B3 GARQs

• What is the term that describes blood collecting in the peritoneal cavity? Identify the structures indicated by green arrows.

- Hemoperitoneum - loops of small bowel

How do the sympathetic trunks and the thoracic splanchnic nerves pass from thoracic to abdominal cavities?

Sympathetic trunk: passes deep to the medial arcuate ligament, accompanied by the least splanchnic nerves. Greater and lesser splanchnic nerves pass through two small apertures in each crux of the diaphragm.

proper hepatic artery ->

divides into right and left hepatic arteries, and right hepatic artery gives off cystic artery to the GB as it nears the liver.

Please name three different types of contrast agents (identified by chemical compound).

1. gastrografin (contains iodine) 2. barium sulfates 3. IV gadolinium

There is normally a small amount of fluid present in the peritoneal cavity. • What is the term that describes an abnormal accumulation of this fluid in the peritoneal cavity?:

Ascites

The celiac trunk is the anterior branch of the abdominal aorta supplying the foregut. It immediately divides into:

left gastric -> Sends esophageal branches to abdominal part of esophagus splenic artery -> Gives off short gastric arteries, and the left gastro-omental artery common hepatic artery -> Gives off right gastric artery, then divides into two terminal branches: - proper hepatic artery - gastroduodenal artery

• When an accumulation of fluid in the abdominal cavity is identified, using CT, how do you determine whether this fluid is simple "water-equivalent fluid or blood?

soft tissue like blood shows up more hyper dense than water so will appear more white, while water will appear darker.

What is the portal triad?

● A distinctive arrangement in a liver lobule containing: ○ Portal venule** ○ Proper hepatic arteriole** ○ Bile ductule(s)** ○ Lymphatic vessels ○ Branch of vagus

GARQ 10: Describe the extrahepatic bile passages and the pancreatic ducts.

- Extrahepatic bile passages: common hepatic duct + common bile duct. Common hepatic duct: union of left and right hepatic ducts. - Cystic duct: Duct that drains bile from gallbladder. - Common bile duct: forms from union of cystic duct and common hepatic duct - Pancreatic ducts: Main pancreatic duct begins in tail of pancreas and runs to pancreatic head. It joins the common bile duct at the Ampulla of Vater to drain digestive enzymes (from pancreas) and bile into the major duodenal papilla in the descending (2nd) part of the duodenum. Accessory pancreatic duct opens into the duodenum at the summit of the minor duodenal papilla.

• What is the Cystohepatic Triangle (of Calot)?

- A triangle formed by these 3 structures: Lateral: cystic duct Medial: common hepatic duct Superior: cystic artery

• Please name the anatomic structures labeled A through E:

- A: Gallbladder - B: Common Bile Duct - C: Left Hepatic Duct - D: Duodenum - E: stomach

Answers:

- Blue: the omentum (an apron from the anterior wall) - Yellow: mesentery (the fat that fills the two peritoneal layers)

• Please indicate which type of examination is shown in Figure 3 (below). Please name the type of post-processing / reconstruction that was performed from the original data set. Indicate the vessels that are labeled with the letters A, B & C. Answer:

- CT Angiogram (Sagittal MDCT) - A: Celiac Artery, B: SMA, C: abdominal aorta

• Please indicate the most appropriate imaging technique to demonstrate pancreatitis:

- Contrast enhanced CT

• Please identify the type of examination demonstrated in Figure 1. Describe briefly how it is performed.

- Digital Subtraction Angiogram of Celiac Trunk - Arterial puncture (femoral), catheter intubation advanced to suspect vessel, injection of dye, imaging via x-ray

- In which of these two vessels is a filter placed to prevent pulmonary embolism? What is the high-density structure in the other vessel? - Are such filters placed above or below the level of the renal vasculature? Why?

