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OS

206: Abdomen and Pelvis

Liver, Gallbladder, and Stomach


Dr. Gracia Teodosio

November 12, 2012

TOPIC OUTLINE
I.

II.

III.

Liver
A. Surface Anatomy
B. Ligaments
C. Fissures
D. Lobes
E. Surfaces
F. Vascular Supply
G. Lymphatics
H. Nerve Supply
I. Perhepatic Spaces
J. Clinical Correlation Editing the Header
and Footer
Gallbladder
A. Parts
B. Vascular Supply
C. Lymphatics
D. Nerve Supply
E. Referred Pain
Stomach
A. Parts
B. Curvatures and Orifices
C. Interior of the Stomach
D. Surfaces
E. Vascular Supply
F. Lymphatics
G. Nerve Supply
H. Clinical Correlation

Blunt trauma to the liver can cause blood and bile to


enter the preperitoneal cavity, SMV cavity and the
retroperitoneal area.
Bile
o Passes from the liver via the biliary ducts (right
and left hepatic ducts) that join to form the
common hepatic duct which unites with the
cystic duct to form the common bile duct
o Produced continuously
o Accumulates between meals and is stored
In the gallbladder, which concentrates bile by
absorbing water and salts
A. SURFACE ANATOMY
Lower border: extends along a line from the tip of the
right 10th rib to the left 5th intercostal space in the
mid clavicular line; this may just be palpable in normal
subjects, especially on deep inspiration.
Upper border: follows a line passing through the 5th
intercostal space on each side.

Transers Note: Maam prohibited the copying of pictures


from her lecture (she also did not give a copy of her ppt
presentation), so all pictures are taken from the net and
previous transes. Additional information has also been
added but weve highlighted the important points that
maam has discussed.

I. LIVER
Largest gland in the body (2nd largest single organ
next to skin)
Enclosed by a tight fibrous capsule of strong
connective tissue called Glissons capsule
Weight: male 1400-1800g; female 1200-1400g
o 2.5% of adult body weight
o 5% of the total fetal weight because it also a
hematopoetic organ
Location: right upper quadrant (RUQ) of the
abdomen; specifically, in the right hypochondrium,
epigastric
and
part
of
the
left
hypochondrium area
Pyramidal in shape, base found at the right and apex
towards the left
Surrounded by peritoneum except on the bare area
of the posterior aspect of the liver, which is in contact
with the diaphragm
Deep to ribs 7-11 on the right side and crosses the
midline toward the left nipple
Protected anteriorly by the lower rib cages, and
posteriorly by the muscles and bones of the
abdominal wall
Function: glycogen storage, bile secretion (yellowbrown or orange- green fluid that aids in the
emulsification of fat) + other metabolic activities
All nutrients (except fat) absorbed from the digestive
tract are initially conveyed to the liver by the portal
venous system

ADRE, ALMORA, ANARNA

Figure 1. Parts of Liver


B. LIGAMENTS

Figure 2. Ligaments

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1. FALCIFORM LIGAMENT

Extends from the umbilical notch on the inferior


surface of the liver porta hepatis

Ascends to the liver from the umbilicus

Subdivides the subphrenic space

As the ligaments pass over the dome of the liver, it


divides into 2 leaflets:
o the right leaflet becomes the coronary ligament
o the left leaflet becomes the left triangular
ligament
o the right and left leaflets bear the ligamentum
teres hepatis (round ligament)

hepatic nerve plexuses


lymphatic vessels

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2. CORONARY LIGAMENT
Upper Layer (Superior Layer): reflected from the
superior surface on to the inferior surface of
diaphragm

Lower Layer (Inferior Layer): reflected from the


posterior surface of the right lobe of liver on to the
right kidney, right suprarenal gland and inferior vena
cava (IVC); also called the hepatorenal ligament;
also the upper boundary of the right lumbar gutter

3. RIGHT TRIANGULAR LIGAMENT

Begins at the extreme right of the bare area of the


liver where the converging upper and lower layers
of the coronary ligament fuse

Attaches the liver to the undersurface of the right


leaflet of the diaphragm
4. LEFT TRIANGULAR LIGAMENT

Peritoneal fold that connects the superior surface of


the left lobe of the liver to the undersurface of the
diaphragm

When traced posteriorly and to the right, it joins the


lesser omentum in the upper end of its fissure for the
ligamentum venosum
5. ROUND LIGAMENT/ Ligamentum teres hepatis

