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Gastrointestinal
Anatomy
Abdominal layers

What is the most superficial muscle group making up the lateral abdominal wall?

External oblique

What individual layers of fascia join to make the rectus sheath?

Fascia of the external oblique, internal oblique, and transversus abdominus

What is the name of the connective tissue that lies between the rectus muscles at the
midline?

Linea alba

What is the deepest muscle group making up the lateral abdominal wall?

Transversus abdominis

What two blood vessels and one nerve run anterior to the spine at the level of the umbilicus?

The aorta, inferior vena cava, and sympathetic trunk run together along the spine.

Retroperitoneal structures

Which two parts of the urinary system are retroperitoneal?

The kidney and ureters

What part of the pancreas is not found in the retroperitoneal space?

The tail of the pancreas

Name two major organs that lie completely in the retroperitoneal space.

The kidneys and adrenal glands

Which parts of the duodenum are retroperitoneal?

The second, third, and fourth parts of the duodenum

Which portion of the colon is not retroperitoneal?

Transverse colon

Important GI ligaments

The gastrocolic ligament contains what structures?

The gastroepiploic arteries

In the gastrointestinal tract, the gastrohepatic ligament connects which two structures?

The liver and the lesser curvature of the stomach

What gastrointestinal ligament can be cut to access the lesser sac during surgery?

The gastrohepatic ligament

What ligament is part of the greater omentum?

Gastrocolic ligament

From what fetal structure is the falciform ligament derived?

Fetal umbilical vein

The falciform ligament contains what structure?

The ligamentum teres

In the gastrointestinal tract, the splenorenal ligament connects which two structures?

The spleen and the posterior abdominal wall

In the gastrointestinal tract, the gastrosplenic ligament connects which two structures?

The spleen and the greater curvature of the stomach

The portal triad can be compressed through what opening to control bleeding?

The omental foramen (also known as the epiploic foramen of Winslow)

The gastrohepatic ligament contains what structures?

The gastric arteries

What ligament separates the greater and lesser sacs?

Gastrosplenic ligament

The _____ ligament connects the liver and the duodenum.

Hepatoduodenal

In the gastrointestinal tract, the falciform ligament connects which two structures?

The liver and the abdominal wall

The splenorenal ligament contains what structures?

The splenic artery and the splenic vein

The hepatoduodenal ligament contains what structures?

The portal triad (the portal vein, the portal artery, and the common bile duct)

In the gastrointestinal tract, the gastrocolic ligament connects which two structures?

The transverse colon and the greater curvature of the stomach

Digestive tract anatomy

What is the primary function of the lamina propria of the gut wall mucosa?

Support

What is the primary function of the epithelium of the gut wall mucosa?

Absorption

What is the rate of basal electrical rhythm in the duodenum?

12 waves/min

What lies between the inner circular and outer longitudinal layers of the muscularis externa?

The myenteric nerve plexus (Auerbach's plexus)

Villi are found in which section of the digestive tract?

Small intestine

Which layer of the muscularis externa is closer to the lumen: the circular layer or the
longitudinal layer?

The circular layer

What structure is found within the submucosa of the gut wall?

The submucosal nerve plexus (Meissner's plexus)

List the four main layers of the gut wall, starting from the inside and going out.

Mucosa, submucosa, muscularis externa, and serosa

What is the rate of basal electrical rhythm in the stomach?

3 waves/min

What is the primary function of the muscularis mucosa of the gut wall mucosa?

Mucosal motility

List three components of the gut wall mucosa.

Epithelium, lamina propria, and muscularis mucosa

Meissner's plexus controls what three functions of the submucosal gut wall?

Secretions, blood flow, and absorption

What is the rate of basal electrical rhythm in the ileum?

8-9 waves/min

Digestive tract histology

Which immunologic structures are unique to the Ileum?

Peyer's patches

Describe the epithelium of the esophagus in histological terms.

Nonkeratinized stratified squamous cell epithelium

What part of the small intestine has the highest concentration of villi and microvilli?

Duodenum; villi increase the surface area of the epithelium to maximize absorption

Name a major histological difference between the duodenum and the colon.

The duodenum has villi whereas the colon only has crypts

Goblet cells are highly concentrated in this area of the small intestine.

Jejunum

Name a submucosal structure that is unique to the duodenum.

Brunner's glands

These epithelial glands are found throughout the small intestine.

Crypts of Lieberkhn

A patient presents with intractable diarrhea and is found to have celiac disease. What
microstructure is damaged and where is it located?

The villi and the microvilli of the small intestine are likely damaged resulting in decreased
absorptive capacity and diarrhea

Enteric nerve plexuses

The submucosal plexus is located between what two layers?

The mucosa and the inner layer of smooth muscle

The primary function of the myenteric plexus is to coordinate what function?