- Filter cap in IVC - Calcified atherosclerotic plaques in aorta - "The filter should be positioned with the tip of the filter just at the inflow of the renal veins, which minimizes the accumulation of thrombus above the filter in the event of filter thrombosis. If the filter thrombosis is substantially below the renal vein inflow, then the dead space between the thrombosed filter and the renal veins would allow a clot to form, potentially leading to pulmonary embolism. IVC filters placed across the renal veins may have no significant effect on renal function, but they may not be stable in a pararenal location due to the inability of fixation mechanisms to fully engage the IVC wall' Uptodate

The circulatory system of the liver is unique. Describe the pattern of blood flow through the liver, including consideration of the following: terminal branches of portal vein, terminal branches of hepatic artery, liver sinusoids, central veins, hepatic veins, and inferior vena cava.

- Hepatocytes are arranged into lobules with an interlobular portal triad in between each lobule. - Nutrient rich blood from the GI tract enters from the 1. Terminal branches of the portal veins and 2. Drains into the sinusoids (blood filled channels between hepatocytes). 3. Oxygenated blood enters the sinusoids via the terminal branches of the hepatic arteries. 4. This mixed blood flows to the central vein at the center of the lobule, which drains to the hepatic veins and finally to the inferior vena cava. Summary: portal vein & hepatic artery → sinusoids → central vein → hepatic veins → IVC

GARQ 9: describe the vagal trunks. • What is the location of the cell bodies of the preganglionic parasympathetic neurons whose axons are in the vagal trunks?

- Medulla oblongata

Describe the path taken by a thrombus in the left popliteal vein to reach the left pulmonary artery:

- Popliteal -> Femoral -> External Iliac -> Common Iliac -> IVC -> RA -> RV -> Pulmonary Trunk -> right or left Pulmonary Artery

Which vascular territory is shown in fig 2? • Please identify the vessels that are labeled A and B. • Which organ territory is supplied by the vessels labeled C? • Please name one clinical condition, and indication, in which it would be appropriate to perform this examination so that diagnosis and treatment can be accomplished in the same session.

- SMA and branches - A: Right colic of SMA - B: Ileocolic - C: Jejunum - GI Bleed in the small bowel, treated with catheter cauterization.

• What are the branches of the vagal trunks? What is their relationship to the plexuses on the anterior surface of the abdominal aorta?

- The anterior vagal trunk runs along the lesser curvature of the stomach --> where it gives off hepatic and duodenal branches that distribute through the hepatoduodenal ligament, and anterior gastric branches that supply the stomach. - The larger posterior vagal trunk runs along the lesser curvature of the stomach --> gives off posterior gastric branches as well as a celiac branch that goes to the celiac plexus.

• How are the pancreas and duodenum (anatomically) related?

- The duodenum pursues a C-shaped course around the head of the pancreas. Exocrine pancreatic juices secreted into pancreatic ducts that continue into the duodenum via the major duodenal papilla.

Answer, + • What organ(s) or anatomical structure(s) do you see in this image?

- US of gallbladder - Gallbladder, liver, and cystic duct

• What structure is highlighted by the yellow arrow? • Is contrast agent needed for this examination? If so, what type of contrast agent is used? Please indicate if this is an invasive or non-invasive procedure.

- Yellow Arrow: catheter - Invasive use of gadolinium contrast (femoral puncture most common)

• Are there axons of sensory neurons in the vagal fibers in the abdominal cavity? If so, what is their function?

- Yes, They are visceral afferent fibers that convey unconscious reflex sensations.

Please indicate the vessels in this image which ultimately drain into the main portal vein and identify them. Which type of contrast is used for MR imaging? The spleen in this picture is abnormal. How? Why?

- splenic vein, IMV,SMV (D,E,F on prior image) - Gadolinium - Splenomegaly due to portal hypertension

How does venous blood leave the liver?

1. Blood from Hepatic Portal Vein and Hepatic Artery mix in the Sinusoids 2. Drain into central vein 3. Central veins converge into hepatic lobules 4. Lobules drain into 3 hepatic veins that drain into the IVC

Angiography is the visualization of vessels with radiologic imaging techniques. It means: "imaging a vessel". An arteriogram is the imaging of an artery or arterial system of an organ; a venogram is the imaging of a vein or venous system. • Please identify four imaging modalities which you can use to visualize and evaluate vessels.