Fibrous cord that ascends within the base of the


falciform ligament from the umbilicus to the umbilical
notch on the inferior surface of the left lobe of the liver

Forms free border of the falciform ligament

Runs on the fossa on the visceral surface of the liver


to the porta hepatis and becomes continuous with
the ligamentum venosum

Is the obliterated umbilical vein

Several weeks after birth, umbilical vein obliterates


close to the umbilicus, but usually remain patent as
part of the left branch of the portal vein

Ligamentum venosum: fibrous remnant of the fetal


ductus venosus, located on the posterior aspect of
the liver and shunts blood from the umbilical vein to
the inferior vena cava, ultimately short-circuiting the
liver

Porta hepatis: gastrohepatic and hepatoduodenal


ligament
C. FISSURES
The H arrangement of the liver can be seen in the
posterior view of the organ

The right limb of the H arrangement contains:


o anteriorly and to the right - fossa for the
gallbladder
o posteriorly and to the right - groove for the
IVC

The left limb of the H arrangement contains:


o anteriorly and to the left - fissure for the
ligamentum teres
o posteriorly and to the left - fissure for
the ligamentum venosum

The crossbar of the H (transverse limb) is the


porta hepatis, which contains the ff:
anterior common hepatic duct
middle hepatic artery
posterior hepatic portal vein
Adre, Almora, Anarna

Figure 3. H-shaped Fissures


D. LOBES
ANATOMICAL DIVISION

The liver is divided into two anatomical lobes and


two accessory lobes by the reflections of the
peritoneum from its surface, the fissures formed in
relation to those reflections and the vessels serving
the liver and the gallbladder

Superficial lobes are not true lobes and are only


secondarily related to the livers internal architecture

In the anterior view, you can only see the liver divided
into two by the falciform ligament: the left lobe and
the right lobe

In the posterior view of the liver, the H fissure


divides the liver into right, left, quadrate and caudal
lobes.

Right and left lobes do not communicate; each lobe


has own arterial supply, venous and biliary
drainage (for liver lobectomy, this implies less
bleeding)

The caudate lobe was so named not because it is


caudal in position (it is not) but because it gives rise to
a tail in the form of an elongated papillary
process. A caudate process extends to the right,
between the IVC and the porta hepatis, connecting
the caudate and right lobes.
FUNCTIONAL SUBDIVISIONS

Although not distinctly demarcated internally, the liver


has functionally independent right and left livers that
are much more equal in size than the anatomical
lobes (but the right liver is still somewhat larger)

Each part receives its own primary branch of the


hepatic artery and hepatic portal vein and is
drained by its own hepatic duct

The caudate lobe may be considered a third liver; its


vascularization is independent of the bifurcation of the
portal triad (it receives vessels from both bundles) and
is drained by one or two small hepatic veins, which
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enter directly into the IVC distal to the main hepatic


veins
The liver can be further divided into four divisions
and then into eight surgically respectable hepatic
segments, each served indepently by a secondary or
tertiary branch of the portal triad

LESSER OMENTUM

Encloses the portal triad

Passes from the liver to the lesser curvature of the


stomach and the first 2 cm of the superior part of the
duodenum

The thick, free edge of the lesser omentum extends


between the porta hepatis and the duodenum (the
hepatoduodenal ligament) and encloses the
structures that pass through the porta hepatis

Hepatogastric ligament: connects the stomach to


the liver; sheet- like remainder of the lesser omentum
which extends between the groove for the ligamentum
teres and the lesser curvature of the stomach
E. SURFACES

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Portion of the supracolic compartment of the


peritoneal cavity immediately inferior to the liver
Hepatorenal recess (Hepatorenal pouch, Morisons
pouch)
o
Posterosuperior extension of the subhepatic
space, lying between the right part of the visceral
surface of the liver, the right kidney and the
suprarenal gland
o
Fluid draining from the omental bursa flows into
this recess
o
Gravity-dependent part of the peritoneal cavity in
the supine position
o
Communicates anteriorly with the right
subphrenic recess
o