Motility along the entire gut wall

The myenteric plexus is located between what two smooth muscle layers?

The inner circular layer and the outer longitudinal layer (remember: AUerbach's is on the
Autside)

What are the functions of the submucosal nerve plexus?

Regulation of secretions, blood flow, and absorption

Esophageal anatomy

The upper one-third of the esophagus is composed of _____ muscle.

Striated

What type of muscle fibers make up the middle one third of the esophagus?

Both striated and smooth muscle

The lower one-third of the esophagus is composed of ______ muscle.

Smooth

Aorta and its branches

At what level does the abdominal aorta bifurcate?

L4

Which paired arteries come off the aorta at the level of L1?

The renal arteries

Which branch of the aorta comes off at the level of L1?

The superior mesenteric artery

This branch of the aorta supplies the foregut.

Celiac trunk

Which paired arteries come off the aorta at the level of L2?

The ovarian or testicular arteries

Which two arteries does the aorta become after the bifurcation?

Left and right common iliac arteries

GI blood supply and innervations

What are the three embryologic divisions of the gastrointestinal tract?

The foregut, midgut, and hindgut

Which artery supplies the foregut?

Celiac artery

Which segments of the gastrointestinal tract receive parasympathetic innervation from the
vagus?

Foregut (stomach to proximal duodenum, liver, gallbladder, pancreas, spleen) and

midgut (distal duodenum to proximal 2/3 of transverse colon)

An elderly patient presents with bright red bleeding per rectum and is found to be
hypotensive. On colonoscopy, she is found to have necrotic mucosa at the splenic flexure.
What is the blood supply to this region?

Inferior and superior mesenteric arteries

What are the main gastrointestinal structures derived from the embryonic foregut?

The stomach, proximal duodenum, liver, gallbladder, and pancreas

Which artery supplies the midgut?

The superior mesenteric artery

What organ supplied by the celiac trunk is not an embryonic gut derivative?

Spleen

What portion of the gastrointestinal tract is derived from the embryonic midgut?

From the distal duodenum to the proximal two-thirds of the transverse colon

Which artery supplies the hindgut?

Inferior mesenteric artery

What portion of the gastrointestinal tract is derived from the embryonic hindgut?

From the distal one-third of the transverse colon to the upper rectum

Celiac trunk

What are the branches of the splenic artery?

The short gastrics and left gastroepiploic artery

The short gastric arteries have poor anastomoses if the _____ artery is blocked.

Splenic

What are the main branches of the common hepatic artery?

The right gastric artery, gastroduodenal artery, and hepatic artery proper

Name the three main branches of the celiac trunk.

Common hepatic artery, splenic artery, and left gastric artery

Strong anastomoses exist between what two sets of arteries of the celiac trunk?

Left and right gastroepiploics and left and right gastrics

What arteries feed the greater curvature of the stomach?

The right and left gastroepiploic arteries

What are the two branches of the gastroduodenal artery?

Superior pancreaticoduodenal and right gastroepiploic arteries

From what artery does the cystic artery arise?

The right hepatic artery, a branch of the common hepatic artery; the cystic artery supplies the
gallbladder

What arteries feed the lesser curvature of the stomach?

The right and left gastric arteries

The stomach receives its main blood supply from branches of what structure?

The celiac trunk

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Collateral circulation

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: _____ _____ (from the inferior mesenteric artery) to the middle
rectal (normally fed by the internal iliac).

Superior rectal

If the abdominal aorta is blocked, there are several anastomoses that will provide
collateral flow. Complete this one: middle colic (from the superior mesenteric
artery) to the _____ _____ (normally fed by the inferior mesenteric artery).

Left colic

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: internal mammary (from the subclavian) to the superior epigastric
(internal thoracic) to the _____ _____ (normally fed by the external iliac).

Inferior epigastric

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: superior pancreaticoduodenal (from the celiac trunk) to the _____
_____ (normally fed by the superior mesenteric artery).

Inferior pancreaticoduodenal

If the abdominal aorta is blocked, which artery can anastamose with the left colic artery (of
the inferior mesenteric artery)?

Middle colic artery (of the superior mesenteric artery)

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: _____ _____ (from the superior mesenteric artery) to the left colic
(normally fed by the inferior mesenteric artery).

Middle colic

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: _____ _____ (from the subclavian) to the superior epigastric (internal
thoracic) to the inferior epigastric (normally fed by the external iliac).

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Internal mammary

If the abdominal aorta is blocked, the superior pancreaticoduodenal artery of the celiac trunk
can anastamose with what vessel?

Inferior pancreaticoduodenal artery (of the superior mesenteric artery)

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: superior rectal (from the inferior mesenteric artery) to the _____
_____ (normally fed by the internal iliac).

Middle rectal

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: _____ _____ (from the celiac trunk) to the inferior
pancreaticoduodenal (normally fed by the superior mesenteric artery).

