Anatomy of the Abdomen

Dr. Ashley Stephen

AshleyStephen@RossU.edu
Department of Anatomy

Recommended reading: Practice questions:

Clinically Orientated Anatomy - 7th Edition: Pages 217-228 Located on eCollege below this lecture file
 Learning Objectives
✓ Outline the abdominal viscera in situ and their relationship to the alimentary system: gastrointestinal tract, liver,
gallbladder, pancreas and the spleen
✓ Differentiate parietal peritoneum from visceral peritoneum and integrate the embryology of the peritoneum
✓ Distinguish intraperitoneal versus extraperitoneal organs and classify: intraperitoneal, retroperitoneal
(primary 1° and secondary 2°) and infraperitoneal (a.k.a subperitoneal)
✓ Describe the following abdominal structures associated or derived from the peritoneum:
 Greater omentum  Mesenteries
 Lesser omentum  Peritoneal ligaments
 Lesser sac a.k.a. Omental bursa – differentiate from the Greater sac
✓ Identify the boundaries of the omental (epiploic) foramen
✓ Define the supracolic viscera (distal esophagus, stomach, spleen, liver, gallbladder, pancreas and proximal duodenum) and relate
the relevant surface anatomy, close anatomical relationships with other structures, arterial supply, venous drainage,
innervation, lymphatic drainage and associated ligaments within the abdominal cavity
✓ Describe the anatomical relationships of the infracolic viscera: small intestine (distal duodenum, jejunum and ileum), large
intestine (cecum, appendix, ascending colon, transverse colon, descending colon, sigmoid colon), rectum and the anal canal
2
 Learning Objectives
✓ Identify the unpaired abdominal arteries (celiac trunk, superior mesenteric artery and inferior mesenteric artery) and distinguish
their associated vertebral levels, branches and the arterial anastomoses which supply the foregut, midgut and hindgut
✓ Define the structures that form the portal triad and outline the biliary system
✓ Outline the formation of the hepatic portal vein
✓ Differentiate the hepatic portal venous system and systemic (caval) venous system and outline the portal-systemic
(a.k.a portocaval) anastomoses, in particular: gastroesophageal, paraumbilical and anorectal
✓ Identify the boundaries of the cystohepatic triangle (a.k.a. Triangle of Calot)
✓ Divide the duodenum into four parts and describe the significance of the ligament of Treitz
✓ Distinguish the proximal jejunum from the distal ileum
✓ Describe the internal features of the gastrointestinal tract by comparing the stomach, small intestine, large intestine,
rectum and anal canal and relate the clinical significance of the pectinate line (e.g. difference of the venous/lymphatic drainage
and innervation above or below)
✓ Describe the external features of the large colon and link the relevance of the teniae coli with the appendix
✓ Recognize referred pain in the associated dermatome and respective spinal cord segment for the innervation of
inflamed GI organs 3
 Learning Objectives
✓ Outline the following clinical correlations:
 Omental bursa herniation
 Ascites
 Pancreatic cancers
 Appendectomy
 Paracentesis
 Carcinoma of the stomach - Troisier’s sign
 Peptic ulcers
 Cholecystectomy
 Peritoneal adhesions
 Cholelithiasis - Gallstones
 Peritoneal dialysis
 Cirrhosis of the liver
 Peritonitis
 Colitis - Crohn disease
 Portal hypertension:
 Collateral circulation
Caput medusa, esophageal varices & hemorroids
 Direction of peritoneal fluid flow
 Pringle maneuver
 Diverticulosis  Pyrosis (Heartburn)
 Intussusception  Splenic rupture
 Ischemia  Volvulus of the sigmoid colon

Recommendation:
**Link the anatomical and clinical information provided in the lecture to the gross anatomy laboratories** 4
 Overview: Function of Abdominal Viscera

Mechanical breakdown
and propulsion
• Peristalsis
• Segmentation
Liver

Stomach
Digestion:
• Gastric acid Gallbladder Pancreas
• Bile Duodenum
Jejunum
• Pancreatic juices & ileum
Descending
colon
Absorption
• Nutrients Cecum
Appendix
• Water Rectum
5
 Peritoneal Cavity
When the anterior abdominal wall is reflected to
Left lobe expose the contents of the abdominal cavity,
of liver
everything that can be seen is covered in
peritoneum
• No structures lie between the parietal and visceral layers of
peritoneum as this “space” is the peritoneal cavity
• In life, fluid occupies this potential space to allow
movement and mobility of certain organs
• Peritoneal cavity can be divided into:
• Greater sac – main compartment
• Lesser sac – hidden from view
• All abdominal viscera have a relationship to the
peritoneum:
Transverse colon • Intraperitoneal – within
partly obscured by the greater omentum • Extraperitoneal – outside 6
 Peritoneum: Abdominal cavity covering
• Parietal layer of peritoneum
Covers and lines the internal walls of the abdomen
→ Pain is well localized (very sensitive)
Transverse colon → Served by the same neurovasculature as
the adjacent wall/structure

• Peritoneal cavity
Normally a “potential” fluid-filled space between the
parietal and visceral peritoneum
IVC
• Visceral layer of peritoneum
Intervertebral Covers and invests abdominal organs that protrude into the
disc
peritoneal cavity
→ Pain is generalized (is referred)
→ Served by the same neurovasculature as
the organ it is covering

• Peritoneal structures
Form from more than one layer of peritoneum
→ e.g. mesentery, omenta 7
 Preview: Development of the Gut Tube
Amniotic Ectoderm
Amniotic cavity Ectoderm
cavity Visceral
(splanchnic)
mesoderm

Parietal Endoderm
(somatic)
mesoderm
Parietal
mesoderm Coelom
Connection (forming the body
between gut & cavity) Body cavity
Visceral (a.k.a. Peritoneal cavity) DORSAL
yolk sac
mesoderm Yolk sac Gut
Endoderm tube MESENTERY
~ Day 21 ~ Day 24 ~ Day 28
Transverse Sections
• Lateral plate mesoderm divides: 1. Visceral (splanchnic) layer
2. Parietal (somatic) layer
• Amnion grows faster than the yolk sac causing the lateral body walls to fold down
Cloacal
towards midline and fuse together to form a cavity.
membrane Oropharyngeal
membrane

Click Here: • Dorsal mesentery suspends the gut tube from the dorsal (posterior) wall into the
Folding of the embryo in relation to peritoneal cavity.
the lateral plate mesoderm 8
 Preview: Development of the Gut Tube
Amniotic cavity Oropharyngeal Lung
membrane Cloacal Liver
bud
Hindgut membrane bud
Foregut
Midgut
Heart Connecting
tube stalk Remnant of
oropharyngeal
membrane
Pericardial Heart Allantois
cavity tube VENTRAL
Yolk sac
MESENTERY
Septum Allantois
Vitelline duct
Yolk sac transversum
~ Day 21 ~ Day 24 ~ Day 28

Midsagittal Sections • Cephalocaudal folding also helps to close the gut tube

• The ventral mesentery is formed from the septum transversum

- ventral mesentery is a mass of mesenchyme below the diaphragm and between
the stomach and ventral (anterior) body wall

• The primitive gut starts as a simple straight tube however increased GI growth in
relation to a limited body cavity at the 10th week results in:
Cloacal Oropharyngeal ▪ Looping & twisting ▪ Retroperitoneal structures ▪ Formation of recesses
membrane membrane
▪ Rotation & displacement ▪ Physiological umbilical herniation 9
 Preview: Embryology of the Peritoneum
Mesenteries and ligaments
Ventral mesentery:
provide pathways for
vessels, nerves, and ▪ Only found between the foregut and
lymphatics to travel back and the upper portion of the duodenum.
forth between abdominal organs
▪ Ventral mesentery is pulled towards
“Mesentery”
Defined as a membranous fold attaching an organ to the body wall
the right side of the body!

Lesser omentum ▪ Associated with the liver &

Liver
(ventral) lesser curvature of the stomach
Diaphragm Dorsal mesogastrium
Falciform ligament
(ventral)
Celiac trunk Dorsal mesentery:
Dorsal mesoduodenum ▪ Extends continuously from the foregut
Vitelline duct
Superior mesenteric a. to the end of the hindgut.

Mesentery proper ▪ Dorsal mesentery is pulled towards the

Allantois
(dorsal) left side of the body!
Inferior mesenteric a.
Cloaca ▪ Associated with the
Dorsal mesocolon
Umbilical artery
posterior abdominal wall 10
 Preview: Development of the Omental Bursa
Greater Lesser
Stomach
peritoneal sac peritoneal sac
Pancreas
(a.k.a. Omental
Duodenum bursa)
Mesentery of the
Lesser peritoneal sac Double layers of
transverse colon
(Omental bursa) peritoneum fuse
Greater together
Mesentery proper
omentum
Bulging of the dorsal
mesogastrium
(a.k.a. Greater omentum)
Small intestine
Sagittal View
Anterior view A Transverse view
L R Liver
P
Lesser omentum
Liver
Ventral Gastrosplenic
mesentery lig.
Stomach
Spleen
(rotating)
Splenorenal
Left Dorsal Lesser sac
(lienorenal) lig.
kidney mesentery (Omental bursa) 11
 Division of the Peritoneal Cavity: Greater sac
Diaphragm Falciform ligament
The peritoneal cavity is a space between the
parietal peritoneum and visceral peritoneum and
can be divided into two “sacs”

Greater Sac:
▪ Main compartment of the peritoneal cavity
▪ Extends from the:
▪ Diaphragm
▪ Pelvis
▪ Remember NO organs are in this potential space!