Note: The liver is entirely covered by peritoneum except:


1. Bare area
o
attached to the retroperitoneal tissue which is
areolar tissue with lymphatics and minor veins
o
in direct contact with the diaphragm
o
demarcated by the reflection of the upper
peritoneum from the diaphragm to it as the
anterior (upper) and posterior (lower) layers of
the coronary ligament
2. Groove for IVC
3. Gallbladder fossa
4. Porta hepatic
F. VASCULAR SUPPLY

Figure 4. Position of Liver in the Body


1. ANTEROSUPERIOR

Fits snugly into the cupola of the diaphragm

Separates it from the overlying pleural cavities


and pericardium

Pus can go directly into the lung through this surface

Smooth and dome-shaped

Subphrenic recesses
o Superior extension of the peritoneal cavity
(greater sac)
o Between the diaphragm and the anterior and
superior aspects of the diaphragmatic surface of
the liver
o Separated into the right and left recesses by
the falciform ligament
2. POSTEROSUPERIOR

IVC found in the posterior surface of caudate lobe

Suprarenal impression

Bare area of liver


3. RIGHT LATERAL

Related to the right lateral surface of the diaphragm


from the 7th to the 11th right midaxillary ribs
4. INFERIOR

Separates diaphragmatic and visceral surfaces

In contact with the following and forms impressions on


the surface of the liver
o
Stomach
o
Colon
o
Kidney
o
Duodenum
o
Esophagus
o
Right suprarenal gland

Subhepatic space
Adre, Almora, Anarna

Figure 5. Vascular System of Liver


1.
2.
3.

Hepatic artery carries oxygenated blood


Portal vein carry venous blood
Renal, Phrenic, lumbar, intercostals veins receive
blood from the mesenteric, pancreatic and other veins

a.

Arterial Supply
Has double blood supply from the hepatic artery (2025%) and the hepatic portal vein (70-80%)
Hepatic artery
o
Branch of the celiac trunk
o
May be divided into the common hepatic artery
from the celiac trunk to the origin of the

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gastroduodenal artery to the bifurcation of the


hepatic artery
o
Blood distributed initially to nonparenchymal structures (eg intrahepatic bile
ducts)
The right and left hepatic arteries carry oxygenated
blood to the liver.
At or close to the porta hepatis, the hepatic artery and
the hepatic portal vein terminate by dividing into right
and left branches. These primary branches supply the
right and left livers, respectively. Within each part, the
simultaneous secondary branchings of the portal vein
and hepatic artery (portal pedicles) are consistent
enough to supply the medial and lateral divisions of
the right and left liver, with three of the four secondary
branches undergoing further (tertiary) branchings to
supply independently seven of the eight hepatic
segments
Hepatic portal vein
o
Short, wide
o
Formed by the union of the superior mesenteric
and splenic veins
o
Ascends anterior to the IVC as part of the portal
triad in the hepatoduodenal ligament
o
Portal blood, containing about 40% more oxygen
than blood returning to the heart from the
systemic circuit, sustains the liver parenchyma
(hepatocytes)
o
Carries virtually all of the nutrients absorbed into
and bypass the liver via the lymphatic system

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which accompany the ramification of the portal triad and


hepatic veins

Most lymph is formed in the perisinusoidal spaces


(of Disse) and drains to the deep lymphatics in the
surrounding intralobular portal triads

Most of the deep lymph vessels in the liver converge


at the porta hepatis and end in the hepatic lymph
nodes scattered along the hepatic vessels and ducts
of the lesser omentum

Superficial lymphatics from the anterior aspects of the


diaphragmatic and visceral surfaces of the liver and
deep lymphatic vessels accompanying the portal
triads>portahepatis>hepatic lymoh nodes (scattered
along the hepatic vessels and ducts in the lesser
omentum)>celiac lymph nodes>chyle cistern (cisterna
chili, a dilated sac at the inferior end of the thoracic
duct)>thoracic duct

Superficial lymphatics in the posterior aspects of the


diaphragmatic and visceral surfaces of the liver drain
toward the bare area of the liver>Phrenic lymph
nodes OR

Join deep lymphatics that have accompanied the


hepatic veins converging on the IVC, and pass with
this large vein through the diaphragm>posterior
mediastinal lymph

Posterior surface of the left lobe>esophageal hiatus of


the diaphragm>left gastric lymph nodes

Anterior central diaphragmatic surface along the


falciform ligament>parasternal lymph nodes

b. Venous drainage

There are 3 major hepatic veins: Right, Central,


and Peripheral

These pass upwards and backwards to drain into the


IVC at the superior margin of the liver.