Superior pancreaticoduodenal

If the abdominal aorta is blocked, there are several anastomoses that will provide collateral
flow. Complete this one: internal mammary (from the subclavian) to the _____ _____ (internal
thoracic) to the inferior epigastric (normally fed by the external iliac).

Superior epigastric

The superior rectal artery (of the inferior mesenteric artery) can anastamose with what
artery?

Middle rectal artery (of the internal iliac)

If the abdominal aorta is blocked, blood can travel through the subclavian artery into the
internal thoracic artery and then through an anastomosis to which artery?
Superior epigastric (internal thoracic)

Portosystemic anastomoses

Portal-systemic anastomoses from the paraumbilical vein to the inferior epigastric and
superior epigastric veins can manifest as what?

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Caput medusae at the navel

A patient with portal hypertension presents with discomfort on defecation and bright red
blood per rectum. Physical examination shows prolapsed dilated veins around the anus that
are not tender. What is the explanation of these findings?

A portosystemic anastomoses between the superior and middle rectal arteries created
internal hemorrhoids, which are painless

Name two potential shunts that can be created surgically to relieve portal hypertension.

Splenic vein to left renal vein; portal vein to inferior vena cava

Give three examples of clinical manifestations of portosystemic anastomoses seen in patients

with portal hypertension.

Esophageal varices, internal hemorrhoids, and caput medusae (remember: gut, butt, and
caput

A chronic alcoholic patient presents with mental status change, tense ascites, and
hematemesis. What is a likely cause of his hematemesis?

Portal hypertension from his cirrhosis (as evidenced by his ascites) created esophageal varices
that ruptured, causing hematemesis

What condition causes portal-systemic anastomoses?

Portal hypertension

What is the underlying principle in surgical treatment of portal hypertension?

Creation of anastomoses to shunt blood from portal circulation into systemic circulation,
thereby bypassing the liver

Pectinate line

What type of hemorrhoids occur above the pectinate line? Below the pectinate line?

Internal; external

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The superior rectal artery is a branch of what artery?

The inferior mesenteric artery

Below the pectinate line, there is what type of innervation, somatic or visceral?

Somatic innervations

The inferior rectal artery is a branch of what artery?

The internal pudendal artery

True or False? Internal hemorrhoids are painful.

False; internal hemorrhoids are not painful whereas external hemorrhoids are painful

_____ hemorrhoids receive somatic innervation and are therefore _____.

External; painful

What type of cancer occurs above the pectinate line in the rectum? Below the pectinate line?

Adenocarcinoma; squamous cell carcinoma

Above the pectinate line, there is what type of innervation: visceral or somatic?

Visceral innervations

Above the pectinate line, the arterial supply comes from what artery?

The superior rectal artery

The pectinate line is formed where the embryonic _____ derivatives meet the _____
derivatives.

Hindgut; ectodermal

Below the pectinate line, the arterial supply is from what artery?

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The inferior rectal artery

A patient with hepatocellular carcinoma and tense ascites presents with mental status change
and bright red blood per rectum. On physical exam, you see dilated veins but cannot deduce if
they are painful given the patient's mental status. What is the likely diagnosis of the rectal
exam findings?

Internal hemorrhoids, which can result from portal hypertension

Liver anatomy

The basolateral surface of hepatocytes face what space?

The sinusoids

Describe bile flow through the liver.

Hepatocytes secrete bile via their apical surfaces into the bile canaliculi, which then drain into
the bile ductile

Whereas portal veins drain from ____, the central vein drains to ____.

Splanchnic (gut) circulation; hepatic vein and systemic circulation

A patient presents with jaundice, encephalopathy, and oliguria. He has elevated liver
enzymes. What zone of his liver is likely affected?

Zone III

A patient presents with elevated alanine aminotransferase and aspartate aminotransferase

levels with an alanine aminotransferase to aspartate aminotransferase ratio > 2.0. What zone
of his liver is likely affected?

Zone III; alcoholic hepatitis usually affects Zone III

Zone III of the liver is also known as what?

Pericentral vein zone (centrilobular zone)

Why is Zone II of the liver most affected by ischemia?

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It is furthest away from the hepatic artery

Which zone is affected most by viral hepatitis?

Zone I

What major structure is found in Zone III of the liver?

Branches of the central vein

The apical surface of hepatocytes face which space?

The bile canaliculi

Which zone of the liver contains the P450 enzyme system?

Zone III (pericentral vein/centrilobular zone)

What fluid drains through the space of Disse in the liver?

Lymph (in the liver)

Zone I of the liver is also known as the _______ zone.

Periportal

Describe the venous blood flow of the liver in order.

Portal circulation, portal vein, liver sinusoids, central vein, inferior vena cava

What structures are found in Zone I of the liver?

