tubercle) due to the intrinsic ligament and glenoid tubercle
In surgical correction, facial nerve and auriculotemproal branch of mandibular nerve are prone to damage
E.PALATE
Forms roof of the mouth; floor of nasal cavity
Separates oral cavity from nasal cavity and nasopharynx
Divided into two: o Hard Palate o Soft Palate
HARD PALATE o Anterior palate; continuous behind with the soft palate Formed by palatine process of maxillae and horizontal plates of palatine bones; bounded by alveolar arches
o Covered with mucous membrane o Space filled with the tongue when it is at rest o Foramina: Areas where dentist injects anesthesia o Incisive fossa: Slight depression post. To the central incisor
teeth o Incisive canals and foramina that open into the fossa contain
nasopalatine nerves o 2 openings found in the postero-lateral end: Greater palatine foramen (pl, foramina)
- Medial to the 3rd molar tooth; pierces the lateral border of the bony palate from which greater palatine vessels and nerve emerge
Lesser palatine foramen (pl, foramina) - Transmit lesser palatine nerves and vessels - Posterior to the greater palatine foramen, pierces the
pyramidal process of the palatine bone o Undersurface is covered by: mucoperiosteum, and possess
median ridge Has palatine raphe and transverse palatine folds
o Mucous membrane covered by stratified squamous epithelium (at posterior, possess many mucous glands)
Figure3. Palate and its parts
SOFT PALATE o A mobile fold attached at posterior of hard palate o Closes the nasopharynx o Covered on its upper and lower surfaces by mucous membrane o Contains aponeurosis, muscle fibers, lymphoid tissue, glands,
vessels and nerves o Laterally continuous with the wall of the pharynx Joined to the tongue by the palatoglossal arch and to the
pharynx by the palatopharyngeal arch Palatine tonsils masses of lymphoid tissue, one on each
side of the oropharynx; each lies in a tonsillar sinus (fossa), bounded by the palatoglossal and palatopharyngeal arches and the tongue
Uvula conical projection at its free posterior border in the midline
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Group 4 |Baes, Ballero, Baluyot, Banas, Bandoma, Baranda, Borzaga, Bautista, C., Baustista, B. Page 3 of 17
Table 2. Muscles of Soft Palate Muscle Main Action Innervation
Tensor veli palatini Tenses soft palate and opens the pharyngotympanic tube during swallowing and yawning
Medial pterygoid nerve (a branch of mandibular nerve CN V3)
Levator veli palatini Elevates soft palate during swallowing and yawning
Pharyngeal branch of vagus nerve (CN X) via
pharyngeal plexus
Palatoglossus Elevates posterior part of tongue and draws soft palate onto tongue
Palatopharyngeus Tenses soft palate and pulls walls of pharynx during swallowing
Musculus uvulae Shortens uvula and pulls it superiorly
F. TEETH
Functions: o incise, reduce, mix with saliva, and grind during mastication o support and protect the oral cavity articulation(speech)
There are two sets of teeth o Deciduous teeth (temporary) / milk teeth o Permanent teeth
DECIDOUS TEETH OR MILK TEETH o Begin to erupt about 6 months after birth o Completely erupted by the end of second year Central incisors (6-8 mos) Lateral incisors (8-10 mos) First molars (1 yr) Canines (18 mos) Second molars (2 yrs)
o There are 20 in number (5 on each side of the jaw) 4 incisors 2 canines 4 molars in each jaw
Teeth on the lower jaw usually appear before those on upper jaw Lower central incisor first to erupt (temporary set) around 6 months PERMANENT TEETH
o Begin to erupt at 6th year o LAST tooth to erupt is the 3rd molar (17-30th yr) o There are 32 in number First molars (upper-6 yr) Central incisor (7 yr) Lateral incisor (8 yr) First premolars (9 yr) Second premolars (12 yr) Third molars wisdom teeth (17-30 yr)
o Completed by age of 12yo Teeth on the lower jaw usually appear before those on upper jaw Lower first molar first to erupt (permanent set) It is connected to the bone via special type of fibrous joint called
GOMPHOSIS or Dento-alveolar syndesmosis
PARTS OF A TOOTH
o Crown part that protects beyond the gums (it is above the gum/gingival)
o Neck constricted portion between crown and root o Root embedded in maxilla and mandible (alveolar
periosteum); attached to alveolar process of mandible or maxilla
o Root canal transmits nerves and vessels to and from the pulp cavity through the apical foramen
o Apical foramen transmits blood vessels, lymph and nerves. It is the opening at each root
o Pulp cavity internal tooth portion Odontoblast, a single layer of cells, surround the dentin layer Surrounded by dentin (the most sensitive part of the teeth) Contains blood vessels, lymph and nerves Protected by enamel at area of crown Protected by cementum at area of root
o Alveolar periosteum - anchors the teeth
Figure 4. Parts of the teeth
Note: - The only sensation transmitted in the teeth is pain - Incisors have sharp a sharp edge for biting; Molars and Premolars are
for grinding; Canines have rounded edge for tearing and for cosmetic purposes (they maintain the shape of the face of an individual)
- Tongue (medially) and cheeks (laterally) help keep the food in between teeth
G. TONGUE
Mobile mass of voluntary striated muscles covered with mucous membrane
Anterior two thirds lies at mouth
Posterior lies at pharynx
Muscles; attach it to styloid process and soft palate above, and to mandible and hyoid bone below
Also used in phonation
Arises from floor of mouth PARTS OF THE TONGUE
Roof inferior, relatively fixed part attached to the hyoid and mandible and in proximity to the geniohyoid and mylohyoid muscles; it is the pharyngeal portion of the tongue
Body remaining part: anterior 2/3
Apex pointed anterior part of the body
Dorsum posterosuperior surface of the tongue, which includes a v-shaped groove(terminal sulcus), the apex of which points posterior to the foramen cecum
Upper surface of the tongue o Fibrous septum divides tongue in left and right halves o Sulcus terminalis divides mucous membrane of the upper
surface of tongue into posterior thirds (pharyngeal part) and anterior 2/3 (oral part); apex directed posteriorly
o Foramen Cecum a small pit that marks the apex of the sulcus projecting backward; remnant of thyroglossal duct (where fetal thyroid starts to develop)
Anterior 2/3 of the tongue (upper surface) o Papillae increase the area of contact between the surface of
the tongue and the contents of the oral cavity; for proper handling of food
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o Filiform papillae with tapered ends, most abundant, forms small conical projections and are whitish in color due to thickness of cornified epithelium (keratinized, no taste buds)
o Fungiform papillae less numerous, scattered on sides and apex of tongue, mushroom-shaped, reddish tinge due to vascular connective tissue core; contain taste buds
o Circumvallate or vallate papillae 8-12 in number, situated in a row in front sulcus terminalis; surrounded by circular furrow, where taste buds lie; surrounded by deep moat-like trenches, into which the ducts of serous lingual glands of von Ebner open; epithelium rich in tastebuds
o Foliate papillae found at the posterior end of the margin of the anterior 2/3 of tongue, underdeveloped in humans; well-developed in rodents
Figure5. Taste buds
Posterior third of the tongue o Devoid of papillae BUT contains lingual tonsil (small nodules of
lymphoid tissue) which makes the mucosa covering the pharyngeal surface of the tongue irregular in contour
o Vallecula depression of tongue where foreign bodies such as fish bones may lodge
Inferior portion of the tongue (when tongue is up and back) o Lingual Frenulum a fold of mucous membrane that connects
undersurface of tongue to floor of mouth o Plica fimbriata fringe fold formed by mucous membrane,
lateral to deep lingual vein. o Deep lingual veins found in between the fimbriated fold and
frenulum, seen thru mucous membrane; responsible for rapid absorption of drugs taken sublingually e.g nitroglycerine for MI.