Transverse colon Greater omentum

Males → Peritoneal cavity is completely closed

Sac:
A cavity within an organism that is
Females → There is an opening in the peritoneum through the uterine tubes enclosed by a membrane and contains
➢ Infectious (or foreign) materials can travel from the
air, liquid or solid structures
pelvis into the abdominal cavity! 12
 Division of the Peritoneal Cavity: Lesser sac
Cut edges of the Pancreas
(deep to the
Lesser Sac: greater omentum peritoneum)

▪ Also known as the omental bursa

▪ Remember NO organs here either!
▪ Forms due to the twisting and rotation of the gut.
▪ Small compartment that is lined with peritoneum
and is positioned:
▪ Behind → Stomach & greater omentum
▪ In-front of → Peritoneum & pancreas

The omental foramen is an opening that provides a direct

communication between the greater & lesser sacs and can also be known as: Bursa:
Latin word for bag or purse and is defined
▪ Epiploic foramen as being a fluid-filled sac or sac-like cavity
▪ Foramen of Winslow 13
 Boundaries of the Omental Foramen
Hepatogastric Diaphragm
Anterior border: ligament

• Hepatoduodenal ligament:
Hepatoduodenal
• The free edge of the lesser omentum ligament
• Contains the portal triad
1. Common bile duct
Greater
2. Hepatic portal vein omentum
3. Hepatic artery proper

Posterior border:
• Inferior vena cava
• Right crus of the diaphragm
Right Left
Kidney Kidney Spleen

Superior border: IVC

• Caudate lobe of the liver Duodenum

Transverse

Inferior border: colon Stomach

• 1st part of the duodenum Greater

omentum
14
Abdominal structures associated or derived from the
peritoneum:
1. Mesentery: defined as a double layer of peritoneum resulting from the invagination of the
peritoneum by organs.

2. Omenta: are extensions of peritoneum that form ligamentous “aprons” that extend from
the stomach & proximal duodenum to adjacent organs.

3. Peritoneal ligaments: defined as a membranous fold (a.k.a. double layer of peritoneum) that
supports an organ by helping to keep it in anatomical position.

4. Peritoneal recesses: defined as potential spaces in the abdominal cavity where excess fluid
may collect.

5. Peritoneal fossae: are depressions in the anterior abdominal wall that are lateral to the
three respective umbilical folds.
See Anterior Abdominal Wall Lecture for the Median, Medial and Lateral peritoneal folds 15
 1. Mesentery
Mesenteries and ligaments provide pathways for vessels, nerves, and lymphatics to pass between
abdominal organs
Greater omentum ▪ Mesentery helps to provide a continuous connection
(reflected)
between the visceral and parietal peritoneum
▪ Contains fat as well as the arteries, veins, lymphatic
Jejunum vessels, and nerves that supply the abdominal organs
Transverse (cut)
mesocolon ▪ Also functions to connect organs to the posterior
abdominal wall
Mesentery
proper ▪ Named according to the organs they connect:
Ileum (cut)
(cut)  Mesoesophagus
 Mesogastrium
Sigmoid
mesocolon  Mesentery proper
 Mesoappendix
Lateral
umbilical fold  Transverse mesocolon
Arcuate line
 Sigmoid mesocolon 16
 2. Omenta (singular = omentum)
Lesser Omentum: Greater Omentum:
▪ Double layered peritoneal fold ▪ Four layered peritoneal fold
▪ Connects the transverse colon to the
▪ Connects the liver to the LESSER curvature
GREATER curvature of the stomach
of the stomach and the first part of the duodenum
▪ Hangs down and is able to move
▪ Can be divided into two ligaments:
within the peritoneal cavity
1. Hepatogastric → Thin and membranous portion
2. Hepatoduodenal → Thick, free edge containing
the portal triad

“Abdominal Policeman”
Can wrap around organs to localize inflammation
and prevent peritoneal adhesions 17
 3. Peritoneal Ligaments
Coronary lig. Gastrophrenic Ligaments can connect:
lig. • Organs to another organ
• An organ to the abdominal wall

Gastrosplenic Splenorenal lig.

lig.

Falciform lig. *Phrenicocolic

Round lig. of liver lig.

Gastrocolic
▪ Coronary ligament lig.
(a.k.a. left/right triangular ligaments)

▪ Falciform ligament ▪ Hepatogastric ligament

▪ Round ligament of liver
(a.k.a. ligamentum teres hepatis)
▪ Hepatogastric ligament
(a.k.a. membranous lesser omentum)
▪ Hepatoduodenal ligament
(a.k.a. thick edge lesser omentum)
▪ Gastrophrenic ligament
▪ Gastrosplenic ligament
▪ Gastrosplenic ligament
(a.k.a. gastrolienal ligament)
(a.k.a. gastrolienal ligament)
▪ Splenorenal ligament
▪ Gastrocolic ligament (a.k.a. lienorenal ligament)
*Note there is also a phrenicocolic ligament

Liver Stomach Spleen 18

 4. Peritoneal Recesses
Paracolic gutters:
• Groove or space between the abdominal wall and the
lateral aspect of the ascending or descending colon Right Left
• Allows communication between the supracolic paracolic gutter paracolic gutter
and infracolic regions of the greater sac
• Important for peritoneal fluid flow

Diaphragm Lung
Subphrenic recesses:
• Located below the diaphragm Right Left
Coronary lig.
(anterior)
• Separated into left and right by the falciform lig. subphrenic subphrenic Diaphragmatic
space space Bare surface of the liver
• Potential site for fluid collection Coronary Liver
ligament area Visceral surface
of the liver
Subhepatic space: Coronary lig.
Anterior
(posterior)
• Immediately inferior to the liver
Posterior
subphrenic
Hepatorenal recess: Falciform
abdominal mm. recess
ligament
• Extension of the subhepatic space between the Round lig.
Subhepatic
of liver Hepatorenal
visceral surface of the liver and the right kidney
recess space
• Potential site for fluid collection 19
 Abdominal Organs: Relationships to the peritoneum
Visceral peritoneum
Parietal peritoneum
Intraperitoneal
organs Omental bursa - Lesser peritoneal sac

Mesenteries Retroperitoneal
organs

Primary (1°) Secondary (2°)

Infraperitoneal organs

Intraperitoneal Extraperitoneal
20
 Intra-peritoneal Organs
Visceral peritoneum
• Stomach
• Liver
• Spleen
• Tail of the pancreas
• Duodenum: 1st part

Parietal peritoneum • Jejunum

• Ileum
Intraperitoneal organs: • Cecum & appendix
• Transverse colon
• Defined as being almost entirely wrapped in
• Sigmoid colon
visceral peritoneum
• Uterus
• Usually suspended by mesentery in the abdominal cavity
• Highly MOBILE organs • Uterine tubes 21
 Retro-peritoneal Organs
Parietal peritoneum
1° Suprarenal (adrenal) glands
Visceral Aorta and IVC
peritoneum
Ureters
Kidneys
Mnemonic
for retroperitoneal organs: Esophagus
SAD PUCKER
Rectum: Proximal 1/3rd
Retroperitoneal organ:
Defined as lying behind the peritoneum with only part of its 2° Duodenum: 2nd, 3rd & 4th parts
surface wrapped in visceral peritoneum. Pancreas: Head, neck and body
1° - Structures that are retroperitoneal from the start of their development. Ascending Colon
2° - Structures that were once suspended within the abdominal cavity by mesentery Descending colon
but migrated posteriorly behind the peritoneum. 22
 Infra-peritoneal Organs
Parietal peritoneum
• Rectum: Distal 2/3rds

• Urinary bladder

Infraperitoneal organ:
a.k.a. Subperitoneal

• Defined as being beneath the peritoneum

• Only part of its surface is covered by
parietal peritoneum
23
 Organizing Abdominal Viscera: Compartments
In the abdominal cavity, the transverse mesocolon
can be used to delineate the boundary between
supracolic and infracolic abdominal compartments:

▪ Supracolic viscera: ▪ Infracolic viscera:

 Distal esophagus  Small intestine
 Stomach  Duodenum: 2nd, 3rd & 4th parts
 Spleen  Jejunum
 Ileum
 Liver
 Cecum
 Gallbladder
 Appendix
 Pancreas
 Large colon
Duodenum: 1st & part of 2nd
Supracolic:

 Rectum
Visceral structures below the diaphragm and
above the transverse colon  Anus 24
 Organizing Abdominal Viscera: Developmentally
Foregut Inferior phrenic a.
• Distal esophagus
• Stomach
Celiac trunk
• Spleen* Branches from the
• Pancreas abdominal aorta at the
• Liver level of T12
Middle suprarenal a.
• Gallbladder
• Duodenum: 1st & 2nd parts
Superior mesenteric a.
Midgut Branches from the
Left renal a.
• Duodenum: 2nd, 3rd & 4th parts abdominal aorta at the
• Jejunum level of L1
• Ileum Testicular a.
• Cecum or
Ovarian a.
• Appendix
• Ascending colon Inferior mesenteric a.
• Transverse colon: Proximal 2/3rds
Branches from the
Hindgut abdominal aorta at the
• Transverse colon: Distal 1/3rd level of L3
• Descending colon Left common iliac a.
• Sigmoid colon
• Rectum & Anal Canal:
Above pectinate line 25
 Common
hepatic artery a. Celiac Trunk: Foregut (and spleen)
• Common hepatic artery:
Left i. Gastroduodenal artery
gastric a.  Right gastro-omental artery
 Supraduodenal artery
 Superior pancreaticoduodenal arteries
(Anterior and Posterior)
ii. Hepatic artery proper (Proper hepatic a.)
 Right gastric artery
 Left hepatic artery
 Right hepatic artery
➢ Cystic artery
Splenic a. • Hepatic artery proper runs through the hepatoduodenal
ligament (free edge of lesser omentum)

• Splenic artery:
• Runs along superior border of pancreas to spleen
i. Short gastric artery
• Parasympathetic Innervation: ii. Left gastro-omental artery
Vagus nerves (CN X) iii. Dorsal, Greater & Inferior pancreatic arteries

• Sympathetic Innervation: • Left gastric artery:

Pre-ganglionics – Thoracic splanchnic nerves (T5-T9) • Descends along lesser curvature of stomach
Post-ganglionic cell bodies – Celiac ganglion i. Esophageal branches 26
Celiac Trunk

27
 Superior Mesenteric Artery: Midgut
Inferior Middle colic a.
pancreaticoduodenal a. • Inferior pancreaticoduodenal artery
• Supplies the duodenum distal to the papillae

• Intestinal arteries
• Approx. 15-18 branches which end in:
➢ Vasa rectae (a.k.a. arteriae rectae)
Right
colic a. • Middle colic artery
• Travels through the transverse mesocolon
• Clinical anastomosis with the inferior mesenteric artery
Ileocolic a. • Forms the Marginal artery of Drummond

Appendicular a. Intestinal aa. • Right colic artery

• Travels to supply the ascending colon

• Parasympathetic Innervation:
Vagus nerves (CN X) • Ileocolic artery
➢ Appendicular artery
• Sympathetic Innervation:
Pre-ganglionics – Thoracic splanchnic nerves (T9-T12)
Post-ganglionic cell bodies – Superior mesenteric ganglion 28
Superior Mesenteric Artery

29
 Inferior Mesenteric Artery: Hindgut
• Left colic artery
• Travels through the transverse mesocolon
• Clinical anastomosis with the superior
Left mesenteric artery
colic a. • Forms the Marginal artery of Drummond

• Sigmoid arteries
• Travels through sigmoid mesocolon
Sigmoid aa.
• Forms arcades
Superior rectal a.