The portal triad (the portal vein, the portal artery, and the common bile duct)

Sinusoids of liver

Notably, the sinusoids of the liver are lacking what structure that most capillaries have?

Basement membrane

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En route from the liver sinusoids to the hepatocytes, plasma macromolecules must pass
through what space?

The perisinusoidal space (the space of Disse)

Why is it advantageous to have fenestrated capillaries in the liver sinusoids?

They allow macromolecules to have access to the hepatocytes, thereby facilitating

appropriate metabolism of these macromolecules

Liver sinusoids are lined with what kind of endothelium?

Fenestrated

Biliary structures

A gallstone in what location would lead to elevated amylase and lipase as well as serum
bilirubin and alkaline phosphatase?

Ampulla of Vater

Blockage of which biliary structure would cause a dilated gallbladder but no other blockage?

The cystic duct

A patient presents with right upper quadrant abdominal pain. Further work-up reveals a
gallstone obstructing the common bile duct. Which two biliary ducts drain directly into the
common bile duct?

The cystic duct and common hepatic duct

What is the name of the structure formed by the common bile duct and the pancreatic duct as
they empty into the duodenum?

The ampulla of Vater

What is the name of the sphincter through which bile passes to enter the duodenum?

The sphincter of Oddi

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A patient presents with right upper quadrant pain, fever, and jaundice. She has elevated liver
enzymes but normal pancreatic enzymes. If a gallstone is the cause of these findings, where is
it likely to be located?

In the common bile duct

Femoral region

What structure forms the medial border of the femoral triangle?

The adductor longus muscle

What structure forms the superior border of the femoral triangle?

The inguinal ligament

Going from lateral to medial, list the components that are found within the femoral triangle.

Nerve, artery, vein, empty space, lymphatics (remember: the contents lateral to medial are
NAVEL as well as venous near the penis)

What femoral triangle structure lies outside of the femoral sheath?

The femoral nerve

What structure forms the lateral border of the femoral triangle?

The sartorius muscle

What three main structures are contained within the femoral sheath?

Femoral artery, femoral vein, and femoral canal

Inguinal canal

Between which two structures would you find a direct inguinal hernia?

The inferior epigastric vessels and the rectus abdominus

From the most superficial layer to deep, what are the three muscles that cover the internal
(deep) inguinal ring?

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External oblique, internal oblique, and transversus abdominis

Name the layers that compose the spermatic cord, from the most superficial to the deepest
layer.

External spermatic fascia, cremasteric muscle and fascia, and internal spermatic fascia

What is the site of protrusion of an indirect hernia into the inguinal canal?

The internal inguinal ring

Hernias

Which type of hernia usually occurs among older men?

The direct inguinal hernia

Trace the path of an indirect inguinal hernia.

Internal (deep) inguinal ring, through external (superficial) ring, into scrotum

What structure do both direct and indirect inguinal hernias pass through?

The external (superficial) inguinal ring

Which type of hernia is much more common among males?

The indirect inguinal hernia

What structures are displaced in a paraesophageal hernia?

The cardia of the stomach is displaced into the thorax whereas the gastroesophageal junction
is unaffected

What structure is useful for spatially differentiating direct inguinal hernias from indirect
inguinal hernias?

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The inferior epigastric artery (remember: MDs don't LIe: Medial to inferior epigastric artery =
Direct hernia and Lateral to inferior epigastric artery = Indirect hernia to recall locations

A direct inguinal hernia bulges directly through the abdominal wall _____ to the inferior
epigastric artery.

Medial

What type of hernia is most likely to become incarcerated?

Femoral

What is the difference between sliding and paraesophageal hernias?

Sliding hernias result in a displaced gastroesophageal junction, resulting in increased risk for
gastroesophageal reflux disease, whereas paraesophageal hernias lead to displacement of the
gastric cardia increasing risk of gastric incarceration

Which type of hiatal hernia is associated with gastroesophageal reflux disease refractory to
medical treatment?

Sliding hernias result in a displaced gastroesophageal junction, resulting in increased risk for
gastroesophageal reflux disease

What type of inguinal hernia is seen in infants?

Indirect, especially in males

Are femoral hernias more common in men or women?

Women

Indirect hernias occur in infants as a result of the failure of the _____ _____ to close.

Processus vaginalis

Hesselbach's triangle is defined by what structures?

The inguinal ligament, rectus abdominus muscle, inferior epigastric artery

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An indirect inguinal hernia enters the internal inguinal ring _____ to the inferior epigastric
artery.

Lateral

How many layers of the spermatic cord cover the sac of an indirect hernia? A direct hernia?

Only the superficial layer; all layers

Diaphragmatic hernias in infants are often a result of the defective development of what
membrane?

The pleuroperitoneal membrane

Relative to the pubic tubercle, where is a femoral hernia typically located?

Below and lateral to the pubic tubercle (through the femoral canal)