o Sublingual caruncle papilla on each side of the lingual frenulum marking the opening of the submandibular gland or Whartons duct
o Sublingual fold (or plica sublingularis) low fold mucous membrane beneath the tongue which marks the site of the sublingual gland
Figure 6. Floor of Mouth and Vestibule
CLINICAL CORRELATON
If there is lesion in the peripheral nerve, when you stick out your
tongue you expect it to go to the direction of the lesion
Table3. Muscles of the Tongue MUSCLE ACTION NERVE SUPPLY
Extrinsic
Genioglossus fan-shaped
acting bilaterally: depress central part of tongue, acting unilaterally:
deviate tongue toward contralateral side
Hypoglossal nerve
Hyoglossus thin, quadrilateral muscle
depresses tongue, pulling its sides inferiorly, aids in retrusion
(retraction)
Styloglossus small short muscle
retrudes the tongue and curls its sides, acting with genioglossus
creates a trough during swallowing
Palatoglossus primarily pharyngeal
elevates tongue, pulls down soft palate
Pharyngeal plexus
Intrinsic muscles not attached to bone
Superior longitudinal muscle thin layer
deep to mucous membrane on dorsum
of tongue
curls apex of tongue, makes dorsum of tongue concave longitudinally
Hypoglossal nerve
Inferior longitudinal muscle narrow bands
close to inferior surface
curls apex of tongue inferiorly, makes dorsum of tongue convex
superior and inferior makes tongue short and thick in retracting
the protruded tongue
Transverse muscle lie deep to superior longitudinal muscle
narrows and increase the height of tongue
Vertical muscle runs inferolaterally from dorsum of tongue
flattens and broadens the tongue
transverse and vertical makes tongue long and narrow
Figure 7. Muscles of the Tongue
Note: - ALL muscles of tongue are supplied by hypoglossal nerve EXCEPT the
palatoglossus ms, which is supplied by the pharyngeal plexus - The pharyngeal plexus is from vagus n., glossopharyngeal n., and
sympathetic n.
Table 4. Taste Buds
GENERAL SENSATION TASTE
Anterior 2/3 Lingual n. (mandibular
br. of trigeminal n)
Chorda tympani (facial n.) EXCEPT vallate
papillae
Posterior 1/3 Glossopharyngeal n.
posteromedial aspect partly innervated by Vagus nerve
Taste buds of the circumvallate or vallate papillae receive innervation from nerves that supply posterior 1/3 of the tongue (CN IX)
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Group 4 |Baes, Ballero, Baluyot, Banas, Bandoma, Baranda, Borzaga, Bautista, C., Baustista, B. Page 5 of 17
Arterial Supply of Tongue o Dorsal lingual arteries posterior part (root) of the tongue
& send tonsillar branch to the palatine tonsil o Deep lingual artery anterior part of the tongue;
communicates with the dorsal a. Near the apex of the tongue o Sublingual artery sublingual gland & floor of the mouth
Venous Drainage of Tongue o Dorsal lingual veins accompany the lingual a. o Deep lingual veins begin at the apex of the tongue & run posteriorly beside the lingual frenulum to join the sublingual vein All lingual veins terminate, directly or indirectly, in the IJV
(continuation of sigmoid sinus)
Lymphatic Drainage AT the posterior 1/3 and the medial anterior 2/3 of the
tongue, the lymphatic vessels criss cross to the other side
o Superior deep cervical lymph nodes posterior 1/3 o Inferior deep cervical lymph nodes medial anterior 2/3 o Submandibular lymph nodes lateral anterior 2/3 o Submental lymph nodes apex of the tongue & frenulum o ALL eventually drain into the deep cervical lymph node
Clinical Correlation
Carcinomatosis involving the poeterior 1/3 of the tongue, metastasis to tboth side is very early because of the criss crossing of the lymphatic vessels.
H. SALIVARY GLANDS
Secrete saliva, which keeps mucous membrane of mouth moist, lubricates food during masctication, begins digestion of starches, serves as an intrinsic mouthwash, & plays role in prevention of tooth decay & in the ability to taste
Named according to where it is found o Mucosa of cheek- Buccal glands o Mucosa of Lips- Libel gland
Table 5. Salivary Glands
SALIVARY GLAND LOCATION ARTERIAL SUPPLY;
VENOUS DRAINAGE
Parotid glands - largest of the major
salivary glands - duct is called Stensens duct
gap between ramus of mandible & styloid & mastoid processes
of temporal bone
external carotid a. & superficial temporal a.; retromandibular
veins.
Submandibular gland along body of
mandible submental a.; submental v.
Sublingual gland - smallest & most
deeply situated
floor of the mouth between mandible &
genioglossus ms.
sublingual a. & submental a.
Figure 8.1 Salivary Glands
Figures 8.2 Salivary glands
II. PHARYNX
From base of skull to lower cricoid cartilage (C6 level) Behind the nasal cavities, the mouth and the larynx
A musculomembranous tube
Funnel-shaped; common passage of food and air
Upper, wide-end lie under the skull Lower, narrow end becomes continuous with esophagus opposite
C6.