Central veins in lobules are to hepatic veins to IVC

R,C , and L are intersegmental in their distribution and


function, draining parts of the adjacent segments

Central veins of the hepatic


parenchymacollecting veinshepatic veinsIVC
(inferior to diaphragm)

Attachment of veins to IVC helps hold the liver in


position
OBSTRUCTION OF THE PORTAL CIRCULATION
1. Lower part of the rectum, from superior to inferior
middle rectal
2. At the esophagus, from the coronary to esophageal
veins
3. In the falciform and round ligament, from the porta
hepatic to tributaries of the epigastric
4. In the retroperitoneal region
o
tributaries of the splenic and pancreatic veins
anastomose with left renal vein
o
splenic and colic to the lumbar veins
o
veins of bare area communicate with the veins of
diaphragm and right internal thoracic vein
Note: Veins tend to be dilated and tortuous (i.e.
convoluted, twisted) in the following areas:
o
Anal hemorrhoid
o
Gastroesophageal esophageal varices (vomits
blood)
o
Paraumbilical caput medusa (can be due to
liver serosis or any obstruction!)
Note: The veins of Retzius connect intestinal veins with
inferior vena cava and its retroperitoneal branches

G. LYMPHATICS
The liver is a major lymph-producing organ. Between to
of the lymph entering the thoracic duct comes from the
liver
Superficial lymphatics in the subperitoneal fibrous capsule
of the liver (Glissons capsule), which forms its outer
surface, and as deep lymphatics in the connective tissue,
Adre, Almora, Anarna

Figure 6. Lymphatics of the Liver

H. NERVE SUPPLY
Contains both sympathetic and parasympathetic
fibers via the
hepatic plexus (largest derivative of the celiac
plexus)
Receives filaments from the L and R vagus and R
phrenic nerves
Nerve fibers accompany the vessels and biliary ducts
of the portal triad for vasoconstriction (other functions
are unclear)
Hepatic plexus
o
Largest derivative of the celiac plexus
o
Accompanies the hepatic artery and portal vein
and their branches enters liver through porta
hepatic
Consists of sympathetic fibers from the
celiac plexus and parasympathetic fibers from the
anterior and posterior vagal trunks

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Figure 7. Innervation of Liver

I. PERIHEPATIC SPACES
Spaces between diaphragm, transverse colon and
transverse mesocolon
o
Suprahepatic: between diaphragm and liver.
o
Infrahepatic: between visceral surface of liver
and transverse colon/mesocolon.

J. CLINICAL CORRELATIONS
LIVER BIOPSY

The needle is directed through the right 10 in the


midaxillary line

Before the physician takes the biopsy, the person is


asked to hold his or her breath in full
expiration to reduce the costodiaphragmatic
recess and to lessen the possibility of damaging
the lung and contaminating the pleural cavity
HEPATOMEGALY

Hepatic enlargement caused by congestive heart


failure, tumors and bacterial/viral diseases such as
hepatitis

Inferior edge may be readily palpated below the right


costal margin and may even reach the pelvic brim in
the right lower quadrant of the abdomen

Any rise in central venous pressure is directly


transmitted to the liver (IVC and hepatic veins lack
valves), which enlarges as it becomes engorged with
blood. Marked temporary engorgement stretches the
fibrous capsule of the liver, producing pain around the
lower ribs, particularly in the right hypochondrium.
This engorgement, particularly in conjunction with
increased or sustained diaphragmatic activity, has
been proposed as an underlying cause of runners
stitch.
CIRRHOSIS OF THE LIVER

Progressive destruction of hepatocytes (parenchymal


liver cells) and replacement by fat and fibrous tissue

Caused by chronic alcoholism (manin) and also


industrial solvents such as carbon tetrachloride

Alcoholic cirrhosis

Most common of many causes of portal hypertension

Characterized by enlargement of the liver resulting


from fatty changes and fibrosis

The liver has great functional reserve, and so the


metabolic evidence of liver failure is late to appear

Fibrous tissue surrounds the intrahepatic blood


vessels and the biliary ducts, making the liver firm,
and impeding the circulation of blood through it
(portal hypertension)