• Superior rectal artery

• Parasympathetic Innervation: • Terminal branch
Pelvic splanchnic nerves • Supplies the proximal 2/3rds of the rectum
• Sympathetic Innervation:
Pre-ganglionics – Lumbar splanchnic nerves (L1-L2)
Post-ganglionic cell bodies – Inferior mesenteric ganglion 30
Inferior Mesenteric Artery

31
 Unpaired Accessory Digestive Organs:
Anterior view of the supracolic viscera ex situ
Falciform
ligament
Left lobe of
Right lobe of Liver
Liver Spleen
Gallbladder

Head of the
Pancreas

Greater
omentum
32
 Liver
The liver is an intraperitoneal organ that is located in
the right upper quadrant (RUQ)
7
• Major lymph producing organ
→ Link to Semester 2: Lymph is produced in the perisinusoidal spaces of Disse 8 Approx. 4-8cm

9
• Largest gland in the body with many vital functions: 10
→ Weighs approximately 3.3lbs or 1.5kg 11
▪ Synthesis
o BILE
o Amino acids
o Gluconeogenesis Left Coronary
o Cholesterol 4 Right lobe lig.
▪ Breakdown 2 lobe
o TOXINS 1 Falciform lig.
o Hormones
o Drugs
o Amonia 3 Round ligament
▪ Storage of the liver
Gallbladder
o Glucose
o Iron Inferior View: Visceral surface Anterior View 33
 Lobes of the Liver
Inferior View: Visceral surface of the liver
The liver can be described as having lobes
that are classified differently by
anatomists and clinicians
4
• Anatomical lobes (4): 2 1
1. Right
2. Left
3. Quadrate
4. Caudate 3

• Functional lobes (9):

• Based on the blood supply!
• Independent segments can
undergo surgical resection
• Middle hepatic vein is clinically
important – Link to Medical Imaging lecture!
Porta hepatis:
This is the “hilum” of the liver where abdominal
structures can enter or leave
NOTE: The hepatic veins drain blood away from the liver and when
blood is exiting it does not pass through the porta hepatis
→ instead the hepatic veins drain posteriorly to the inferior vena cava 34
 Liver: Visceral Surface
Inferior vena cava Caudate
Bare area
(IVC) lobe Diaphragmatic area not covered in
visceral peritoneum

Left
lobe Right coronary ligament
Ligamentum venosum - Laterally becomes the
• Remnant of ductus venosus Right triangular ligament
• In the fetus, extended between
the umbilical vein and the inferior
lobe
vena cava

Gallbladder
Round ligament of the liver
• Ligamentum teres hepatis
• Thick, free, inferior border of the falciform Portal triad:
ligament
• Common bile duct
Quadrate • Hepatic artery proper
lobe • Hepatic portal vein 35
 Liver: Posterior Surface
Left Middle
Groove for inferior vena cava
hepatic vein hepatic vein
(IVC)

Triangular ligament
Left Right
Bare area
lobe of
hepatic vein
Caudate lobe right lobe

Left hepatic artery Reflection of visceral

and parietal layers of
peritoneum

Extrahepatic Portal Triad: Right

• Common bile duct Cystic
hepatic artery artery
• Hepatic artery proper
• Hepatic portal vein 36
 Liver: Arterial Supply via Celiac Trunk
Hepatic portal Common
Right hepatic vein The common hepatic artery is a direct
bile duct
artery
branch from the celiac trunk:
▪ Changes name to hepatic artery
Left hepatic
artery proper when the gastroduodenal
artery branches off to travel
Hepatic artery inferiorly
proper
▪ Hepatic artery proper divides at
Common the porta hepatis to become:
hepatic
artery ▪ Right hepatic artery
▪ Left hepatic artery

The liver receives blood from ▪ Arterial → Hepatic arteries (20-25%)

two different sources: ▪ Venous → Hepatic portal vein (75-80%) 37
 Hepatic Portal Vein
The hepatic portal vein carries all of the Inferior vena cava
Left hepatic vein
nutrients from the gastrointestinal tract Right
directly to the liver hepatic vein

• Blood in the hepatic portal vein has a slightly

higher oxygen content than the venous blood Hepatic
in the systemic/caval system portal
Splenic
vein vein
- e.g. blood that has drained from muscles in
the lower limb that drains into the inferior
vena cava

• Hepatic portal vein forms when the following

Superior mesenteric Inferior mesenteric
two veins unite: vein vein

 Superior mesenteric vein All useful and non-useful products of digestion are processed and either:
• Stored in the liver
 Splenic vein • Released out (through the hepatic veins) 38
 Liver: Venous Drainage
Middle hepatic vein IVC The hepatic veins drain blood
Left hepatic
Right hepatic vein vein away from the liver and back to
the systemic system

• The central veins of the liver unite

Central
vein together and drain to form the left, right
and middle hepatic veins respectively

• The relationship between the hepatic

veins and the inferior vena cava helps to
keep the liver in position:
→ In addition to the ligaments
of the liver
Hepatic
Common artery proper Click Here:
hepatic duct Structure of the liver and the
Hepatic
portal vein flow of blood & bile 39
 Liver: Summary
Phrenic Posterior mediastinal
lymph nodes
lymph nodes

Celiac
Hepatic lymph nodes
lymph nodes

▪ Arterial supply: Celiac trunk (Note that the hepatic portal vein is not an arterial supply!)

▪ Venous drainage: Hepatic veins → Inferior vena cava → Systemic (caval) venous system
(This is via the right, left and middle hepatic veins)

▪ Lymphatics: Drain by following two routes, either:

1. Superficial (associated with the BARE area) → Phrenic or Posterior Mediastinal l.n.
2. Deep (associated with the porta hepatis/anterior visceral surface) → Hepatic or Celiac l.n.
▪ Innervation: Parasympathetic → Vagus (CN X)
Sympathetic → Hepatic nerve plexus (part of the celiac plexus!) 40
 Gallbladder and the Biliary Tree
The gallbladder is an organ that
STORES and CONCENTRATES bile

Right hepatic duct Left hepatic duct

Cystic duct’s Common hepatic

spiral fold duct
Bile is a yellow-brown (or green) fluid that
Common bile aids in the emulsification of fat
duct ▪ Bile is produced in the liver
→ Secreted by hepatocytes
Sphincter of the ▪ The biliary ducts convey bile from the liver and deposit it
Gallbladder bile duct
into the gastrointestinal tract
→ Specifically, into the 2nd part of the duodenum
▪ The biliary system allows bile to be released intermittently
Emulsification:
and when needed
The breakdown of large fat globules into smaller, uniformly distributed
particles prior to being digested by specific enzymes → For example, when fat enters the GI tract 41
 Parts of the Gallbladder
Right hepatic duct
The gallbladder has three main parts:
Left hepatic duct
Neck 1. Fundus:
Common hepatic duct - Wide, round end

Cystic duct 2. Body

Body - Main portion that is in contact with the first part of the
duodenum and the visceral surface of the liver
Common bile 3. Neck
duct - Narrow s-shaped bend
- Mucosa begins to twirl into a spiral fold which acts like a
valve in the cystic duct
Sphincter of the
bile duct
Fundus ▪ If the sphincter of the bile duct is closed, bile can back up
along the common bile, travel along the cystic duct and be
stored in the gallbladder
Hepatopancreatic Sphincter of the main ▪ Up to 50ml of bile can be stored and it is concentrated
sphincter (of Oddi) pancreatic duct
through the absorption of water and salts
42
 Gallbladder: Arterial Supply
Right hepatic The cystic artery is highly variable,
artery
however, it most commonly branches
directly from the
right hepatic artery

Cystic Left
artery hepatic
artery

Celiac ▪ The cystic artery can be found travelling in the

trunk cystohepatic triangle
▪ May have variable origins although it will
Hepatic artery Common hepatic always reach the gallbladder
proper artery 43
 Gallbladder: Venous Drainage
Small cystic veins drain The cystic veins drain blood away from
directly into liver the gallbladder

• The gallbladder is in direct contact with the

visceral (inferior) surface of the liver and is firmly
adhered

• Common to find multiple veins

• Most small veins from the body of the

gallbladder pass directly into the hepatic
Larger cystic veins sinusoids that are within the liver
drain into the
• Most veins around the neck of the gallbladder
hepatic portal vein
drain into the hepatic portal vein
44
 Gallbladder: Summary
Irritation of the ▪ Arterial supply: Celiac trunk
Diaphragm
▪ Venous drainage: Direct or via the
Phrenic n. carries GSA axons:
Referred pain from the liver, hepatic portal vein → Portal venous system
gallbladder or duodenum

Stomach ▪ Lymphatics: Ultimately drain by following the

arteries towards → Celiac lymph nodes
Spleen Gallbladder
(GVA axons)
Liver
▪ Innervation:
Parasympathetic (GVE) → Vagus (CN X)
Kidney & Ureter
Sympathetic (GVE) → Celiac nerve plexus

NOTE:

C3, 4, 5 The gallbladder also receives general somatic afferent

(GSA) innervation as the right phrenic nerve carries this
keeps the diaphragm alive! sensory information that can lead to referred pain
45
 Pancreas
① Head: Sits in the “C-shaped” curve of the duodenum and lies to the
Tail right of the superior mesenteric artery
• Uncinate process → posterior to the superior
Body mesenteric artery
Neck ② Neck: Constricted part that is between the head and body and lies
directly behind the PYLORUS of the stomach
Head
③ Body: Lies to the left of the superior mesenteric artery and
passes anterior to the abdominal aorta

④ Tail: This is the only INTRAPERITONEAL part as it is closely related to

the hilum of the spleen and lies within the splenorenal ligament

The pancreas is mostly retroperitoneal and is an

TAIL is in the
accessory digestive gland with two distinct functions: splenorenal
1. Exocrine secretion → DIGESTIVE ligament
• Pancreatic juice
Transpyloric plane
2. Endocrine secretion → HORMONE L1
• Glucagon & Insulin 46
 Internal Ducts of the Pancreas
Common bile duct Accessory Accessory Pancreatic Duct:
pancreatic duct • Opens into the GI tract via the
minor duodenal papilla
• Usually communicates with the main
pancreatic duct
• Also known as the duct of Santorini
•

Main Main Pancreatic Duct:

pancreatic duct • Unites with the common bile duct
• Opens into the GI tract with the
common bile duct via the
major duodenal papilla
• Runs from the tail of the pancreas,
Superior through the parenchyma of the gland
mesenteric artery to the pancreatic head
Major duodenal papilla
in the 2nd part of the duodenum • Also known as the duct of Wirsung
47
 Hepatopancreatic Ampulla: Ampulla of Vater
Accessory pancreatic duct Sphincter of the Common bile
Common bile bile duct duct
duct Duodenum

Main
pancreatic
Major
duodenal
duct
papilla
Sphincter of the
Major pancreatic duct
duodenal
papilla Hepatopancreatic
sphincter Hepatopancreatic ampulla
Main pancreatic duct Sphincter of Oddi Ampulla of Vater

Papilla: Ampulla: Sphincter:

Defined as a small rounded Dilated end of a vessel Defined as a ring of muscle surrounding
protuberance on an organ of the body named after ancient flasks and serving to guard or close an opening 48
 Pancreas: Dual Arterial Supply
Anterior SUPERIOR Posterior SUPERIOR
pancreaticoduodenal artery pancreaticoduodenal artery
Branch of the celiac trunk via gastroduodenal a. Branch of the celiac trunk via gastroduodenal a.