1. CT Angio 2. MR Angio 3. DSA 4. US

• For each of them, indicate if you would need to use contrast agents. • Give an example of the use of each technique in the abdomen or pelvis.

1. CTA: contrast, imaging of abdominal aorta and major branches 2. MRA: contrast, stenosis or aneurysm of GI vessels 3. DSA: catheter injection of iodine contrast, imaging of SMA and colic arteries in GI bleed of small bowel 4. US: no contrast, abdominal aorta aneurysm (quick check).

• Identify the three clinically important sites where gallstones can lodge: • Define cholecystitis, jaundice and pancreatitis.

1. Cystic Duct 2. Common Bile Duct 3. Ampulla of Vater - Cholecystitis: inflammation of gallbladder - Jaundice: yellowing of skin caused by high bilirubin - Pancreatitis: inflammation of pancreas

• Identify the structures labeled with the numerals 1, 2, and 3:

1. Liver 2. Gallbladder (really, the bile - hypoechoic) 3. Gallstones (with hyperechoic/echogenic caps)

The liver is a target organ for multiple pathologies including metastases from malignant tumors. • Please enumerate three different imaging modalities that are well suited not only to imaging the liver in general, but also for purposes of identifying metastases. • For each of these 3 modalities, please state whether you would perform the examination with or without contrast.

1. MRI with contrast 2. CT with contrast 3. Ultrasound WITHOUT contrast

GARQ 8: Distinguish among these adjectives: peritoneal (peritonealized), primarily retroperitoneal, and secondarily retroperitoneal. List the organs that are secondarily retroperitoneal; list the structures that are primarily retroperitoneal.

1. Peritoneal: encased in visceral peritoneum and suspended in the abdominal cavity by a mesentery 2. Primary Retroperitoneal: Describes organs that developed between the peritoneum and abdominal wall and remain in this position in the adult 3. Secondarily Retroperitoneal: Refers to organs that were initially peritoneal, but migrated retro peritoneally during development and lost the associated mesentery Organs secondarily Retroperitoneal: Pancreas (except tail), ascending colon, descending colon, and duodenum (2nd - 4th parts). structures primarily retroperitoneal: suprarenal glands, aorta and IVC, ureters, kidneys, esophagus (thoracic portion), and rectum

• What are the four parts of the duodenum, and what are the distinguishing features of each?

1. Superior: intraperitoneal connected to liver by lesser omentum (hepatoduodenal ligament) 2. Descending: curve around head of pancreas, bile and main pancreatic ducts enter (retroperitoneal) 3. Horizontal: lies inferior to head of pancreas and uncinate process, crossed by SMA and SMV 4. Ascending: passes in front of aorta and connects to jejunum, ligament of Treitz marks transition.

GARQ 3: A "filter" can be placed in the inferior vena cava (IVC) of patients in whom a DVT develops and who have contraindications for anticoagulation therapy. The filter is usually introduced through the femoral vein. Why?:

1. The femoral vein passes through the femoral triangle in a superficial position that provides minimally invasive access. The femoral vein communicates directly with iliac vessels in the abdomen through an aperture between the inguinal ligament and pubic bone. Thus, a catheter can be passed superiorly through the femoral vein, into the external iliac vein, into the IVC. 2. Lower risk of thrombosis 3. Easier to cannulate, large diameter and structural integrity - Femoral easily available, direct path to IVC

• If the structure labeled 2 becomes inflamed, there are specific signs in this imaging test which indicate inflammation. Please name three major signs.

3 criteria for acute cholecystitis: 1. Distended gallbladder (>5 cm axial diameter) 2. Wall thickening (>3 mm) 3. Pericholecystic fluid

• What phenomenon seen here is labeled with the 4's?

4: acoustic shadows

GARQ 9 pre-reading:

A vagotomy (surgical cutting of the vagus nerve) may be performed to reduce acid secretion in the stomach. It is used when ulcers in the stomach (or duodenum) do not respond to medication or changes in diet. It is an appropriate surgery when there are complications from the ulcer such as bleeding, perforation, or obstruction of digestive "flow". The frequency with which elective vagotomy is performed has decreased in the past 20 years as it has become clear that the primary cause of ulcers is an infection by a bacterium called Helicobacter pylori. Further, drugs have become increasingly effective in treating ulcers. However, the number of vagotomies performed in emergency situations has remained about the same.