Treatment includes surgical creation of a


portosystemic or portocaval shunt, anastomosing the
portal and systemic venous systems
SUBPHRENIC ABSCESSES

Peritonitis may result in the formation of localized


abscesses in various parts of the peritoneal cavity
such as in a subphrenic recess or space

More common on the right side because of the


frequency of ruptured appendices and perforated
duodenal ulcers

Because the right and left subphrenic recesses are


continuous with the hepatorenal recess (the lowest
parts of the peritoneal cavity when supine), pus from a
subphrenic abscess may drain into one of the
hepatorenal recesses, especially when patients are
bedridden

A subphrenic abscess is often drained by an incision


inferior or through, the bed of the 12th rib, obviating
Adre, Almora, Anarna

OS 206

the formation of an opening in the pleura or


peritoneum
An anterior subphrenic abscess is often drained
through a subcostal incision located inferior and
parallel to the right costal margin

HEPATIC LOBECTOMIES AND SEGMENTECTOMY

Lobectomy: removal of the right or left part of the liver


without excessive bleeding (most injuries to the liver
involve the right liver)

Segmentectomy: removal of only the segments that


have sustained a severe injury with the use of a
cauterizing scalpel and laser surgery. The right,
intermediate, and left hepatic veins serve as guides to
the lanes (fissures) between the hepatic divisions
RUPTURE OF THE LIVER

The liver is easily injured because it is large, fixed in


position, and friable (easily crumbled).

Often a fractured rib that perforates the diaphragm


tears the liver

Liver lacerations often cause considerable


hemorrhage and right upper quadrant pain
LIVER CANCER

The liver is also a common site of metastatic


carcinoma (secondary cancers spreading from organs
drained by the portal system of veins)

Cancer cells may also pass to the liver from the


thorax, especially from the breast, because of the
communications between thoracic lymph nodes and
the lymphatic vessels draining the bare area of the
liver

Metastatic tumors form hard, rounded nodules within


the hepatic parenchyma

II. GALL BLADDER


7-10cm long
Lies in the fossa for the gallbladder on the visceral
surface of the liver
Pear-shaped organ found at RUQ
Naturally lies anterior to the superior part of the
duodenum with its neck and cystic duct immediately
superior to the duodenum (but not seen in dissection
or atlases because its normally retracted superiorly to
be exposed)
Can hold up to 50 mL of bile
Peritoneum completely surrounds the fundus of the
gallbladder and binds its body and neck to the liver.
The hepatic surface of the gallbladder attaches to the
liver by connective tissue of the fibrous capsule of the
liver
A. PARTS

Figure 8. Parts of Gallbladder

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1. FUNDUS

The tip of the fundus is the angle formed by the


lateral border of the rectus abdominis and the 9th
costal cartilage

The rounded edge of the gallbladder (GB) is 0.5-1cm


from the free edge of the inferior border of the right
lobe of the liver

It is directed inferiorly, anteriorly, and to the right, in


contact with the posterior surface of the anterior
abdominal wall and the descending part of the
duodenum

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Adhesions between the GB, flexure, and right side of


the transverse colon are common.
Billary stones can pass directly to the large bowel.
Complication of close coaption of the GB to the
visceral surface of the liver allows for early spread of
carcinoma.
B. VASCULAR SUPPLY

2. BODY

It is directed superiorly, posteriorly and to the left of


the fundus.

It is in contact with the visceral surface of the liver and


is attached to its bed areolar tissue that contains
many lymphatics and veins.

It is in contact with the right part of transverse and


superior part of the duodenum.
3. INFUNDIBULUM

It is the tapering transitional area between the body


and neck.

It is attached to the first part of the duodenum by the


cholecystoduodenal ligament (avascular,
peritoneal fold derived from the right border of the
hepatoduodenal ligament). It has great importance in
the operative search for major vascular and ductal
structures.

The Hartmans pouch is the bulging inferior surface


of the infundibulum.