Common hepatic a.
Supraduodenal a.
Splenic a. Greater
Gastro- pancreatic a.
duodenal a.
Inferior
pancreatic a.
Dorsal
Greater
pancreatic a.
pancreatic a.
Dorsal
pancreatic a.

Anterior INFERIOR Posterior INFERIOR

pancreaticoduodenal artery pancreaticoduodenal artery
Branch of the superior mesenteric artery Branch of the superior mesenteric artery 49
 Pancreas: Venous Drainage
The pancreatic veins drain blood from
Splenic the pancreas and as they are part of
vein
Hepatic portal the portal system, will first drain to the
vein liver before heading to the heart
• Majority of veins follow the arteries, therefore
most veins will drain into the splenic vein

• Some veins, particularly around the head of

the pancreas, will drain via the superior
mesenteric vein

Superior • Ultimately drain to the

mesenteric vein hepatic portal vein
50
 Pancreas: Summary
Celiac
lymph nodes

Pancreaticosplenic
Superior mesenteric lymph nodes
lymph nodes
Prepyloric
lymph nodes

▪ Arterial supply: Celiac trunk and Superior mesenteric artery

▪ Venous drainage: Ultimately to the Hepatic portal vein → Portal venous system
(Majority of pancreatic veins drain to splenic vein but some near the head will drain to SMV)

▪ Lymphatics: Ultimately drain by following the arteries → Celiac lymph nodes, or

→ Superior mesenteric lymph nodes
▪ Innervation: Parasympathetic → Vagus (CN X) 51
Sympathetic → Greater splanchnic (T5-T9) via the celiac plexus and superior mesenteric plexus
 Spleen
Splenic artery travels in the
The spleen is ovoid in shape and is splenorenal ligament with the Close anatomical
typically a “pulpy” mass located in tail of the pancreas
relationships:
the left upper quadrant (LUQ)
• Anteriorly
• Lies on the midaxillary line and is an
intraperitoneal organ
• Stomach
• Largest lymphatic organ in the body • Posterolaterally
▪ Capable of marked expansion & relatively • Diaphragm: Left dome
rapid contraction
• Ribs 9, 10 and 11
• Acts as a blood reservoir
▪ Identifies, removes & destroys old red blood Mid- • Medially
axillary
cells (RBCs)
line • Left colic flexure
▪ Recycles iron & globin Pleural
reflection Spleen • Inferiorly
• Not a vital organ although highly (Ribs 9, 10

vulnerable
& 11) • Left kidney
→ Close relationship with ribs!
Left colic
flexure
• Pancreas: Tail 52
 Spleen: Arterial Supply via Celiac Trunk
The splenic artery is a direct branch from the
celiac trunk which arises from the
abdominal aorta at T12:

▪ The largest branch of the celiac trunk

▪ Tortuous in nature

▪ Lies against the posterior abdominal wall;

therefore is immediately posterior to the
omental bursa and behind the
peritoneum
Splenic artery
▪ Courses along the superior border of the
Celiac trunk
pancreas
53
 Spleen: Venous Drainage
Hepatic The splenic vein is formed by
portal vein many tributaries that leave the
hilum of the spleen

• Splenic vein runs posterior to the

body of the pancreas

• The inferior mesenteric vein

usually drains into the splenic v.
Splenic vein
• The splenic vein unites with the
superior mesenteric vein to form:
Inferior
mesenteric vein → Hepatic Portal
Superior
mesenteric vein Vein 54
 Spleen: Summary
Celiac
lymph nodes
Sympathetic trunk

Celiac nerve
plexus Pancreaticosplenic
Inferior mesenteric lymph nodes
nerve plexus

▪ Arterial supply: Celiac trunk

▪ Venous drainage: Ultimately to the Hepatic portal vein → Portal venous system
(Initially the tributaries drain into the splenic veins)

▪ Lymphatics: Ultimately drain by following the arteries towards → Celiac lymph nodes

▪ Innervation: Parasympathetic → Vagus (CN X)

Sympathetic → Greater splanchnic (T5-T9) and Lesser Splanchnic (T10-T11) 55
 Gastrointestinal tract:
Anterior View of the supracolic viscera ex situ
NOTE:
Lesser omentum has been Fundus of the
dissected and removed Stomach

Pylorus of the
Second part of the Stomach
Duodenum

Transverse
colon
Greater
omentum
56
 Esophagus: Abdominal part
The esophagus travels through the Phrenico-esophageal
esophageal hiatus of the diaphragm (T10) ligament

Diaphragm
• Esophagus is attached to the diaphragm by the
phrenico-esophageal ligament

• Terminates at the cardinal orifice of the stomach:

→ Inferior esophageal ligament
Junction
of esophageal mucosa and
→ Clinically significant!
gastric mucosa
▪ Arterial supply: Esophageal branches from the left gastric artery
▪ Venous drainage – Left gastric vein → Portal venous system
– Esophageal veins → Systemic venous system (via azygos v.)

▪ Lymphatics: Left gastric lymph nodes → Celiac lymph nodes

▪ Innervation: Parasympathetic → Vagus (CN X)

Sympathetic → Greater splanchnic nerve (T5-T9) 57
 Parts of the Stomach
The stomach is an expanded part of the gastrointestinal 1. Cardia
(GI) tract where food can accumulate and prepare for • Level of T11 when supine
mechanical breakdown and chemical digestion.
2. Fundus
Cardial notch
• Dilated part (gas or sometimes fluids)
2
Esophagus

Lesser 3. Body
curvature 1 • Has two curvatures

3
4. Pylorus:
Angular notch • “Gate Keeper” that controls the
outflow of chyme
4
Greater
• Pyloric antrum → Chamber
curvature
Duodenum • Pyloric canal → Outflow region
58
 Internal Features of the Stomach
Gastric rugae
• Longitudinal folds of mucosa
• Can be temporary → diminish as stomach distends
• Can be permanent → form the gastric canal

Gastric canal Ruga:

Latin word for a wrinkle, fold or
• Groove that appears along the lesser curvature ridge
during swallowing
• Visible on medical imaging! Gastric
canal
Pyloric sphincter
• Circular band of
smooth muscle
• Junction between
Gastric
stomach and small intestine
rugae
Pyloric sphincter
→ Link to embryological clinical correlate: Congenital hypertrophic pyloric stenosis 59
 Stomach: Arterial Supply via Celiac Trunk
Hepatic artery proper Left gastric a. Left gastro-omental a.
Lesser curvature
• Left gastric artery
→ Direct branch of celiac trunk
• Right gastric a.
→ Branch of hepatic artery proper

Greater curvature
Short • Left gastro-omental (gastroepiploic) artery
gastric aa. → Branch of splenic artery
• Right gastro-omental (gastroepiploic) artery
→ Branch of gastroduodenal artery

Fundus
• Short / Posterior gastric arteries
→ Branches of splenic artery
Gastroduodenal a. Right gastric a. Right gastro-omental a. 60
 Stomach: Venous Drainage
Splenic vein
• Right gastric veins
Left
Hepatic gastric v.
→ Drain directly into the
hepatic portal vein
portal vein
Right
Short • Left gastric veins
gastric v.
gastric v. → Drain directly into the
hepatic portal vein
Middle • Right gastro-omental veins
Prepyloric v.
gastric v. → Drain into the
Pancreatico- superior mesenteric vein
duodenal vv.
Left gastroepiploic v. • Left gastro-omental veins
→ Drain into the splenic vein
Inferior
• Short gastric veins
mesenteric vein
→ Drain into the splenic vein
Superior Right gastroepiploic v. • Prepyloric vein
mesenteric vein → Drain into the right gastric vein
61
 Stomach: Summary
Anterior trunk of
Celiac
Gastric
Vagus nerve lymph nodes lymph nodes

Celiac plexus Prepyloric

Greater splanchnic lymph nodes
of nerves wrap
nerve
around the
arteries to reach Pancreaticosplenic
Pancreaticoduodenal
the different parts lymph nodes
lymph nodes
of the organ

▪ Arterial supply: Celiac trunk

▪ Venous drainage: Ultimately to the Hepatic portal vein → Portal venous system
(Initially the tributaries either drain into splenic veins or superior mesenteric veins)

▪ Lymphatics: Ultimately drain by following the arteries towards → Celiac lymph nodes

▪ Innervation: Parasympathetic → Vagus (CN X)

Sympathetic → Greater splanchnic nerves (T5-T9) 62
Infracolic Viscera
Infracolic abdominal organs are the visceral
structures related to the gastrointestinal tract
that are located below the transverse colon

• Small colon • Large colon

- Duodenum (partly) - Ascending colon
- Jejunum - Transverse colon
- Ileum - Descending colon
- Sigmoid colon
• Cecum • Rectum
- Appendix - Anal canal
63
 Abdominal Viscera: Anterior View ex situ
Pylorus of the
Right lobe of Stomach
Liver
Spleen