Has musculomembranous walls, which is deficient anteriorly (replaced by posterior nasal apertures, oropharyngeal isthmus and inlet to larynx)
Pharynx connects with 7 cavities anteriorly o (R) & (L) nasal cavities (choanae/nares) o (R) & (L) eustachian tube (lateral) o Oral cavity (front) o Laryngeal cavity o Esophagus (below)
A.MUCOUS MEMBRANE
Continuous with the nasal cavity, mouth and the larynx
Continuous with the tympanic cavity thru the auditory tube
Upper part, pseudostratified ciliated columnar epithelium Lower part, stratified squamous epithelium
Transitional zone where the two areas come together
B. FIBROUS LAYER
Pharyngobasilar fascia strong internal fascial lining of the constrictor muscles o Between the mucous membrane and the muscle layer o Thicker above, strongly connected to the base of the skull o Becomes continuous with the submucous coat of the
esophagus Buccopharyngeal fascia thin external fascial lining of the
pharyngeal muscles Pharyngeal aponeurosis: covers the the pharyngeal muscle which
if extends to esophagus, will be the muscularis mucosa of esophagus
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Group 4 |Baes, Ballero, Baluyot, Banas, Bandoma, Baranda, Borzaga, Bautista, C., Baustista, B. Page 6 of 17
C. MUSCULAR LAYER
Table 6. Pharyngeal Muscles
MUSCLE ACTION NERVE SUPPLY
External circular
Super constrictor aids soft palate in closing off nasal pharynx, propels bolus downward
Pharyngeal plexus
Middle constrictor propels bolus downward
Inferior constrictor
Cricopharyngeus sphincter at lower end of pharynx; prevents the swallowing of air
Internal longitudinal
Stylopharyngeus elevates larynx during swallowing
CN IX
Salpingopharyngeus elevates pharynx Pharyngeal plexus Palatopharyngeus elevates wall of pharynx, pulls
palatopharyngeal arch medially
ALL pharyngeal ms are innervated by pharyngeal plexus EXCEPT stylopharyngeus, which is innervated by the glossopharyngeal n
Muscularis externa is always made up of inner circular and outer longitudinal muscle layer but the pharynx is made up of inner longitudinal and outer circular muscle layer
The posterior fiber of the superior constrictor muscles works hand-in-hand with the soft palate in closing the nasopharynx when swallowing
D.PARTS OF PHARYNX
NASOPHARYNX or EPIPHARYNX o Posterior to nasal cavity/chonae o Purely respiratory in function; only allows passage of air o Mucosa lined with respiratory epitheleum o Anterior: choanae/posterior nares o Posterior: base of skull (c1/atlas) o Roof : supported by the sphenoid and occipital bone; where
pharyngeal tonsils can be seen o Floor: upper surface of soft palate; opening is called pharyngeal
isthmus o Lateral wall : contains opening of the Eustachian/
pharyngotympanic tube and mucosal elevations and folds covering the tube and the adjacent muscles Salpingopharyngeal fold desends from the tubal elevation
and overlies salpingopharyngeus muscle Torus levatorius broad elevation emerging from under the
tube; overlies levator veli palitini muscle Tubal tonsil (important structure of the nasopharynx from
Dr. Elevazo) - lymphoid tissue around opening of the tube; should atrophy during puberty
Sensory nerve supply (nasopharynx): maxillary nerve (V2)
Clinical Correlation
Pharyngeal tonsils, when enlarged, are called adenoids which
can block the Eustachian tube opening
Tubal tonsil may cause otitis media when it blocks the opening of the Eustachian tube
OROPHARYNX o Digestive function; stratified squamous epithelium o Behind the soft palate to hyoid between laryngeal inlet and soft
palate Superiorly: bounded by soft palate Inferiorly: base of the tongue Laterally: palatoglossal and palatopharyngeal arches
o Waldeyers ring = pharyngeal + palatine + lingual tonsils + tubal tonsils Lingual tonsils anteroinferior part of ring Palatine tonsils (important structure of the oropharynx
from Dr. Elevazo) most frequently infected; together with tubal tonsils are found on the lateral wall of the oropharynx
Pharyngeal tonsils posterior part of ring; hypertrophic in children but atrophies in puberty
o Valecula depression or space between posterior 1/3 of tongue and epiglottis where fish bone may lodge
o Median glossoepiglottic fold: fold in midline of base of the tongue
o Oropharyngeal isthmus: interval between palatoglossal arches Sensory nerve supply (orophraynx): glossopharyngeal nerve
LARYNGOPHARYNX OR HYPOPHARYNX o Behind laryngeal inlet o Posterior to the larynx, from superior border of epiglottis and
the pharyngoepiglottic folds to the inferior border of the cricoid cartilage, where it narrows and becomes continuous with the esophagus
o Cricopharyngeus muscle acts as a sphincter that prevents the air to pass in esophagus Posteriorly, related to bodies of C4 thru C6 vertebrae Behind the laryngeal inlet or aditus (formed by epiglottis:
aryepiglottoc fold and interarytenoid notch) o Piriform fossa groove in the mucous membrane on each side
of laryngeal inlet, behind the cuneiform and corniculate tubercles and between cricoid and thyroid cartilage lamina
Where foreign bodies such as fish bone may lodge when fish bone is not found at the valecula
Sensory nerve supply (laryngopharynx): internal laryngeal branch of the vagus nerve
E.ARTERIAL SUPPLY
Upper part o Ascending pharyngeal a. o Ascending palatine and tonsillar branches of facial artery o Maxillary artery o Lingual artery
Lower part (including cricopharyngeus ms) o Superior thyroid artery
Figure 9. Blood Supply of Pharynx
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Figure 10. Parts of Pharynx
E. VENOUS DRAINAGE
External palatine vein (paratonsillar vein) Retromandibular v. union of superficial temporal and maxillary
veins o Drain into pharyngeal venous plexus into internal jugular v.
E. LYMPHATIC DRAINAGE
Directly into superior cervical group of nodes (runs along IJV)
Indirectly into retropharyngeal or paratracheal nodes then into deep cervical nodes
All eventually drain into deep cervical lymph nodes
Figure 11. Venous and lymph drainage of pharynx
III. ESOPHAGUS Extends From Lower border of cricoids cartilage (C6) to are where
it inserts at cardia of stomach at level of (T11) Goes down and enters the super and inferior mediastinum of
thorax
Enters esophageal hiatus(T10) to enter cardia of stomach (T11)
Conduct food from the pharynx into the stomach
A muscular collapsible tube 10 in. (25 cm) long
Joins pharynx to stomach
Greater part lies within the thorax Covered anteriorly and laterally by peritoneum
Anteriorly : related to posterior of LEFT lobe of liver
Posteriorly : related to LEFT crux of diaphragm
Divided into 3 parts: cervical, thoracic and abdominal Enters the abdomen via right crux of diaphragm
A. THREE PORTIONS OF ESOPHAGUS
Cervical o Anterior: trachea o Posterior: cervical vertebrae o Lateral: thyroid gland, carotid sheath o In groove between trachea and esophagus: recurrent laryngeal
nerves
Thoracic (thorax)
o Anterior: trachea, (L) recurrent laryngeal nerve, (L) principal bronchus (T5) & pericardium Left atrium(below thoracic bifurcation)
o Posterior: bodies of upper thoracic vertebrae, thoracic duct, azygos veins,hemiazygous vein, (R) posterior intercostals arteries, descending thoracic aorta
o Laterally on Right: mediastinal pleura ,terminal branch of azygos vein (T4) and parietal pleaura
o Left: above tracheal bifurcation: ascending portion of left subclavian artery, aortic arch (T4), thoracic duct, parietal pleura
o Below tracheal bifurcation: descending aorta o T8: descending aorta lies beneath esophagus
Abdominal
o Anterior: inferior surface of (L) lobe of liver o Posterior: (L) crus of diaphragm
B. COURSE OF ESOPHAGUS
In the neck, lies in the midline
In the thorax, it is to the left, passing thru superior then posterior mediastinum
At the level of sternal angle (T4-T5), aorta pushes esophagus back to midline
At t10, passes on opening of right crux of the diaphragm, then after course, joins stomach at right side 7th left costal cartilage and T11
Note: - (L) vagus n. Anterior to esophagus, (R) vagus nerve Posterior to
esophagus [L.A.R.P.] - Peristalsis wave-like contraction of the muscular coat, propels
the food onward - Phrenicoesophageal ligament: attach esophagus to margins of
esophageal hiatus in diaphragm
C. FOUR CONSTRICTION AREAS
Where foreign bodies may lodge
Offer resistance in passageway 1. C6 : caused by cricopharyngeus (superior esophageal sphincter)
/ cricopharyngeal constriction -at junction between pharynx and esophagus -When it contracts- prevents entry of air when swallowing
2. T4 : arch of the aorta / bronchoaortic constriction 3. T5 : level of (L) main bronchus / bronchoaortic constriction (2 and 3)- 4. T10 : esophageal hiatus of diaphragm / diaphragmatic
constriction /inferior esophageal sphincter
Clinical Correlation
If you ingest acid, these constriction areas will obtain the most damage
During endoscopy, these areas are most common sites of injury
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Figure12. Location of Esophagus
D. MUSCULAR LAYER OF ESOPHAGUS
Upper 3rd: Skeletal
Middle 3rd: Mixed
Lower 3rd:Smooth o Inner circular o Outer longitudinal
Note: - Trachea (trachealis) ms and anterior esophagus forms the
common party wall (above and below isthmus of thyroid) - In children, trachea is pencil size; esophagus is prone to damage
during a tracheostomy
E. BLOOD SUPPLY
Cervical part: inferior thyroid a. (r & l thyrocervical, sca)- branches of thyrocervical trunk from subclavian artery
Thoracic part : esophageal arteries (branches of descending aorta) & branches of bronchial arteries (2 on left 1 on right), right posterior intercostal arteries
Abdominal part :comes mainly from left gastric a. (br. Of celiac a.) And recurrent branch from left inferior phrenic a.