It is used to mark the positions of the neck and cystic


duct of the gallbladder, which the pouch overhangs.
4. NECK

It is the narrowed, tapering structure directed toward


the porta hepatis.

It is 5-6 mm long, forms an S and is constricted


at its junction with the cystic duct.

The cystic duct is 2-4 cm long and connects the


gallbladder to the common hepatic duct which passes
between the layers of the lesser omentum to become
the common bile duct. The mucosa of the neck spirals
into the spiral valve of Heister.

Figure 10. Inferior View of the Gallbladder


1. ARTERIAL SUPPLY

2. VENOUS DRAINAGE

There is no major cystic vein.

The cystic veins pass directly into the liver and


end in the portal capillary system.

Figure 9. Ductal Structures of Gallbladder

Spiral valve of Heister:

Helps keep the cystic duct open (to easily divert bile
into GB when the distal end of the bile duct is closed
by the sphincter of the bile duct and/or
hepatopancreatic sphincter, or bile can pass to the
duodenum as the GB contracts

Offers additional resistance to sudden dumping of bile


when the sphincters are closed, and intra-abdominal
pressure is suddenly increased (e.g. sneeze or
cough)

CYSTIC ARTERY
o Commonly arises from the right hepatic artery in
the triangle between the common hepatic duct,
cystic duct, and visceral surface of the liver, the
cystohepatic triangle (of Calot).
o Supplies the gallbladder and cystic duct.
o Divides into two, supplying:
o The free surface of the gallbladder
o The attached surface of the gallbladder
o Can originate from:
o Right and left hepatic arteries
o Common hepatic artery
o Superior mesenteric artery

C. LYMPHATICS
The lymphatic drainage of the GB is to the hepatic
lymph nodes, often through cystic lymph nodes
located near the neck of the GB. Efferent lymphatic
vessels from these nodes pass to the celiac lymph
nodes.
D. NERVE SUPPLY
The nerves follow the path of the cystic artery.
They come from celiac plexus (sympathetic and
visceral afferent [pain] fibers), vagus nerve
(parasympathetic), and right phrenic nerve (sensory).
E. REFERRED PAIN
Irritation in the liver (near the diaphragm) will manifest
as pain in the neck and shoulder region (C3, C4, C5).
Shoulder pain could also mean biliary stones.
Irritation in the gallbladder will manifest as pain in T7
and T9 (until posterior) and infrascapular area.
If the phrenic nerve is irritated, it will cause ipsilateral
pain in the shoulder and neck.
Abdominal pain in the crouching position may suggest
appendicitis.
Cholecystitis is gallbladder inflammation (tenderness
occurs at ipsilateral side of RUQ and shoulder)

CLINICAL IMPORTANCE OF RELATIONSHIP OF GB


TO RIGHT COLON AND HEPATIC FLEX
Adre, Almora, Anarna

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III. STOMACH
Most dilated part of the alimentary canal between the
esophagus and small intestine
Lies in the epigastric, umbilical and left
hypochondriac region
o Hypochondriac region = region on either side of
the abdomen beneath the cartilages of the false
ribs [chondros = cartilage]
It is intraperitoneal and covered by visceral
peritoneum (except where blood vessels run along its
curvature)
Relations to other organs:
o
Anteriorly: related to the diaphragm, left lobe of
liver, anterior abdominal wall
o
Posteriorly: related to the omental bursa and
pancreas; the posterior surface of the stomach
forms most of the anterior wall of omental bursa
A. PARTS

Liver, Gallbladder, and Stomach

OS 206

4. CARDIA

Part surrounding the cardiac orifice which is the


superior opening or inlet of the stomach
B. CURVATURES AND ORIFICES
GREATER CURVATURE

From the cardiac notch, it curves upwards towards the


level of the 5th intercostal space, then downward and
forward up to the pyloric region, where the right and
left gastroepiploic vessels anastomose
LESSER CURVATURE

Continuous posteriorly with the right margin; where


the right and left gastric arteries anastomose.
CARDIAC ORIFICE

Usually lies posterior to the 6th left costal cartilage, ~4


cm from the median plane at the level of the T11
vertebra.
PYLORIC ORIFICE

The opening into the duodenum

Its position is usually indicated by a circular groove on


the surface of the organ termed as the pyloric
constriction, which indicates the position of the
pyloric sphincter (formed by circular muscle of
stomach)

The two layers of the lesser omentum extend around


the stomach and leave its greater curvature as the
greater omentum.