Second part of the

Left colic flexure
Duodenum
Transverse
Right colic flexure
colon
Greater omentum

Ileum Descending
colon
Ascending
colon Jejunum
Sigmoid
colon
Cecum
Appendix 64
 Small Intestine: Duodenum
The duodenum is the first section of the small intestine and is
considered the shortest, widest, most fixed part of the small colon

1
① Superior part:
• INTRAPERITONEAL - mobile
• Duodenal cap or ampulla is continuous with the pylorus of the stomach (approx. L1)
• Hepatoduodenal ligament connects superiorly
Minor duodenal papilla • Greater omentum connects inferiorly
Pyloric • Supplied by the celiac trunk
sphincter
② Descending part:
• Secondarily RETROPERITONEAL – immobile and covered by transverse mesocolon
• Important relationship to the head of the pancreas and gallbladder
• Lies right of the midline (approx. L2) and is anterior to the hilum of the right kidney
• Supplied by the celiac trunk AND superior mesenteric artery
• Internal features include:
- Minor duodenal papilla: Opening for accessory pancreatic duct
- Major duodenal papilla: Opening for the common bile duct and main pancreatic duct
Major duodenal papilla 65
Internal Features: 2nd part of the duodenum
Minor duodenal papilla
▪ Also known as the lesser duodenal papilla
▪ Where the accessory pancreatic duct opens
Minor
duodenal ▪ Releases pancreatic juices only
papilla ▪ Is located approximately 2cm superior to the major duodenal papilla

Major duodenal papilla

▪ Also known as the greater duodenal papilla
▪ Where the main pancreatic duct opens
▪ Elevation of mucosa protruding into the duodenum and is larger due
Major to the hepatopancreatic ampulla and sphincter internally within the
duodenal
papilla head of the pancreas
▪ Opening of the common bile duct and the main pancreatic duct
▪ Releases pancreatic juice and bile
66
 Small Intestine: Duodenum
③ Transverse / Inferior / Horizontal part:
• Secondarily RETROPERITONEAL
• Crosses posteriorly under the superior mesenteric artery
• Passes anteriorly over the inferior vena cava
• Closely related to the uncinate process of the pancreas and the root of the mesentery
• Lies at the level of L3 and crosses from right to left
• Longest section of the duodenum
• Supplied by the superior mesenteric artery
④ Fourth / Ascending:
• Mostly RETROPERITONEAL
• Terminates at the duodenojejunal flexure
• Closely related to the abdominal aorta
• Ascends back up to approx. L2 1
• Supplied by the superior mesenteric artery
2
• Supported by a suspensory ligament: 4
• Circular folds create a large The Ligament of Treitz 3
internal surface area:
- Plicae circulares
- Valves of Kerckring Histologically, the duodenum contains submucosal Brunner’s glands
67
 Suspensory Ligament of the Duodenum:
Ligament of Treitz
The suspensory ligament of the duodenum is rarely seen when
dissecting, however, it is clinically significant!
• Connects the duodenum to the diaphragm and the posterior abdominal wall
• Facilitates with the movement of the intestinal content
1 • Marks the duodenojejunal flexure – junction between the duodenum and jejunum
• Ligament clinically divides the gastrointestinal tract:
UPPER GI tract bleed is proximal
2
•
IVC
4 → Blood would appear in vomit
→ Stool would typically be dark and “tarry”
3 • LOWER GI tract bleed is distal
→ Blood would only appear in the stool

Hematemesis: Melena: Hematochezia:

Vomiting of blood that can Dark, sticky, tarry stool containing Fresh, bright red blood
be similar to coffee grounds partly digested blood in the stool 68
 Duodenum: Dual Arterial Supply
NOTE:
Supraduodenal artery is not Celiac trunk
depicted in this diagram Common hepatic a. Left gastric a.

Hepatic artery proper

Splenic a.

Gastroduodenal a.

Anterior and Posterior Dorsal pancreatic a.

SUPERIOR pancreaticoduodenal
arteries
Branches of the celiac trunk Inferior pancreatic a.

Anterior and Posterior

INFERIOR pancreaticoduodenal
arteries Superior
Branch of the superior mesenteric artery
mesenteric artery

69
 Duodenum: Summary
Hepatic Celiac
portal Splenic v. lymph nodes
vein
Pyloric
lymph nodes

Pancreaticoduodenal
lymph nodes Superior mesenteric
SMV lymph nodes

▪ Arterial supply: Celiac trunk and Superior mesenteric artery

▪ Venous drainage: Ultimately to the Hepatic portal vein → Portal venous system
(The tributaries either drain directly or may first drain into superior mesenteric/splenic veins)

▪ Lymphatics: Ultimately drain by following the arteries:

Anterior surface towards → Celiac lymph nodes
Posterior surface towards → Superior Mesenteric lymph nodes
▪ Innervation: Parasympathetic → Vagus (CN X)
Sympathetic → Greater splanchnic (T5-T9) and Lesser splanchnic nerves (T10-T11) 70
 Small Intestine: Jejunum and Ileum
The jejunum is the second section of the small intestine and the
ileum is the third (last) segment of the small intestine
Duodenum

Jejunum Jejunum Ileum

Ileum
Appendix
▪ Mostly found in the left upper ▪ Mostly found in the right lower
quadrant (LUP) quadrant (RLQ)
▪ Accounts for proximal 2/5ths ▪ Accounts for the distal 3/5ths
• Jějŭnus: ▪ INTRAPERITONEAL → highly mobile ▪ INTRAPERITONEAL →
Latin word which and attached to the posterior abdominal The mesentery proper acts as a conduit for
wall by the root of the mesentery the neurovasculature
means fasting
▪ Specialized epithelial lining for ▪ Absorbs any products of digestion that
• Eilein: absorbing nutrients that have been the jejunum missed
Greek word which digested ▪ Clinically significant epithelial lining:

means to twist up ▪ Gradual change → no clear Peyers patches

delineation of when ileum begins Link to embryological clinical correlate
tightly
→ Meckel’s diverticulum 71
 Jejunum and Ileum: Arterial Supply
Long
vasa recta SMA

Long Few, large Short Many, small

vasa recta arterial arcades vasa recta arterial arcades

Mesentery Short
proper vasa recta

 Form follows function:

▪ As there is less absorption of nutrients in ileum when compared with the jejunum, the ileum therefore does
not need as much oxygenated blood
▪ The ileum also has a smaller surface area and less circular folds which accounts for the fact that it needs less arterial supply!
72
 Jejunum versus Ileum
There is no clear boundary between the jejunum and
ileum, therefore always compare the features of the
PROXIMAL jejunum and DISTAL ileum

Distinguishing Features Jejunum Ileum

Color Deeper red Pale pink
Circular folds
Diameter 2-4cm 2-3cm (Plicae circulares)
a.k.a. Caliber
Wall Thick and heavy Thin and light
• Greater density • Lesser density
Vascularity • Long vasa recta • Short vasa recta
• Few large arterial arcades • Many short arterial arcades

Mesenteric fat Less Plenty

Peyers patches
Large, tall and closely Low and sparse (possibly (Lymphoid nodules)
Circular folds packed absent)

Peyer’s patches Few Many 73

 Jejunum and Ileum: Summary

Hepatic portal vein

Splenic vein
Superior
Inferior mesenteric
mesenteric vein
vein

▪ Arterial supply: Superior mesenteric artery

▪ Venous drainage: Ultimately to the Hepatic portal vein → Portal venous system
(The tributaries of the small intestine drain into the superior mesenteric vein)

▪ Lymphatics: Ultimately drain by following arteries towards → Superior Mesenteric lymph nodes
▪ Innervation: Parasympathetic → Vagus (CN X)
Sympathetic → Greater splanchnic (T5-T9) and Lesser splanchnic nerves (T10-T11) 74
Large Intestine
Right colic Left colic
(hepatic) (splenic)
flexure flexure
Transverse colon

Descending colon
Ascending colon
Cecum

Sigmoid colon
Rectum
75
Features of the Large Intestine:
Teniae Coli & Omental Appendices
Teniae Coli:
• Three distinct bands of smooth muscle that run
longitudinally
• Begin at the appendix
• Are named according to their position and location:

3 1. Mesocolic tenia
Where the transverse and sigmoid mesocolon attach
Omental 2. Omental tenia
3
appendices Where the omental appendices attach
2
1 2 3. Free tenia
1 Can be visually followed on the external, visceral
surface of the colon

• Terminate by merging together at the rectosigmoid junction

• Contract lengthwise to form haustra

Omental Appendices:
• Small, fatty projections that are only found on the colon
• Also known as epiploic appendages 76
 Features of the Large Intestine: Teniae Coli & Omental Appendices
Haustra:
• Contraction of the teniae coli results in the
shortening of the intestinal wall
• Sacculations form as the wall becomes “baggy”
and gathered
• Visible on the external surface
Haustra • Collectively these pouches are called haustra
(external sacculations) → singular is haustrum
Semilunar folds
(internal ridges)
Semilunar folds:
• The haustra are internally separated by prominent
ridges of mucosa that are called semilunar folds
• Visible on the internal surface
Ileocecal valve • Also known as plicae semilunaris

Peristalsis: Segmentation:
Ripple-like wave of circular and longitudinal muscular Circular muscular contractions that mix and churn
contractions forcing material to propel forwards material forwards and backwards 77
 Features of the Large Intestine: Ileocecal Valve
Ileocecal junction:
Opening of the • Marks the junction between the small intestine
appendix and large intestine when the ileum empties
content into the cecum via the ileocecal valve

Ileocecal valve:
• Formed by two semilunar shaped flaps that
Frenulum surround a slit-like orifice (hole)
of the • Located approximately 2cm above the opening of
ileocecal
the appendix
valve
• Acts to prevent REFLUX of chyme from the cecum
back into the ileum when digested material is
Ileocecal valve acting against gravity to be propelled up the
ascending colon
Superior and inferior ileocolic lips • The ileocolic lips create a PASSIVE flap valve that
remains closed with tonic contractions
78
 Large Intestine: Cecum
The cecum is the first part of the large
Right PARACOLIC gutter

Mesenter intestine and is continuous with the

y proper
Ileocolic ascending colon
artery
• Located in the right lower quadrant (RLQ)
→ iliac fossa close to the inguinal ligament
• INTRAPERITONEAL organ as it can be lifted
relatively freely and is entirely covered in a
visceral layer of peritoneum
• Bound to the posterior abdominal wall by
Meso-appendix cecal folds instead of having it’s own
mesentery