What are the three apertures in the diaphragm, what does each transmit, and at what vertebral level does each occur?

Caval opening: T8; transmits IVC, Right phrenic nerve, lymphatics. Esophageal hiatus: T10; anterior and posterior vagal trunks, esophageal branches of left gastric artery and vein, and lymphatic vessels. Aortic hiatus: T12; transmits abdominal aorta, thoracic duct, lymphatic trunks, and sometimes azygos and hemiazygos veins.

GARQ1 pre-information:

Acute mesenteric thrombosis of the celiac or superior mesenteric arteries is usually found in patients with atherosclerosis. An atherosclerotic lesion located at the beginning of the vessel (more often the superior mesenteric artery) gradually compromises the flow to the gut; during periods of low blood flow, a thrombus can form, leading to severely compromised arterial flow to the gut. Once a diagnosis of acute mesenteric thrombosis is made, the patient should undergo surgery because of the risk of bowel infarction, perforation, sepsis, and death.

GARQ 12 pre-reading:

An article entitled "Thoracoscopic Splanchnicectomy for Control of Intractable Pain in Pancreatic Cancer" was published in the late 1990's in The Annals of Thoracic Surgery, the official journal of the Society of Thoracic Surgeons. In it, a procedure was described in which the "roots" of the greater thoracic splanchnic nerves were transected very near the sympathetic trunk in the posterior mediastinum. The excruciating pain that is perhaps the most distressing feature of pancreatic cancer was relieved in the great majority of cases that were reported in this article.

What is the blood supply of the diaphragm?

Arteries: Superior: supplied by musculophrenic and pericardiophrenic arteries from the internal thoracic, superior phrenic artery from thoracic aorta Inferior: inferior phrenic arteries from abdominal aorta Venous drainage: Pericardiacophrenic and musculophrenic veins → internal thoracic veins Superior phrenic → IVC Inferior phrenic veins → IVC and left suprarenal vein Posterior veins may drain into azygos/hemiazygos veins

GARQ 6: Describe the origin of the diaphragm from the sternum, from the ribs, from the fascial thickenings over the quadratus lumborum and psoas major muscles, and from the superior three lumbar vertebrae.

Attachement points/origins of the diaphragm: 1. sternum: attach to the posterior aspect of xiphoid process 2. Ribs: Lower 6 costal cartilages and ribs, and peripherally from ends of ribs 11-12 3. Lumbar part arises from the lateral arcuate ligament (a fascial thickening arising from the quadratus muscles - from superior part of pelvis to lowest rib/T12), the medial arcuate ligament (a fascial thickening arising from the psoas major muscles) 4. superior 3 lumbar vertebrae: ​forms (along with medial and lateral arcuate ligaments) the right and left muscular crura that ascend to the central tendon0

• What type of examination is shown in Figure 4? • Is this examination performed with intravenous contrast? How can you determine this? • Identify the vascular structures labeled A and B.

CT abdomen without contrast. - Without CT contrast; the contrast in the vasculature would appear much more brightly A: IVC B: abdominal aorta

• What classification system is used to describe the location of an abnormality in the liver? • What major landmarks are used to determine the segments of the liver? How many liver segments are there?

Couinaud segments 8 segments. ○ Portal vein bifurcation divides upper and lower segments ○ Hepatic veins determine vertical borders of the segments in coronal plane Exceptions: ■ Caudate lobe (I) is separate ■ Segment IV combines upper and lower

• Is a common bile duct stone seen? If so, please identify it with an arrow.

Just above the letter B (called a "filling defect")

GARQ 3 pre reading:

Deep vein thrombosis (DVT) of one or more of the deep veins of the lower limb can lead to the breaking-off of a large thrombus that travels to a lung, forming a pulmonary thromboembolism (or pulmonary embolism), obstructing a large pulmonary artery. Such an event can be fatal. The most common risk factors are recent surgery or hospitalization. A frequent contributing cause of DVTs is the immobility and dehydration that occur during air travel.