Figure 10. Parts of Stomach


1. FUNDUS

The dilated superior part that is related to the left


dome of the diaphragm and is limited inferiorly by the
horizontal plane of the cardiac orifice

Cardiac notch is between the esophagus and the


fundus

Reaches the left 5th intercostal space


2. BODY

The major portion of the stomach between the


fundus and the pyloric antrum

Lies in contact with the left costal margin and upper


anterior abdominal wall on the left side as it
descends from the level of T10 to the middle lumbar
vertebral area
3. PYLORIC REGION

Funnel-shaped outflow region of the stomach; its wide


part, the pyloric antrum, leads to the pyloric canal,
which is the narrow part

The pyloric region is divided into smaller regions by a


groove, the sulcus intermedius (separates pyloric
antrum and pyloric canal)

Pyloric antrum
o Part of the pyloric region that is more proximal to
the stomach proper, found near midline position
and begins to ascend as it blends into the pyloric
canal; it is the entryway to the pyloric canal
(Latin, pylorus meaning gatekeeper; antrum
meaning cave)

Pyloric canal
o The more distal part of the stomach proper; it is
located 2-3cm from the pylorus

Pyloric canal and sphincter lie on the transpyloric


plane that horizontally transverses the interverterbral
disc between L1 and L2 vertebrae

Pylorus: distal, sphincteric region of the pyloric part,


is a marked thickening of the circular layer of smooth
muscle, which controls discharge of the stomach
contents through the pyloric orifice into the duodenum
Adre, Almora, Anarna

Figure 11. Greater and Lesser Curvature of the Stomach


C. INTERIOR OF THE STOMACH
RUGAE (GASTRIC FOLDS)

Temporary longitudinal folds formed when gastric


mucosa is contracted (in contrast to permanent folds
of small intestine)

Diminish and obliterate as the stomach is distended.


GASTRIC CANAL

Temporarily formed during swallowing between the


longitudinal gastric folds of the mucosa along the
lesser curvature

Forms because of the firm attachment of the gastric


mucosa to the muscular layer, which does not have
an oblique layer at this site.

Saliva and small quantities of masticated food and


other fluids pass through the gastric canal to the
pyloric canal when the stomach is mostly empty
D. SURFACES
ANTEROSUPERIOR SURFACE

The pressure exerted by a dilated fundus against the


undersurface of the left leaf of the diaphragm is
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2018 IA


responsible for many pulmonary and cardiac
symptoms

Clinical correlation:
o
The near proximity of the heart to the stomach is
illustrated by a case where a thorn (tinik) has
been swallowed and had found its way throug the
diaphragm and pericardium into the wall and
cavity of the right ventricle
POSTEROINFERIOR SURFACE

The stomach bed is composed of the:


o
Left suprarenal gland
o
Upper part of the front left kidney
o
Splenic artery
o
Anterior surface of the pancreas
o
Diaphragm
o
Transverse mesocolon
o
Left colic flexure
E. VASCULAR SUPPLY
ARTERIAL SUPPLY

Most blood is supplied by anastomoses formed by


the:
o
Right and Left Gastric arteries along the
lesser curvature
o
Right and Left Gastro-Omental arteries along
the greater curvature

The fundus and upper body receive blood from the


short and posterior gastric arteries

3 primary branches of the celiac trunk


o
Left Gastric Artery
o
Splenic Artery
o
Common Hepatic Artery

Liver, Gallbladder, and Stomach

OS 206

Figure 13. Venous Drainage of the Stomach


F. LYMPHATICS
**This section was not discussed. We just took this from
2017 trans for further knowledge :)

Table 1. Lymphatic Circulation of the Stomach


The lymphatic vessels can be found in these areas:
1. Along the left part of the lesser curvature
2. Along the greater curvature and most of pyloric region
3. Along the left of the greater curvature
4. Along a small part of the pyloric

Figure 14. Lymphatics of the Stomach


Figure 12. Arterial Supply of the Stomach
VENOUS DRAINAGE

Gastric veins parallel the arteries in position and


course.