Retrocecal Arterial supply is via:

recess
The ileocolic artery which is a direct
Appendicular branch of the superior mesenteric a.
Appendix artery
79
 Large Intestine: Appendix
Acute appendicitis: Initial appendicitis:
The appendix is a 6-10cm blind intestinal
McBurney’s Periumbilical
Point pain pain diverticulum which contains masses of lymphoid
tissue

ASIS • Located in the right lower quadrant

0.5%
(RLQ)
• INTRAPERITONEAL organ
64%
• Held in place by a short, triangular
1% mesentery called the mesoappendix
• Arises from the posteromedial aspect
2% 32% of the cecum

Arterial supply is via:

The Appendicular artery which travels in the
mesoappendix and branches directly from the ileocolic a.
Healthy Initial: GVA axons Acute: GSA axons 80
 Large Intestine: Ascending Colon
Peritoneum covering the
retroperitoneal organs The ascending colon is the second part of the
large intestine and connects the cecum to the
right colic flexure where it becomes the
transverse colon

• Located in the right quadrants (RLQ and RUQ)

• Secondarily RETROPERITONEAL organ
→ link to embryology as only the anterior surface
and sides are covered by peritoneum
Mesentery • Right paracolic gutter is located laterally
• Narrower than the cecum
proper • The right colic (hepatic) flexure is closely related to
the inferior surface of the liver and 9th and 10th ribs

Arterial supply is via:

Median
umbilical The Right colic artery which is typically a
fold direct branch of the superior mesenteric a. 81
 Large Intestine: Transverse Colon
The transverse colon is the third part of the
Greater
omentum large intestine and is the longest, most mobile
section
Transverse
• INTRAPERITONEAL organ
mesocolon • Connected to the posterior abdominal wall by the
transverse mesocolon which allows it to hang down
to level of the umbilicus
→ approximately L3/L4 vertebral level
• Attaches to the diaphragm at the left colic (splenic)
flexure via the phrenicocolic ligament
Hepatic
(right colic) Dual arterial supply via:
flexure
 Proximal 2/3rds → Middle colic artery
 Distal 1/3rd → Left colic artery

82
 Proximal Large Intestine: Summary
Hepatic
portal
vein

Superior
mesenteric
vein

▪ Arterial supply: Superior mesenteric artery

▪ Venous drainage: Ultimately to the Hepatic portal vein → Portal venous system
(The ileocolic, right colic and middle colic veins drain into the superior mesenteric vein)

▪ Lymphatics: Ultimately drain by following arteries towards → Superior Mesenteric lymph nodes
▪ Innervation: Parasympathetic → Vagus (CN X)
Sympathetic → Lesser splanchnic (T10-T11) and Least splanchnic nerves (T12) 83
 Large Intestine: Descending Colon
Hepatic portal The descending colon is the fourth part of
vein Splenic vein
the large intestine and begins at the left
Splenic
(left colic) flexure
colic flexure where it connects the
transverse colon to the sigmoid colon

• Located in the left quadrants (LUQ and LLQ)

Inferior • Secondarily RETROPERITONEAL organ
mesenteric → link to embryology as only the anterior surface
vein and sides are covered by peritoneum
• Left paracolic gutter is located laterally
• Typically longer than the ascending colon
Left colic • The left colic (splenic) flexure is closely related to
the spleen
artery
Arterial supply is via:
The Left colic artery which is a direct
branch of the inferior mesenteric a. 84
 Large Intestine: Sigmoid Colon
Mesentery The sigmoid colon is the fifth part of the
proper Splenic vein
large intestine and connects the
Peritoneum descending colon to the rectum
with left colic
arteries and veins
travelling deep • Located in the left lower quadrant (LLQ)
• Extends from the iliac fossa to approximately S3
vertebral level
• Characterized by S-shaped loop
• INTRAPERITONEAL organ
→ link to clinical correlate: Volvulus
Sigmoid • Teniae coli terminate at the rectosigmoid junction
→ approximately 15cm from the anus
mesocolon
Arterial supply is via:
The Sigmoid arteries which is a direct
branch of the inferior mesenteric a.
85
Large Intestine: Rectum and Anal Canal
The rectum lies between the sigmoid colon
Superior transverse and the anal canal
rectal fold
• Fixed terminal part of the gastrointestinal tract
• Follows the sacrococcygeal curve
Middle transverse • Internal surface features: Rectal folds
rectal fold • External surface:
• No haustra
• No teniae coli
• No omental appendices
Inferior transverse
rectal fold • Primarily RETROPERITONEAL → Proximal part
• INFRAPERITONEAL (subperitoneal) → Distal part

Anorectal Anal Canal

junction • Continuous with the rectum at the pelvic diaphragm where it
makes a 90 degree posterior bend known as the
Pectinate line ANORECTAL FLEXURE
• Divided into an upper and lower part by the PECTINATE LINE
86
 Anal Canal: Internal Features
Anal
Anal Columns
column
• Series of longitudinal ridges containing the
Rectal ampulla superior rectal vessels
→ Most distal extent
Anal Valves
• Located at the inferior ends of the anal
Anorectal columns
junction
Anal Sinuses
• Small recesses that are superior to the anal
Pectinate valves
line → Secrete mucus during defecation
Anal Anal  Superior part of the anal canal lies between the
sinus valve anorectal junction and the pectinate line
- VISCERAL innervation
The pectinate line indicates the junction of the  Inferior part of the anal canal lies between the
pectinate line and the anus
superior and inferior parts of the anal canal - SOMATIC innervation
87
 Rectum and Anal Canal: Rich Arterial Supply
Inferior mesenteric a. Abdominal aorta Proximal 2/3rds:
Left common
iliac a.
• Superior rectal artery
 Terminal branch of the
inferior mesenteric artery

Superior Middle:
rectal artery • Middle rectal artery
 Internal iliac artery
Superior gluteal a.

Distal:
Middle • Inferior rectal artery
rectal a.  Internal pudendal artery

NOTE:
Inferior The rectum is arbitrarily divided into
proximal, middle and distal parts based on
rectal a. the arterial supply, however, this is not
visibly distinguishable and is not equal 88
 Rectum and Anal Canal: Venous Drainage
Inferior mesenteric Superior
Proximal:
vein rectal vein
• Superior rectal vein
→ Inferior mesenteric vein
 Portal venous system

Middle:
• Middle rectal vein
→ Internal iliac vein
 Caval venous system

Distal:
• Inferior rectal vein
Middle Inferior → Internal pudendal vein
 Caval venous system
rectal vein rectal vein 89
 Distal Large Intestine: Summary
Distal rectum ▪ Arterial supply:
ABOVE pectinate line: Above pectinate line → Inferior mesenteric artery
• VISCERAL Innervation
Below pectinate line → Internal iliac artery (via internal pudendal aa.)
→ Parasympathetic and
sympathetic ▪ Venous drainage:
Above pectinate line → Portal venous system
Below pectinate line → Systemic (caval) venous system

▪ Lymphatics:
Ultimately drain by following the arteries:
Descending & Sigmoid colon, Proximal rectum → Inferior Mesenteric l.n.

Distal rectum: Above pectinate line → Internal iliac lymph nodes

Pectinate line Distal rectum: Below pectinate line → Superficial inguinal lymph nodes

Distal rectum
▪ Visceral Innervation ABOVE pectinate line:
BELOW pectinate line:
Parasympathetic (above pectinate line) → Pelvic splanchnic nerves (S2-S4)
• SOMATIC Innervation
→ Inferior rectal nerves Sympathetic (above pectinate line) → Lumbar splanchnic nerves (L1-L3) 90
Review: Abdominal Viscera

91
 Review of Concepts: Abdominal Viscera
• Inflammation of parietal peritoneum results in localized pain
• Inflammation of organs (a.k.a. visceral peritoneum) results in radiating, referred pain
• The omental bursa (a.k.a. lesser peritoneal sac) is a “dead-end” area that is located behind the stomach &
lesser omentum and is in-front of the pancreas – the only access to this pouch is via the omental (epiploic)
foramen
• An intraperitoneal organ is highly mobile inside the abdominal cavity as it has it’s own mesentery and will
be covered in visceral peritoneum
• An extraperitoneal organ is “fixed” or anchored inside the abdominal cavity
• A mesentery is a double layer of peritoneum that provides a “safe, hidden” pathway for neurovasculature
to pass between abdominal organs without being exposed in the peritoneal cavity
• Foregut (distal esophagus to proximal duodenum) supplied by celiac trunk (T12)
• Midgut (distal duodenum to proximal 2/3rds transverse colon) supplied by superior mesenteric artery (SMA – L1)
• Hindgut (distal 1/3rd transverse colon to proximal 1/3rd rectum) supplied by inferior mesenteric artery (IMA – L3)
• Lymphatic drainage of the abdominal cavity typically follows the arteries – would not want infections of the
abdominal region draining towards the liver
• Hepatic portal vein forms from the union of the splenic vein and superior mesenteric vein
• Portal venous system drains nutrient rich blood away from the gastrointestinal tract towards the liver
• Systemic (a.k.a. caval) venous system drains deoxygenated blood towards the heart
• The portal triad is defined as the common bile duct, hepatic artery proper and the hepatic portal vein which Jejunum &

run within the hepatoduodenal ligament

• Suspensory ligament of the duodenum (ligament of Treitz) divides upper GI tract bleeds (e.g. blood entering
the digestive tract via the esophagus/stomach/duodenum) from lower GI tract bleeds (e.g. blood entering the
Sigmoid colon
digestive tract via the jejunum/ileum/large intestine/rectum/anal canal)
• Internal features: Stomach = gastric rugae, Small intestine = circular folds, 2nd part of Duodenum = major and minor
papillae, Pancreas = main and accessory pancreatic ducts plus the hepatopancreatic ampulla, Large intestine = semilunar
folds, Rectum = transverse rectal folds, Anal canal = anal columns.
• Pectinate line divides the anal canal into an internal visceral part (painless) and external somatic part (very
sensitive to pain) 92
 Clinical
Correlations

“Your radiograph showed a broken rib,

but we fixed it with Photoshop” 93
 Collateral Circulation
Marginal artery
of Drummond
• Can be seen at
the splenic flexure!

Anterior Superior
pancreaticoduodenal a.
Inferior
pancreaticoduodenal a.

Anterior Inferior
pancreaticoduodenal a.