+++may also come from short gastric artery from splenic artery that supplies fundus of stomach
F. VENOUS DRAINAGE
Drain into the left gastric vein, tributary into the left gastric nodes o Cervical part: (R) & (L) inferior thyroid veins to (R) & (L)
brachiocephalic veins o Thoracic part: azygos and hemiazygos v. o Abdominal part:primarily to portal venous system via left
gastric vein (portocaval anastomoses) on lower 1/3 of esophagus
o +++submucosal venous plexus penetrate entire wall of esophagus forming peri-esophageal venous plexuses
Clinical Correlation
Liver cirrhosis progressive destruction of hepatocytes, which are replaced by fibrous tissue; fibrous tissue surrounds intrahepatic vessels, impeding the circulation of blood; there is then retrograde flow of blood; submucosal plexuses becomes dilated and tortuous causing varices which are prone to hemorrhage-> bleeding esophageal plexuses. ++obstruction of portal vein because of alcoholic cirrhosis of liver will cause retrograde flow of blood back from portal vein, left gastric vein, peri-esophageal sinuses and back to submucosal venous plexuses producing esophageal varices> liver cirrhosis
G. PORTAL-SYSTEMIC OR PORTO-CAVAL ANASTOMOSES
Communication between the portal and systemic systems; become important when direct route (hepatic veins to IVC) becomes blocked
Table 7. Portal System
PORTAL SYSTEM SYSTEMIC SYSTEM
A
esophageal branches of (L) gastric vein
esophageal branches of azygos veins
when abnormally dilated: esophageal varices
B
superior rectal veins continuing as the inferior mesenteric veins
inferior and middle rectal veins
when abnormally dilated: hemorrhoids
C
paraumbilical veins connected to the (L) branch of the portal vein
superficial epigastric veins
when dilated: caput medusae
D twigs of colic veins (veins of
descending & ascending colon, duodenum & pancreas)
retroperitoneal veins (renal, lumbar & phrenic veins)
Figure 13. Portal-system
H. LYMPH DRAINAGE
Follows arteries into the left gastric nodes Starts below the tracheal bifurcation
Cervical: inferior deep cervical nodes in lower portion of IJV
Thoracic: o Above carina: o Anterior: paratracheal and superior and inferior
tracheobronchial nodes o Posterior: posterior mediastinal & intercostal nodes,
collectively called posterior parietal nodes o Below carina: superior phrenic nodes
Abdominal: left epigastric and celiac nodes draining to cisterna chyli then to thoracic duct
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Summary of lymphatic drainage( Dr. Elevazo):
Cervical portion: nodes on lower portion of Internal jugular vein
and find its way on thoracic duct (left) and Right lymphatic duct
(right)
Abdominal: lymphatic channels emptying on left gastric nodes>
efferent on left gastric nodes empty on ciliac nodes> efferent on
ciliac nodes empty on intestinal trunk( major tributary of cysterna
chylli/thoracic duct together with aorta at level of T12/ L1)
Thoracic: Landmark is tracheal bifurcation:
o Above: ant wall: tracheobronchial and paratracheal nodes
o Posterior wall: both above and below: post mediastinal
bifurcation
o Below tracheal bifurcation: phrenic nodes
o Right: right lymphatic duct
o Left: thoracic duct
I. NERVE SUPPLY
Anterior and posterior epigastric nerves (vagi)
Sympathetic branches of the thoracic part of the sympathetic trunk(S4-S6)
Postganglionic sympathetic: follow branchings of blood vessels of cervical, thoracic and abdominal portions
Parasympathetic : vagus nerve o Cervical (R) & (L) vagus nerves and (R) & (L) recurrent
laryngeal nerves o Thoracic - Above tracheal bifurcation: (R) & (L) vagus nerves
and (L) recurrent laryngeal nerve - (R) recurrent hooks around the subclavian artery and does
not get in contact with the esophagus - Below tracheal bifurcation: esophageal plexus: 1-2 cm above
esophageal hiatus unite to form: (L vagus) anterior & (R vagus) posterior vagal trunks (LARP) + sympathetic nerves
Abdominal anterior and posterior vagal trunks
IV. GASTROESOPHAGEAL JUNCTION Also known as cardia, Z-line or esophagogastric junction lies in
left of T11 and left 7th
costal cartilage
Transition from stratified squamous to simple columnar epith.at area of cardia of stomach
Has specialized smooth mucles fibers at esophagogastric vestibule which is a thickening of lower portion of esophagus to cardia, about 2cm above esophageal hiatus and with thickened smooth muscle
Contain inferior or lower esophageal sphincter (LES) o Angulation o Rosette arrangement o Sphincteric effect of contraction of diaphragm o Prevents regurgitation of food from stomach to esophagus
Netter: 1-2 cm above esophageal hiatus at area of cardia> muscle thickening called esophagogastric vestibule which contains specialized smooth muscle fiber called inferior esophageal sphincter
Moore: contraction of diaphragm prevents regurgitation of food from stomach into esophagus
A. GASTROESOPHAGEAL SPHINCTER
NOT an anatomic sphincter BUT a physiologic sphincter because of circular layer of smooth muscle
Its tonic contraction prevents regurgitation of stomach contents into esophagus
Closure of this is under vagal control
o Gastrin augment closure and dilatation o Secretin, cholecystokinin, and glucagons reduce response
Note: - No anatomical sphincter exists at lower end of esophagus
Clinical Correlation: if this area does not contract well, the patient will experience reflux esophagitis
Other factors that prevent regurgitation of food: 1. Angle of junction between esophagus and stomach 2. Rosette arrangement 3. Sphincteric effect of diaphragm
V. STOMACH
Expanded part of the digestive tract between the esophagus and small intestine.