Portal vein - main draining vein formed by the union of


the splenic and superior mesenteric vein; receives
from:
o
Right and Left Gastric veins
o
Splenic vein - receives from the short gastric
veins and left gastro-omental veins
o
Superior mesenteric vein (SMV)- receives
from the right gastro-omental vein

Prepyloric vein - ascends over the pylorus to the R


gastric vein; used for identifying the pylorus.

G. NERVE SUPPLY

Figure 15. Distribution of Vagal Nerve to Stomach


Adre, Almora, Anarna

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2018 IA

Liver, Gallbladder, and Stomach


PARASYMPATHETIC NERVE SUPPLY

Anterior Vagal Trunk


o
Derived mainly from the left vagus nerve runs
toward the lesser curvature, where it gives off
hepatic and duodenal branches,which leave the
stomach in the hepato-duodenal ligament.
o
It continues along the lesser curvature, giving rise
to anterior gastric branches.

Posterior Vagal Trunk


o
Larger of the two, it is derived mainly from the
right vagus nerve, enters the abdomen on the
posterior surface of the esophagus and passes
toward the lesser curvature of the stomach.
o It supplies branches to the anterior and posterior
surfaces of the stomach.
o
It gives of a celiac branch, which runs to the
celiac plexus, and then continues along the
lesser curvature, giving rise to posterior gastric
branches.

you as anatomates!! Naaappreciate ko talaga kayo!!


^___________^ And thank you din pala to our cool friends
from tables 1 and 3! God bless!! <3

Appendix 1. Origin and Distribution of Stomach Arterial


Supply
Artery

H. CLINICAL CORRELATION

Initial
aorta

Celiac trunk

Left gastric

Origin
abdominal


Celiac trunk

Splenic

Splenic
artery
posterior to stomach

Posterior gastric

SYMPATHETIC NERVE SUPPLY

Comes from T6-T9 segments of the spinal cord


which passes to the celiac plexus through the greater
splanchnic nerve and is distributed through the
plexuses around the gastric and gastro-omental
arteries.

OS 206

Left gastro-omental

Splenic

Short gastric
Hepatic

artery
in hilum of

spleen
Celiac trunk

Right gastric


Hepatic artery

Gastroduodenal

Right gastro-omental

Gastroduodena
l artery

Distribution

Stomach
Lesser curvature of
stomach
Greater
curvature
and
posterior
stomach body
Posterior wall and
fundus of stomach
Left portion of greater
curvature of stomach
Fundus of stomach
Stomach
Right
portion
of
lesser curvature of
stomach
Stomach
Right
portion
of
greater curvature of
stomach

Table 2. Summary table of referred pain and organs


involved

In stomach ulcer, the sharp knifelike pain after


perforation is due to peritoneal irritation by gastric
secretion and contents
The rigidity of the abdominal wall is due to the
contraction of the muscular wall
o
It is a reflex response of the abdominal muscles
to abnormal stimuli arising from the involved area
Breathing with avoidance of abdominal respiration
excursions can be explained as a protective
mechanism shielding the abdominal wall and parietal
peritoneum from painful movement
The lesser omentum and the posterior wall of the
stomach form the important anterior boundaries of the
main part of the omental bursa o Ulcers of the
anterior wall of the stomach are apt to perforate into
the greater sac
Ulcers of the posterior wall may rupture into the
omental bursa
o
The pancreas and splenic artery are also subject
to erosion and possible fatal hemorrhage
The parietal peritoneum and the skin in the area of the
umbilicus is supplied by the 10th intercostal nerve
Pain from the small intestine is referred to the
neighborhood of the umbilicus
The sharp pain which is fairly well localized in the
epigastric region would point to the involvement of the
6th to 9th intercostal nerve
End of Transcription

Kia: At dahil matatapos na ang anatomy... gusto ko lang iaffirm na super awesome/happy/gwapo(heh)/sipag/bibo
ng anatomates ko!! Thank you Jasmine, Almira, Aldwin,
Julian, and Carlos!! Ang saya matuto at magdissect
kasama kayo. Sa sobrang galing nyo, 2pm pa lang ata
umuuwi na tayo :P Im so blessed and thankful to have
Adre, Almora, Anarna

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