Anastomosis between the Anastomosis between the

foregut and midgut: midgut and hindgut:
• Superior pancreaticoduodenal aa. • Middle colic a.
• Inferior pancreaticoduodenal aa. • Left colic a. 94
 Marginal Artery of Drummond
The Marginal artery of Drummond is a
term that is used to describe the arteries
supplying the midgut and hindgut when
collectively they form a continuous circle
along the inner border of the large colon

• During development, the middle colic artery may

Arc of not meet with the left colic artery and this is why
Marginal artery the commonest area of colonic ischemia is at the
Riolan
of Drummond splenic flexure
→ In this case it is known as Sudeck’s point
Mesenteric meandering artery
(Arc of Riolan or Central anastomotic mesenteric artery): • Clinically, the anastomosis of the superior and
inferior mesenteric arteries provides COLLATERAL
Occasionally clinicians may refer to the arc of Riolan which can be an flow in the event of occlusion or significant stenosis
additional arterial loop connecting the middle colic artery with the left colic
artery, however, surgeons believe this term should be abolished 95
Reference: Variation of the arterial supply

 Name the arteries

according to the part
of the gastrointestinal
tract that the branch
is supplying

 Use the relation of

the other arteries to
help determine the
pattern
96
 Review of the venous systems:
 Systemic venous system:
▪ Veins that drain deoxygenated
blood directly towards the heart
▪ Sometimes referred to as
“Caval” system as it involves
the superior & inferior vena cavae
Portal versus Caval
 Hepatic portal venous system:
▪ Veins that drain nutrient rich deoxygenated
blood from the intestines and the spleen
directly towards the liver
▪ Remember, the liver is unique in that it
receives both oxygenated and deoxygenated
blood → from the proper hepatic artery and hepatic
portal vein respectively

Portal System:
Defined as a part of the circulation in which blood draining
from the capillary bed of one structure flows through a larger
vessel(s) to supply the capillary bed of another structure
before returning to the heart
Examples include:
• Hypothalamus and pituitary gland
• Liver 97
 Cirrhosis of the Liver
▪ Progressive destruction of hepatocytes
- Primary site for detoxification of substances absorbed by the GI
tract so the liver is vulnerable to cellular damage
▪ Liver cells are replaced by fibrous (scar) tissue and regenerative
nodules (lumps)
➢ Liver becomes firm
Cirrhotic liver ➢ Circulation becomes inhibited
▪ Commonly caused by:
• Chronic alcoholism
• Hepatitis B and C
• Fatty liver disease

Treatment may involve a shunt of venous blood from the portal

system to the caval (systemic) system, or if the cirrhosis is very
Normal liver advanced then a liver transplant may be necessary 98
 Portal Hypertension
▪ Suprahepatic causes:
 Cardiac diseases
 Hepatic vein thrombosis
▪ Hepatic causes:
 Cirrhosis and acute liver failure
 Hepatocellular cancer
 Schistosomiasis
▪ Infrahepatic causes:
 Arteriovenous malformation
 Tumor in the head of the pancreas
 Splenomegaly
 Portal vein thrombosis
Varices:
Increased portal blood pressure can result in
potentially fatal, abnormally dilated veins
Portal hypertension is defined as an increase in
pressure of the blood travelling in the veins of
the portal system
▪ Venous blood draining away from the GI tract usually
drains to the liver before draining into the inferior vena
cava…so if the route to the liver is obstructed then the
reverse (collateral) flow from the portal system veins
through to the caval system veins instead can divert blood
to the heart instead of the liver
▪ The small caliber veins of both the portal and caval system
are not designed or built to handle this reversed blood
flow for an extended period of time, as these collateral
veins are forcing through a very large volume of blood
→ think about how much blood usually gets processed by
the liver!
99
 Portocaval Anastomoses
Esophageal ▪ The hepatic portal vein and its tributaries have no
Veins
(Azygos system) valves, therefore if the venous drainage of the
Left gastric gastrointestinal tract gets blocked at the hepatic
vein
portal vein, then blood can bypass the liver by
Superior, flowing in a reverse direction and drain to the
Inferior &
Superficial
inferior vena cava through an alternative route:
Paraumbilical epigastric
veins  Gastroesophageal: Left gastric vv. → Esophageal vv.
veins
 Paraumbilical: Paraumbilical vv. → Epigastric vv.
 Retroperitoneal: Colic (& Splenic) vv. → Retroperiotneal vv.
Colic  Anorectal: Superior rectal vv.
veins → Middle/inferior rectal vv.
Retroperitoneal
veins

Superior rectal Inferior rectal These portocaval anastomotic connections become

vein clinically important when the direct
vein
drainage route to the liver is blocked! 100
 Esophageal Varices: Portal Hypertension
Esophageal
veins Anastomosis between:
Left gastric
vein Portal system – Left and right gastric veins
Caval system – Esophageal veins

▪ In severe cases of portal hypertension, the blood is unable to

effectively flow through the liver which causes retroflow in the gastric
veins which change to drain into the esophageal veins instead
▪ Potentially fatal if one of the fragile, dilated esophageal veins gets
damaged and excessive bleeding occurs

Can be treated using an Symptoms may include:

endoscope to directly ▪ Black, tarry stool (upper GI tract bleed)
inject the varices with ▪ Paleness
clotting medicine or by ▪ Light-headedness
placing a band to cut off ▪ Vomiting → Emesis
circulation ▪ Symptoms of chronic liver disease 101
 Caput Medusa: Portal Hypertension
Anastomosis between:

Superficial,
Portal system – Paraumbilical veins
Superior and
Inferior
Caval system – Epigastric veins
Paraumbilical
veins epigastric
▪ In severe cases, blood is unable to effectively flow through the
veins
liver which can cause retroflow in the paraumbilical veins which
now drain into the periumbilical veins
▪ The superficial veins of the anterior abdominal wall (superficial
epigastric and thoracoepigastric) then become extremely dilated and
varicose which over time look like snakes slithering under the skin

A common method to treat and reduce portal

hypertension is to divert the portal blood by creating a
“shunt” or communication between larger veins of the
caval system in order to relieve pressure:
• Hepatic portal vein → Inferior vena cava
• Splenic vein → Left renal vein 102
 Hemorroids: Portal Hypertension
Anastomosis between:
Portal system – Superior rectal veins
Caval system – Inferior rectal veins

Internal hemorrhoids:
▪ Found above the pectinate line
▪ Will not be painful → visceral innervation!
▪ If damaged then would result in bright red blood in the stool
as this is close to the source and the blood has not been
Superior rectal Inferior rectal
vein digested → Lower GI tract bleed
vein
External hemorrhoids:
▪ Found below the pectinate line
▪ Would be extremely painful → somatic innervation!
▪ Develop from varicose perianal veins that are part of the caval
system
103
 Accumulation of Inflammatory Exudates
Peritonitis: ▪ Exudate:
Infection can occur if gas, fecal matter or bacteria enter
A fluid rich in cellular elements, serum, fibrin,
the peritoneal cavity which would result in inflammation
of the peritoneum acid or pus that has seeped out and been
discharged from an inflamed organ or vessel

▪ Ascitic fluid:
Excess fluid in the peritoneal cavity

= Ascites

▪ Paracentesis:
Surgical puncture of the peritoneal cavity for the
aspiration/drainage of ascitic fluid
http://thepolishedwidow.com/tag/ascites/

Inflammation of PARIETAL peritoneum Inflammation of VISCERAL peritoneum

• Sharp, well-localized pain • Generalized, referred pain that is felt in the
• Tenderness on palpation associated dermatome of the organ 104
 Right
Left
anterior Direction of Peritoneal Fluid Flow
anterior subphrenic
subphrenic recess
recess  Supine position Right posterior Hepatorenal
subphrenic recess recess
• Two sites where inflammatory
Right Left exudate tends to collect: Pelvic
paracolic Pelvic cavity
paracolic
gutter 1. Hepatorenal recess brim
gutter

1. Flow of normal peritoneal fluid

is up towards the subphrenic spaces 2. Right posterior
subphrenic recess

✓ Inclined position
Pelvic
• Inflammatory exudate collects in cavity

pelvic cavity where there is a

2. Ascitic fluid (or pus) drains
slow absorption of toxins
away from the liver → Link to Pelvis and Perineum lecture 105
 Peritoneal Dialysis
Dialysis is defined as the separation of particles in a liquid on the basis of differences in their
ability to pass through a membrane

• The peritoneum is a semipermeable membrane which permits relatively rapid absorption of solutions
• Solutes and water diffuse between blood in the vessels and the peritoneal cavity as these two fluid compartments
have a concentration gradient.

In the case of renal failure:

▪ A dilute, sterile solution can be introduced into the peritoneal
cavity on one side of the patient

▪ Excess water and soluble waste products (e.g. urea) can be

transferred from the blood vessels

▪ The dilute solution and waste products can be drained out of

the peritoneal cavity from the other side
Click image: Peritoneal dialysis animation 106
 Pringle Maneuver
Dr. Pringle described a technique to minimize blood loss during hepatic surgery by
clamping the blood vessels entering the liver (entering through the porta hepatis or hilum of the liver)

• The portal triad travels within the

hepatoduodenal ligament and this can be
clamped to control bleeding.

Hepatic artery
• It can determine the extent of trauma in patients
proper
with liver injury.
Hepatic portal
• If a patient is still bleeding internally after vein
clamping, there must be a hemorrhage elsewhere Common bile duct
which could be from:

▪ (Right or left) Hepatic veins Blood normally flows INTO the liver via: Portal Triad:
1. Hepatic artery proper
▪ (Retrohepatic) Inferior vena cava ➢ Hepatic artery proper, or 2. Hepatic portal vein
➢ Hepatic portal vein 3. Common bile duct 107
 Omental Bursa Herniation
Part of the gastrointestinal tract (usually a loop of the
small intestine) can pass through the omental foramen
(Epiploic foramen of Winslow) and become twisted and
strangulated inside the lesser sac.