Acts as a food blender and reservoir
Its main function is Enzymatic Digestion
Can hold 2-3 liters of food
Gastric juice converts food into a semi-liquid mixture, chime Position and Shape o Size shape and position can vary markedly in persons of
different body types. o Found in left hypochondrium and epigastric area and may
extend to area of umbilicus o In supne position, it commonly lies in the upper right and left
quadrants o J shaped, and vertical (in tall,thin person) o Fixed at both ends, but mobile in between
Figure14. Parts of the Stomach
A. Parts of the Stomach
Cardia part that surrounds the cardial or cardiac orifice, the superior opening or inlet of the stomach o Receives distal end of esophagus o Posterior to 6th (L) costal cartilage, 2.4cm from the median
plane at the level of T11 vertebra
Fundus of the stomach o Dome-shaped; usually full of gas o Related to the left dome of the diaphragm o The Cardial Notch is between the esophagus and the fundus o Projects upward and to left of cardiac orifice o In supine position, fundus usually lies posterior to the L 6th rib
in the plane of MCL
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Body of the Stomach o Extends from level of cardiac orifice to level of inciscura
angularis o Largest region of the stomach o No definite bifurcation from body to pylorus o Incisura angularis (angular inscisure) constant notch in lower
part of the lesser curvature; (L) of the midline; junction of body and pyloric part of stomach
Pyloric Part funnel-shaped region; lies at the transplyoric plane o Pyloric antrum wide part; extends from incisura angularis to
the pylorus; narrows to form the pyloric canal o Pyloric canal narrow part; ends at pyloric sphincter o Pylorus sphincteric region Thickening of inner circular muscle Tubular part of stomach containing pyloric sphincter, thick
muscular wall of pylorus which controls the rate of discharge of stomach contents into duodenum
Recognized externally as slight constriction on stomach Lies on (r) side
o Pyloric orifice outlet of the stomach
B. Openings of the Stomach
Cardiac o Where esophagus enters stomach o Has physiologic sphincter only
Pyloric o Formed by pyloric canal o Thicker muscular coat (circular) o With both anatomic and physiologic sphincter
C. Curvatures of the Stomach
Greater curvature o From left of cardiac orifice, over dome of fundus, to pylorus and
along left border of the stomach to the pylorus o Much longer than lesser curvature o It passes inferiorly to the left from the junction of the 5th ICS
and MCL, then curves to the right, passing deep to the 9th or 10th left cartilageas it continues medially to reach the pyloric antrum
Lesser curvature o Shorter, concave, right border of stomach o From cardiac orifice to pylorus o Angular Incisure most inferior part of the curvature, indicates
the junction of the body and pyloric part of the stomach o Suspended from liver by lesser omentum
D. Omenta
Mobile Could adhere to possible infection
Temporarily prevents spread of infection (not useful in children below 2yo since their omenta is not yet well developed)
Greater omentum from greater curvature of the stomach to other viscera; has 3 parts: o Gastrocolic ligament colon o Gastrosplenic ligament spleen o Gastrophrenic ligament diaphragm
Lesser Omentum suspends the lesser curvature os the stomach from the fissure of the ligamentum venosum and the porta hepatic on the undersurface of the liver: o Hepatogastric or Gastrohepatic ligament connects lesser
curvature of the stomach to the liver; membranous portion of lesser omentum; proximal part ; thicker
o Hepatoduodenal ligament connects the proximal part of the duodenum to the liver; thickened free edge of the lesser omentum; conducts the portal triad: portal vein, hepatic artery and bile duct; distal part; narrower
Stomach bed on which stomach rests when person is in supine position, is formed by the structures forming the posterior wall of the omental bursa o from superior to inferior: Left dome of diaphragm Spleen Left kidney and suprarenal gland Splenic artery Pancreas Transverse mesocolon
E. Blood Supply
From branches of celiac artery/trunk
Left gastric artery o Directly from celiac artery o Supplies lower 1/3 of esophagus and upper right (lesser
curvature) of stomach
Right gastric artery o From hepatic a., a branch of celiac trunk o Supplies right portion of thelesser curvature of stomach
Short gastric artery o From splenic a., a branch of celiac trunk o Supplies fundus
Left gastroepiploc (gastro-omental) artery o From splenic artery o Supplies stomach along the left portion of the greater
curvature
Right gastroepiploc (gastro-omental) artery o From gastroduodenal branch of the common hepatic artery o Supplies right portion of the greater curvature
Figure 15. Blood Supply of stomach
F. Venous Drainage
Right and Left Gastric veins o Drain directly into hepatic portal vein (at neck of pancreas, L1,
L2)
Short gastric and Left gastroepiploic or gastro-omental veins o Join splenic vein, which drains into the superior mesenteric vein
(SMV) to form the hepatic portal vein
Right gastroepiploic or gastro-omental vein o Drains into the superior mesenteric vein
Note: - Portal vein is formed by the union of superior mesenteric vein
and splenic vein. - Prepyloric vein: ascends over pylorus to drain to right gastric
vein; being use by surgeons to identify the pylorus
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Figure 16. Venous drainage of stomach
G. Lymph Drainage
Gastric Lymphatic Vessels follow the arteries along the greater and lesser curvatures to: o Left and right gastric nodes o Left and right gastroepiploic nodes o Short gastric nodes All lymph from stomach eventually passes toceliac
nodeslocated around root of celiac artery on posterior abdominal wall
Celiac node cysterna chili thoracic duct Clinical Correlation
In carcinoma of the stomach, the spread of cancer is hard to contain because lymph nodes are shared
H. Nerve Supply
Parasympathetic vagus nerve o Secretory nerve fibers to glands and muscles o Anterior vagal trunk anterior surface of stomach, pyloric
branch to pylorus (Left) o Posterior vagal trunk posterior (main) and anterior surface
of stomach (Right)
Sympathetic celiac plexus / thoracic splanchnic nerves o Pain transmitting nerve fiber o Greater splanchnic T6-T9 o Lesser splanchnic T10-T11 o Least splanchnic T11
H. Histology of the Stomach
Mucous membrane o Thick and vascular o Rugae numerous folds of the mucous membrane of stomach,
longitudinal in direction o Magenstrasse Pliable, linear rugal folds or groove of the gastric mucosa
along the lesser curvature that is the route food and liquids tend to take in moving toward the pylorus
Has no oblique muscles Bounded externally by the gastrohepatic ligament Frequent site of most spontaneous gastric rupture (peptic
ulcer formation), due to the lesser curvature's lower distensibility
Muscular walls o Oblique innermost coat, loop over fundus and pass down
along anterior and posterior walls, parallel with lesser curvature; not seen in curvatures
o Inner circular encircle body of stomach, thickened at pylorus, few in the fundus, forms the pyloric sphincter (middle circular muscle layer) which regulates flow of chime from stomach to first part of duodenum
o Outer longitudinal most superficial, concentrated along curvatures
Visceral peritoneum o completely surrounds the stomach o leaves lesser curvature as lesser omentum o leaves greater curvature as gastrosplenic omentum and greater
omentum
LOWER GASTROINTESTINAL TRACT
II. SMALL INTESTINE
Greatest surface area (22 ft. long)
From the pylorus of the stomach to the ileocecal junction where the ileum joins the cecum (first part of the large intestine)
Pyloric part empties in duodenum and pylorus regulates duodenal admission
Where the greater part of digestion and food absorption takes place
Figure 17 . Three Parts of small intestine: Duodenum, Jejunum, Ileum
A.DUODENUM
First part of the small intestine and the shortest one
10 in. (25 cm) long
Also the widest and most fixed part
C-shaped tube that course around the pancreas and joins the stomach to the jejunum
Runs from pylorus on right side to the duodenojejunal junction /flexure (an acute angle) on the left
Junction occurs at the level of the L2 vertebra, 2-3 cm to the left of the midline
Receives the openings of the bile and pancreatic ducts
Situated in the epigastric and umbilical regions
First part is smooth; remainder is thrown into circular folds called theplicae circulars
Most of the duodenum is fixed by peritoneum to structures on the posterior abdominal wall and is considered partiallyretroperitoneal except the 1st inch that is intraperitoneum
Parts of the Duodenum o SUPERIOR: FIRST PART 2 inches (5 cm) long ,Lined by smooth mucous membrane Ascends from the pylorus and is overlapped by the liver and
gallbladder runs upward and backward on the right side of the first
lumbar vertebra (L1) Lies on thetranspyloric plane
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Anterior aspect covered by peritoneum but posterior part is bare, except for the ampulla
Proximal part has thehepatoduodenal ligament attached superiorly and the greater omentum attached inferiorly
Note: - AMPULLA or DUODENAL BULB - it is the only portion of
the duodenum that is mobile since it is suspended by a mesentery. The rest of the duodenum is retroperitoneal, applies to the first inch of the duodenum
Table7 . Boundaries of superior duodenum
Anterior quadrate lobe of the liver and gallbladder
Posterior lesser sac, gastroduodenal artery, bile duct portal vein, IVC
Superior epiploic foramen
Inferior head of the pancreas
o DESCENDING: SECOND PART Longer than superior part 7- 10 cm long and descends along
the right sides of L1 L3 vertebra Runs vertically downward in front of the hilum of the right
kidney at the right side of L2 and L3 Appearance ofplicaecirculares or valves of Kerckring,Entirely
retroperitoneal Peritoneum reflects from its middle third to form the double
layered mesentery of the transverse colon, the transverse mesocolon
Plicaecirculares or Valves of Kerckring: Increase the surface area of small intestine for absorption
Hepatopancreatic ampulla or Ampulla of Vater: Formed where the bile duct and pancreatic duct enter the posteromedial part of the second duodenum, opening into the duodenal papilla
Major duodenal papilla: Small, rounded elevation where the bile duct and the main pancreatic duct pierce the medial wall of the duodenum
Minor duodenal papilla: Where the accessory pancreatic duct opens. This part of the duodenum is not present if the pancreatic duct has no accessory part
Table 8. Boundaries of superior duodenum
Anterior fundus of the gallbladder, right lobe of the liver, transverse colon, SI
Posterior hilum of the right kidney, right ureter
Lateral ascending colon, right colic flexure, right lobe of the liver
Medial head of the pancreas, bile duct, main pancreatic duct
o INFERIOR/ HORIZONTAL: THIRD PART 3 in (8 cm) long Runs transversely to the left, passing over the IVC, aorta, and
L3 vertebra Runs horizontally to the left on the subcostal plane Crossed by the superior mesenteric artery and vein and the
root of the mesentery of the jejunum and ileum Anterior surface is covered by peritoneum except where it is
crossed by the superior mesenteric vessels and the root of the mesentery
Table 9. Boundaries of inferior duodenum
Anterior root of the mesentery of SI, superior mesenteric vessels, jejunum
Posterior separated from the vertebral column by the right psoas major, IVC, aorta, and right testicular or ovarian vessels
Superior head of the pancreas and its uncinate process
Inferior jejunum
o ASCENDING: FOURTH PART curves anteriorly to join the jejunum at duodenojejunal
flexure supported by the suspensory muscle of duodenum (suspensory ligament of Treitz)
2 in. (5 cm) long Begins at the left of the L3 vertebra and rises superiorly as far
as the superior border of the L2 vertebra Runs upward and to the left to the duodenojejunal flexure Suspensory ligament of Treitz
-peritoneal fold which holds the duodenojejunal flexure in place, attaching to the right crus of the diaphragm -composed of a slip of skeletal muscle from the diaphragm and a fibromuscular band of smooth muscle from the third and fourth parts of the duodenum -contractions of the muscle widens the angle of the duodenojejunal fixture, facilitating movement of the intestinal contents -passes posteriorly through the pancreas and splenic vein and anterior to left renal vein
Table10 . Boundaries of ascending duodenum
Anterior beginning of the root of the mesentery, coils of jejunum
Posterior left margin of the aorta, medial border of the left psoas muscle.
B .JEJENUM and ILEUM
Figure 18. Jejenum and ileum
has no clear line of separation and together, is 6-7 m long
Runs from the duodenojejunal junction to the ileocecal junction
Its coils are freely mobile
Attached to the posterior abdominal wall by a fan-shaped fold of peritoneum known as mesentery of the small intestine
Mesentery a fan-shaped fold of peritoneum that attaches the jejunum and ileum to post. Abdominal wall
Root of the mesentery o (approx. 15 cm long) attached to posterior abdominal wall from
L2 to the right sacroiliac joint. It conveys nerves and blood vessels
o between the two layers of mesentery are superior mesenteric vessels, lymph nodes, variable amount of fat, autonomic nerves
Peyer's patches: aggregated lymphoid nodules that could be used to distinguish the ileum from the duodenum and jejunum.
JEJENUM o second part of small intestine and begins at duodenal flexure
where digestive tract resumes an interperitoneal course o 8 feet long Forms the upper 2/5 of the interperitoneal section
(jejunuileum) o double layer of peritoneum o mostly lies in left upper quadrant of infracolic compartment
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ILEUM o third part of small intestine and ends at ileocecal junction
(union of the terminal ileum and cecum) o 12 feet long o Forms the lower 3/5 of the jejunuileum, o Ends at ileocecal junction o mostly lies at right lower quadrant
CLINICAL CORRELATON Meckel's diverticulum
Congenital anomaly.
Persistent vitellointestinal duct
Small bulge or malformation found in the terminal 2 ft. of the ileum
Usually asymptomatic, but can sometimes form an intestinal obstruction
May develop inflammation that can be confused with appendicitis (Meckel's Diverticulitis), mimicking its signs and symptoms
In distinguishing the jejunum from the ileum in radiographs, note that the JEJUNUM has a feathery
appearance while the ILEUM has a solid appearance.
Table 11. Summary of the differences between jejunum and ileum
II. LARGE INTESTINE
Extend from the ileocecal junction to the anus
Primary function: absorption of water and electrolytes; storage of undigested material until it can be expelled from the body as feces
Parts: cecum, ascending colon , transverse colon, descending colon, sigmoid colon, rectum and anal canal
Figure 19. Terminal ileum and large intestine
Can be distinguished from the small intestine by: o Omentum appendices: small, fatty, omentum-like projections o Teniae coli: 3 distinct longitudinal thickened bands of smooth
muscle Mesocolic tenia to which the transverse and sigmoid
mesocolon attach Omental tenia to which the omental appendices attach Free tenia to which neither mesocolons nor omental
appendices are attached. o Haustra: sacculations of the wall of the colon between teniae
These are formed due to teniae coli being shorter than the entire length of the large intestine
o A much greater calibre (internal diameter) Teniae, haustra, and fatty omentum appendices characteristic of
the colon are not associated with the rectum
A.CECUM
Blind intestinal pouch at the iliac fossa of the right lower quadrant abdomen (lies within 2.5 cm of the inguinal ligament)
Approx 7.5 cm in both length and breadth
Palpable through the anterolateral abdominal wall if distended with feces and gas
Devoid of mesentery and it is freely movable
completely covered with peritoneum Bound to the lateral wall by cecal folds of peritoneum o Ileal orifice - the opening at the junction of the ileum and
cecum. It has two lips, one above and one below called the ileocolic lips.
o Ileocecal valve two folds or lips that project around the orifice of ileum; rudimentary structure usually mistaken as the structure responsible for preventing the reflux of food back into the ileum, when it is actually the ileocecal sphincter that does the job.
o Frenulum a fold that runs from the ileocecal valve along o the wall at the junction of the cecum and ascending colon
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Table12 . Boundaries of cecum
Anterior Small intestine, greater omentum, anterior abdominal wall in the right iliac region
Posterior Psoas and iliacus major, femoral n., lateral cutanoues nerve of the thigh
Medial Appendix
B. APPENDIX
Blind intestinal diverticulum (6-10cm) that contains masses of lymphoid tissue
Arises from the posteromedial aspect of the cecum inferior to the ileocecal junction
Attached to lower layer of the mesentery of SI by a short mesentery of its own called mesoappendix
Usually retrocecal but variations may occur In relation to the anterior abdominal wall, its base is situated 1/3
of the way up the line joining the RIGHT ASIS to the umbilicus (McBurneys point)
Anatomical position of the appendix will determine the site of muscular spasm and tenderness in appendicitis
C. ASCENDING COLON
Location: o lies in the right lower quadrant; o Extends upward from the cecum to the inferior surface right
lobe of the liver Turns to the left at the right colic flexure /hepatic flexure (lies
deep to the 9th and 10th rib) and becomes continuous with the transverse colon.