This type of internal abdominal hernia is relatively

rare, however, there are some predisposing
factors: Omental Herniation of the
foramen ileum into
▪ Large omental (epiploic) foramen
the lesser sac
▪ Redundant or mobile mesentery
▪ Elongated right liver Boundaries of the omental (epiploic) foramen:
▪ Defect in the lesser omentum  Anterior: Hepatoduodenal ligament
- Contains the portal triad
 Posterior: IVC and the right crus of the diaphragm
Surgery is required to manually reposition and free  Superior: Caudate lobe of the liver
the trapped intestinal tract  Inferior: 1st part of the duodenum 108
 Peritoneal Adhesions
Peritoneal adhesions are fibrous bands that form abnormal connections:
▪ Visceral peritoneum attaching to an adjacent organ
▪ Visceral peritoneum attaching to the parietal peritoneum
(of the abdominal wall)

• Form as a result of damage (acquired through injury, infection or surgery)

Fibrin: to the peritoneal surface when sticky fibrin appears in order to assist
Insoluble, elastic protein that
becomes replaced with fibrous scar with the healing process.
tissue

• Adhesions limit the normal movement of viscera and could lead to

complications: ➢ Intestinal obstruction (a.k.a. volvulus)

➢ Chronic pain

Laparotomy: Adhesiotomy:
Surgical incision into abdominal cavity Surgical separation of adhesions
prior to major surgery
109
 Appendectomy
Surgical removal of the appendix:

1. Through a transverse or grid-iron (muscle-splitting) incision

centered at McBurney’s point
 Nerves most at high risk of damage during this surgery due to
travelling through the anterior abdominal wall musculature:
• Iliohypogastric nerve (L1)
• Ilioinguinal nerve (L1)

2. Through laparoscopic surgery

• Initial appendicitis: Both surgical techniques involve

the correct ligation of the
General VISCERAL Afferent (GVA) pain fibers are referred to T10 dermatome appendicular artery
• Acute appendicitis: and also to ensure the appendix
opening is adequately sealed
General SOMATIC Afferent (GSA) pain fibers are localized at McBurney’s Point 110
 Splenic Rupture
Costodiaphragmatic Left Lung
recess The spleen is the most commonly
Diaphragm injured abdominal organ
Liver
Spleen ▪ Despite being protected by the rib cage, a
Stomach Ribs 9, traumatic blow to the left side may fracture the
10 & 11 ribs and result in fragments of bone lacerating
the spleen
Transverse → Example could be becoming impaled
colon against the steering wheel during a
road traffic accident
Splenectomy:
Surgical removal of the spleen ▪ If the spleen ruptures, this will lead to:
to prevent bleeding to death
• Shock
Splenomegaly: • Intraperitoneal hemorrhage
Pathological enlargement of the spleen – profuse internal bleeding
(up to 10x normal size) accompanied by
high blood pressure 111
Cholelithiasis: Gallstones
Cholelithiasis are small lumps of solid stone-like deposits which
form in the gallbladder
▪ Crystals form when there are high concentrations of cholesterol and can be
associated with individuals who are regularly dehydrated

▪ Relatively common in females and often asymptomatic, however, symptoms

may include:
• Pain in the right upper quadrant (RUQ)
• Pain may be referred to the right neck/shoulder region
• Nausea
• Cholecystitis → Inflammation of the gallbladder
• Jaundice
(due to obstruction of either the major duodenal papilla or common bile duct)

The hepatopancreatic ampulla is a common constriction

site where cholelithiasis often become painfully lodged 112
 Cholecystectomy
Fair
Cholecystectomy is a surgical procedure to remove
Fat
the gallbladder
Female
Fertile ▪ The gallbladder is not a vital organ, therefore if gallstones have a high
Forty (40) risk of reoccurrence and regularly cause severe biliary colic then an
individual may elect to undergo key-hole surgery to remove the
gallbladder

▪ Important to identify the the cystohepatic triangle to

determine if there is a variation the cystic artery or biliary apparatus

▪ Once identified, the cystic duct and cystic artery are ligated and
P!nk:
The singer Alecia Beth Moore underwent a cholecystectomy divided to prevent bleeding and the release of bile 113
 Cystohepatic Triangle: Triangle of Calot
① Superior border: Dissection of the cystohepatic triangle is regarded as the
• Inferior border of the Liver key component to performing a safe laparoscopic
② Medial border: cholecystectomy
• Common hepatic duct ▪ The modern definition of the 3 boundaries of the triangle
③ Lateral border: varies from Dr. Calot’s original thesis (1891)
• Cystic duct Left
Right
hepatic duct
hepatic duct

1 2
Cystohepatic
triangle
3
Common
bile duct 114
http://michikomaruyama.ca/artoflearning/
 Pancreatic Cancer
Normal
Tail  Cancer of the head of the pancreas:

▪ Is the most common type of pancreatic cancer - Ductular adenocarcinoma

▪ Tumor could obstruct:
Cancer:
Head of pancreas • Common bile duct
• Hepatopancreatic ampulla
▪ Retention of bile pigments will lead to JAUNDICE
→ can lead to stools/feces becoming acholic - light/grey colored

 Cancer of the neck and body of the pancreas:

Jaundice: ▪ Tumor could obstruct:
Yellowing of the skin and sclera of the eyes • Hepatic portal vein
usually results if bile is unable to be released
into the duodenum
• Inferior vena cava 115
 Pyrosis: Heartburn
▪ Pyrosis is the most common type of esophageal
discomfort and substernal pain
• Burning sensation in the abdominal part of the
esophagus which is perceived in the chest

▪ Typically a result of regurgitation of gastric acid into the

abdominal part of the esophagus
Normal
inferior → GastroEsophageal Reflux Disorder (GERD)
Reflux of
esophageal
gastric
sphincter
acid
▪ The function of the inferior esophageal sphincter
is to prevent acid reflux

▪ May be associated with a hiatal hernia:

• When the proximal part of the stomach protrudes
through the esophageal opening in the diaphragm
into the mediastinum 116
 Peptic Ulcers: Gastric and Duodenal
If on posterior wall:
If on lesser curvature: Erode SPLENIC a. & the PANCREAS ▪ Gastric ulcers and gastritis are the 2 most common
Erode GASTRIC aa. stomach diseases
• Men are affected 3x more than women
Left gastric a. ▪ Strongly associated with:
➢ Mucosal exposure to gastric acid and pepsin
Splenic a. ➢ Helicobacter pylori bacterial infections
➢ Nonsteroidal anti-inflammatory drugs
➢ Aspirin
Symptoms may include:
Gastro-omental a.
 Hematesmesis: vomiting “coffee ground” blood
 Melena: black, foul-smelling feces
If on anterior wall:
Erode the LIVER and cause peritonitis

Peptic Ulcer:
A distinct lesion (or necrosis) of the mucosa in either the stomach,
Duodenal Gastric
pyloric canal or duodenum as a result of acid erosion ulcer ulcer 117
 Carcinoma of the Stomach
▪ Majority of gastric cancers are adenocarcinomas
- originate in glandular tissue!

▪ Surgery is difficult due to the inability to

remove all of the lymphatic nodes associated
with the stomach

▪ Transillumination can help identify small tumors although if

Virchow’s lymph nodes (left supraclavicular) are palpable,
the malignancy is advanced and prognosis is poor

▪ Three main types of surgical approach for treatment:

Troisier’s Sign 1. Endoscopic resection
Hard, palpable, enlarged LEFT supraclavicular 2. Partial gastrectomy
lymph nodes indicate metastatic cancer in the 3. Total gastrectomy
abdomen 118
 Crohn Disease: Colitis
Pouch or Crohn disease is a type of Inflammatory Bowel Disease (IBD) and has very
Colostomy similar symptoms as ulcerative colitis, however, colitis is limited to the colon
bag
▪ Crohn disease is defined as chronic inflammation of the
gastrointestinal tract:
▪ Most commonly affects the ileum and the beginning of the large intestine but
can occur anywhere from the mouth to the anus
▪ Treatment is designed to suppress the immune system’s abnormal
inflammatory response
In 70% of cases treatment may be more invasive:
▪ Symptoms of an inflamed GI tract
• Colectomy:
may include: Terminal ileum, colon, and rectum are removed
• Persistent diarrhea • Ileostomy:
• Rectal bleeding Artificial opening (stoma) of the healthy ileum is
• Urgency when time to defecate created through the abdominal wall

• Abdominal cramps and pain • Colostomy:

Dr. Burrill B. Crohn Opening is created to drain stool (feces)
First described the disease in 1932 • Constipation - bowel obstruction 119
 Colonic Diverticulosis
Diverticula
External evaginations or out-pocketings of the
mucosa of the colon
▪ Condition when multiple false diverticula develop along
the large intestine
▪ Acquired mucosal herniations which protrude through
weak areas of the muscular wall
▪ Most commonly occur on the mesenteric side of two
bands of tenia coli (omental and free) due to the perforating
nutrient arteries
▪ Can become infected and rupture
▪ Most commonly:
• Affect middle-aged and elderly
• Found on the sigmoid colon
• Develop in individuals with a low fiber diet
120
 Intussuception
Ileum
Intussusception is defined as the “telescoping” or
invagination of one bowel segment into a distal
segment of the gastrointestinal tract

▪ Commonly occurs in infants at the ileocecal junction

and causes bowel obstruction

▪ Abdominal emergency in early childhood as if left untreated,

this can be fatal in 2-5 days
Currant jelly
Cecum stool ▪ Can be diagnosed with medical imaging
– typically using water soluble contrasts like Gastrograffin

▪ Symptoms may include:

• “Currant jelly” stool
• Lethargy and abdominal pain – infant draws legs up to abdomen
• Emesis - vomiting
121
 Volvulus of the Sigmoid Colon
▪ Condition involving the twisting and
rotation of the mobile loops of the
intestinal tract

▪ Typically associated with the

sigmoid colon

▪ Results in the obstruction of the

lumen and can lead to:

▪ Constipation:
Inability of stool to pass
If left untreated, necrosis (cell death) could
occur and an immovable collection of ▪ Ischemia of the intestine:
compressed feces may develop Absence of blood flow
122
 Referred Pain from Abdominal Organs
Irritation of Diaphragm
Irritation of (Liver, Gallbladder or
Diaphragm Duodenum)

Duodenum &
Head of pancreas Stomach
Stomach
Gallbladder Spleen Spleen Gallbladder
Liver
Small Liver
Appendix intestine
Kidney &
Cecum & Sigmoid colon Ureter
Ascending colon Kidney & Ureter

▪ Stomach → T6-T9 ▪ Ascending & Transverse colon → T10-T11 ▪ Rectum → S2-S4

▪ Small intestines → T8-T10 ▪ Proximal descending colon → T12-L1
▪ APPENDIX → T10 ▪ Distal descending colon → L2-L3
123