Retroperitoneal Greater omentum separates the ascending colon from the
anterolateral abdominal wall
Right paracolic gutter deep vertical groove lined with parietal peritoneum that lies between the lateral aspect of the ascending colon and the adjacent abdominal wall (see Figure 2.49 page 245 of Moore)
Narrower than cecum
Table13 . Boundaries of ascending colon
Anterior SI, greater omentum, anterior abdominal wall
Posterior Iliacus, iliac crest, quadrates lumborum, origin of tranversus abdominis muscle and right kidney. Iliohypogastric & ilioinguinal nerves cross behind it
C. TRANSVERSE COLON
Longest and most mobile part of the large intestine
Location: o crosses the abdomen from right colic flexure left colic
flexure o hanging to the level of the umbilicus (L3)
-in tall, thin people, it may extend in to the pelvis
left colic flexure/ splenic flexure o more superior, more acute and less mobile than the right colic
flexure o anterior to the inferior part of the left kidney
phrenicocolic ligament suspends the splenic flexure from the diaphragm
transverse mesocolon mesentery of the transverse colon, suspends the transverse colon from the pancreas
root of the transverse mesocolon along the inferior border of the pancreas and continuous with the parietal peritoneum posteriorly
Table14 . Boundaries of transverse colon
Anterior Greater omentum, anterior abdominal wall
Posterior 2nd
part of duodenum, head of pancreas, coils of duodenum and ileum
D. DESCENDING COLON
Location: o Lies in the left upper and lower quadrants o extends downward from the left colic flexure left iliac fossa
or pelvic brim
Retroperitoneal
Has a left paracolic gutter on its lateral aspect Covered anteriorly and laterally and attached to the posterior wall
by the peritoneum
Table15 . Boundaries of descending colon Anterior SI, greater omentum, anterior abdominal wall
Posterior Lateral border of left kidney, origin of tranversus abdominis ms, quadrates lumborum, iliac crest, iliacus and left psoas. Iliohypogastric, ilioinguinal, lateral cutaneous of the thigh and femoral nerve
E. SIGMOID COLON
S-shaped loop, links descending colon and rectum
Location: extends from iliac fossa S3, where it joins the rectum Rectosigmoid junction termination of teniae coli, approx 15cm
from anus
Sigmoid mesocolon long mesentery of sigmoid colon; attaches the sigmoid colon to the posterior pelvic wall
Root of the sigmoid mesocolon inverted V-shaped attachment, extending first medially and superiorly along the external iliac vessels and then medially and inferiorly from the bifurcation of the common iliac vessels to the anterior aspect of the sacrum.
Distinguising characteristics o Teniae coli disappears and then come together to form a broad
band of longitudinal fibers in the walls of the rectum o Omental appendices are long
Table 16. Boundaries of sigmoid colon Anterior Urinary bladder (males), poetrior surface of the uterus
and upper part of vagina (females)
Posterior Rectum, sacrum, lower coils of the terminal ileum
F.RECTUM
pelvic part of digestive tract, 5 in. (13cm) long follows the curvature of the cecum
extends from S3 up to the area where it pierces the levator ani muscle
peritoneum covers the anterior and lateral surfaces of the upper 1/3 of the rectum and only the anterior surface of the middle 1/3, leaving the lower 1/3 devoid of peritoneum because it is subperitonium
is S-shaped when viewed laterally
has NO mesentery, sacculations (haustra of the colon), taenia coli, appendices epiploicae
continuous proximally with the sigmoid colon, distally with the anal canal.
lying anterior to the S3 vertebra is the rectosigmoid junction, where (a.) teniae of the sigmoid colon spreads forming a continuous outer longitudinal layer of smooth muscle, and (b.) fatty omental appendices are discontinued
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lies posteriorly against the inferior three sacral vertebrae and the coccyx, anococcygeal ligament, median sacral vessels, inferior ends of the sympathetic trunks and sacral plexuses
Rectal valves- support the weight of the feces and prevent over-distention of rectal ampulla (2 on the left namely the superior and inferior rectal valves and 1 on the right called the middle rectal valve)
Rectal ampulla distal dilated portion above the levator ani muscle; NOT covered by peritoneum (proximal third is covered anteriorly and laterally by pelvic peritoneum, the middle third is covered ONLY ON ITS ANTERIOR aspect by the peritoneum)
In Males: the peritoneum that covers the rectum goes down and covers the posterior aspect of the urinary bladder forming the floor of rectovesical pouch o rectum is related anterorly to the fundus of the urinary
bladder,terminal parts of the ureters, ductus deferentes, seminal glands and prostate
For Females: the peritoneum that covers the proximal 2/3 of the rectum covers the posterior fornix of the vagina to form the rectouterine pouch (Pouch of Douglas)
Pararectal fossae o (one in the right and one in the left) formed in the lateral
reflections of the peritoneum from the superior third of the rectum (in BOTH sexes); permit the rectum to distend as it fills with feces
o follows the curve of the sacrum and coccyx forming the sacral flexure of the rectum
o ends anteroinferior to the tip of the coccyx that perforates the pelvic diaphragm, immediately before the sharp posteroinferior angle of the anorectal flexure of the anal canal (an important mechanism for fecal continence)
o apparent anteriorly are the three sharp lateral flexures of the rectum (superior and inferior-on the left side, intermediate-if right)
o flexures are formed in relation to three internal infoldings (transverse rectal folds/valves of Houston): two on the left, one on the right;
Transverse rectal folds o overlie thickened parts of the circular muscle layer of the rectal
wall o support the weight of fecal matter to prevent its urging toward
the anus o superior to and supported by the pelvic diaphragm (levator ani)
and anococcygeal ligament o receives and holds fecal mass until it is expelled during
defecation o ability to relax to accommodate initial and subsequent arrival
of fecal material is important in maintaining fecal continence
G. ANAL CANAL
1.5 in. (4cm) long
extends from the superior aspect of levator ani muscleor pelvic diaphragm down to the anal orifice (anal verge) outlet of the alimentary canal
begins where the rectal ampulla abruptly narrows at the level of the U-shaped sling formed by the puborectalis muscle
lateral walls are kept in apposition by the levatores ani muscles and the anal sphincters except during defecation
Dendate line- lower border of anal column joined by anal valves;important landmark (derivative if ABOVE: HIND GUT, if BELOW: ECTODERM)
surrounded externally by internal and external anal sphincter (internal anal sphincter in the proximal 2/3 is made up of smooth muscles; thickened distal portion of the inner circular muscle layer of the anus)
Conjoined longitudinal muscle distal end of the outer longitudinal muscle layer that separates the internal from external anal sphincter
External anal sphincter is voluntary, supplied by inferior rectal nerve; internal anal sphincter is involuntary (visceral innervations)
Anal column-proximal third are ridges that contain the terminal branches of the superior rectal muscle
in the submucosa of the proximal third of anus, the internal venous plexuses are found
superior end of anal column corresponds to the anorectal line (where the lining epithelium from simple columnar epith. with goblet cells of the rectum changes to stratified squamous epith. In the anal canal)
lining epithelium DOES NOT change at the area of dendate line
Anal Valves- connect the inferior end of anal column Anal Crypts- spaces or depressions superior to anal valves into
which the secretion of perianal gland are emptied (important in BRONCHOTITIS and formation of FISTULA EDEMA)
White Line of Hilton- corresponds to the area where the conjoined longitudinal muscle attaches to the mucous membrane of the anal canal
Anal pecten the transitional zone between the skin and the mucous membrane; between the pectinate line and the anal verge
Surgical anal canal from anocutaneous line to the anal verge
Anatomical anal canal portion from dendate line (pectinate line/anatomic anorectal line) down to the anal verge
Table17 . Difference between small and large intestine
Small Intestine (SI) Large Intestine
EXTERNAL
Mobile (except duodenum) Ascending and descending are fixed
Located centrally Located in the periphery
Smaller calibre Larger caliber
Mesentery (except duodenum) Mesocolon (transverse, mesocolon, mesoappendix, mesosigmoid)
Continous layer of longitudinal muscles
Longitudinal muscle is collected into 3 bands, the teniae coli (except in the appendix, where the longitudinal ms are continous, teniae are absent in the rectum
Wall is smooth Haustra or sacculations bet the teniae are present
No fatty tags attached to its wall Appendices epiploicae/omentum appendices (fatty tags) are present
INTERNAL
Plicae circularis (valve of Kerckring)-permanent infoldings of the mucous membrane
Plicae circulars are absent, has semilunar folds called anal valve at the anal canal
Has villi in the mucosa No villi
Peyers patches (aggregations of lymphoid tissue) are present in the mucosa
No Peyers patches, appendix contains lymphoid tissue
III. BLOOD SUPPLY
first paired branch of the abdominal aorta is the right and left phrenic artery
1cm below the take off of the right and left inferior phrenic artery is the celiac trunk
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A.CELIAC TRUNK
Artery of the foregut supplies GIT from lower of esophagus to middle 2nd part of duodenum
Arises from Abdominal aorta T12 Branches:
1. Left Gastric A. o Goes all the way up to provide branches to the abdominal
portion of the esophagus and occupies the upper lesser curvature of the stomach
o Anastomose with Right Gastric A. 2. Splenic A. o Going to the spleen via behind the stomach and upper
border of pancreas o Gives rise to Left Gastroepiploic A- supply the greater curvature; Short Gastric A - supply the fundus and greater curvature; some branches to pancreas including the dorsal
pancreatic artery 3. Common Hepatic A.
o Runs to the right along the upper border of pancreas o Gives rise to Right Gastric A., - supply the other part of lesser curvature
and pyrolus of stomach Proper Hepatic A., that enters the portal triad, and Gastroduodenal A.
B.SUPERIOR MESENTERIC ARTERY
Supplies the GIT from the 2nd part of duodenum to distal 1/3 of Transverse colon
Artery of the midgut that arise infront of Abdominal Aorta below Celiac Trunk
Branches: 1. Inferior pancreaticoduodenal A. o supply the pancreas and inferior half of duodenum
2. Middle Colic A o supply the proximal 2/3 of the transverse colon and divides
into right and left branches 3. Right Colic A. o often a branch of Ileocolic A. that supply the ascending colon
and further divide into ascending and descending 4. Ileocolic A. o The inferior branch is further divided into Anterior cecal a.
and posterior cecal artery that supply the Cecum o The appendicular a. supply the appendix is arises from the
posterior cecal artery. 5. Intestinal A. o Jejunal and Ileal branches: series of arcades in the small
intestines particularly jejunum and ileum
C. INFERIOR MESENTERIC ARTERY
Artery of the hindgut
distributes to the distal 1/3 of transverse colon to halfway down
of anal canal
Also a abdominal aorta branch that crosses the left common iliac artery.
Branches: 1. Left Colic A. o supply the distal 1/3 of transverse colon, left colic flexure,
and proximal half of descending colon 2. Sigmoid A o supply the distal of the descending colon and sigmoid
colon 3. Superior Rectal A o supplies the superior part of the rectum o Anastomose with middle and inferior rectal artery o Termination of inferior mesenteric artery
Note: MARGINAL ARTERIES of DRUMMOND anastomoses between superior and inferior mesenteric artery D. RECTAL ARTERY
Middle Rectal A o Supply the middle and inferior rectum o Arises from the inferior vesical (male) or uterine (female)
arteries, both are branches of internal iliac artery. Superior Rectal Artery o continuation of inferior mesenteric artery that supplies the
rectum and the upper half of anal canal
Inferior Rectal Artery o Supply the anorectal junction and anal canal o Arises from the internal pudendal artery ( a branch of internal
iliac A.)
IV. VENOUS DRAINAGE
Note: Veins follow the arterial blood vessels, even the names. They eventually drain into superior and inferior mesenteric veins, then to hepatic portal vein.
Through the portal vein (which is formed by the splenic and superior mesenteric veins, behind the neck of the pancreas at L2) liver sinusoids hepatic v. inferior vena cava
Superior mesenteric and inf. Mesenteric v.: follows the corresponding arteries
Sup. mesenteric and inf. mesenteric veins drain to the hepatic portal vein portal systemic anastomosis
Portal - systemic anastomoses o Esophageal branches of the left gastric vein (portal)
esophageal draining middle third of the esophagus into azygos v (systemic)
o Paraumbilical v (portal) superficial v. of anterior abdominal wall (systemic)
o Superior rectal v. (portal tributary) middle and inferior rectal v. (systemic)
o Retroperitoneal v. of ascending, descending colon, pancreas and liver (portal) renal, lumbar and phrenic v, (systemic)
above the pectinate line, all the lymph will find its way into your intestinal trunk which is one of the tributaries of thoracic duct
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V. LYMPHATIC DRAINAGE
Follows the arterial vessel mesenteric nodesceliac
nodesmesenteric duct Lumbar nodes: drains lymph from rectum, descending colon
Superficial inguinal nodes and ext. iliac nodes: below the pectinate line, anal canal
Internal iliac nodes: upper canal (drains into inf. mesenteric nodes)
Lacteals - specialized lymphatic vessels in the intestinal villi that absorb fat that empty milk-like fluid to lymphatic plexuses in the walls of jejunum and ileum
o lacteals mesentery lymph passes through 3 groups of nodes: Juxta-intestinal (close to intestinal wall), Mesenteric lymph nodes (scattered among arterial arcades) and superior central nodes (located along proximal part of superior
mesenteric artery) superior mesenteric lymph node lymphatic vessels from terminal ileum follow ileal branch of
ileocolic artery to the ileocolic lymph nodes
VI. NERVE SUPPLY
Parasympathetic o From VAGUS nerve o From SACRAL PLEXUS, S2 to S4 o The vagus nerves supply preganglionic parasympathetic
innervation up to the splenic flexure and then the sacral parasympathetic nerves (S2-S4) take over
o Postganglionic neurons are located within the walls of the organs (Meissners and Auerbachs plexus) where postganglionic fibers are given off
Sympathetic o From pelvic splanchnic nerves o Sympathetic innervation is provided by the preganglionic
greater (T5-T9), lesser (T10-T11) and least (T12) splanchnic nerves pass through the diaphragm and synapse at the prevertebral ganglia (celiac, superior and inferior mesenteric) and postganglionic fibers follow the branching of the arteries.
o Additional preganglionic sympathetic fibers from the lumbar splanchnic (L1-L2-L3) synapse at the postganglionic neurons inferior mesenteric ganglion to supply postganglionic fibers to the lower digestive tract and the pelvic organs
Plexuses formed by the Parasympathetic and Sympathetic Nerve Fibers in Walls of Intestines are: o Auerbachs plexus Located between inner circular and outer longitudinal layers
of muscle Regulates peristalsis
o Meissners plexus Innermost, in the submucosa Regulates glands of mucosa and smooth muscles of
muscularis mucosae