GARQ 10 radiology: • Please name the two main imaging examinations with which you can look for gallstones in the common bile duct. For each examination, briefly describe the technique, including whether it is invasive or non-invasive, whether it uses contrast agents, and whether it allows for treatment in the same imaging session.

ERCP: endoscopy that introduces contrast and places stent or withdraw stone with X-ray fluoroscopy, invasive, can treat in same session MRCP: magnetic resonance choleangiopancreaticography, no contrast, non-invasive

GARQ 6 radiology: • The two images (Figures 6a and 6b) below demonstrate an imaging examination of the upper gastrointestinal tract. Please name the examination and describe briefly how it is performed. • Which contrast agent is used for this examination? • Please name the structures that are labeled 1-4 in Figure 6a.

Exam: Upper gastrointestinal tract radiography/fluoroscopy. Fluoroscopy uses a continuous or pulsed x-ray beam to create a sequence of images that are projected onto a fluorescent screen. When used with a contrast material, physicians can view joints or internal organs in motion. contrast agent used: Barium Swallow 1. Esophagus (LES) 2. body of stomach 3. Stomach Fundus (Herniated) 4. Duodenum

For each, identify (1) the anatomic area/structure for which it is best suited, (2) the imaging modality for which it is best suited, (3) at least one clinical condition in which it should be employed, and (4) at least one clinical condition in which it should NOT be employed:

Gastrographin: - Stomach - Fluoroscopy - Gastrographin YES for perforation - not to be used in patients with renal insufficiency (can be nephrotoxic) Barium: - Large bowel - barium enema - X-ray - Diverticulitis, dysphagia or Tumor Obstruction of Bowel - YES - perforation - NO Gadolinium: - Hepatic Trunk/ GI Circulation - MRI - Celiac Trunk Stenosis/Renal Stenosis YES - Calcified structures cystic duct blockage - NO

the gastroduodenal artery ->

Gives off the posterior superior pancreaticoduodenal artery. Then, gives off two terminal branches: o Right gastro-omental artery o Anterior superior pancreaticoduodenal artery

What is the lesser omentum? What is the greater omentum?

Lesser: A double-layered peritoneal fold that connects the lesser curvature of the stomach and the proximal part of the duodenum to the liver. The membranous portion is the hepatogastric ligament. The thickened, lateral, free edge is the hepatoduodenal ligament, which contains the portal triad. Greater: A prominent, four-layered peritoneal fold that hangs down like an apron from the greater curvature of the stomach and the proximal part of the duodenum. After descending, it folds back and attaches to the transverse colon. Comprised of the gastrocolic, gastrophrenic, and gastrosplenic ligaments. The gastrocolic ligament forms the "fatty curtain.

GARQ 2: Illustrate the common branching pattern of the superior mesenteric artery. Be sure to include these vessels - inferior pancreaticoduodenal, right colic, middle colic, intestinal branches, and ileocolic. Also illustrate the vasa recta and the arterial arcades of the jejunum and of the ileum.

Lucas's drawing:

Describe the marginal artery (of Drummond).

Lucas: Marginal Artery of Drummond: anastomosis of the SMA and IMA forming a continuous arterial vessel along the length of the colon close to the mesenteric border. Me: The inferior mesenteric artery may become atherosclerotic and blocked, but many of these patients don't suffer complications because anastomoses between the right, middle and left colic arteries will gradually enlarge, forming a continuous marginal artery of Drummond. This enlarged marginal artery of Drummond replaces the blood supply of the inferior mesenteric artery to the distal large bowel.

• Please indicate the most appropriate imaging technique to demonstrate cholecystitis:

MRCP

Answer:

MRCP: Magnetic Resonance Cholangio-Pancreatography. ​(MRI - using signal given by fluid in T2w imaging - fluid shows white without any invasiveness, radiation, or contrast medium)

What is a mesentery? What is THE mesentery?

Mesentery: A double layer of peritoneum that wraps around an organ and is continuous with the visceral and parietal peritoneum. A mesentery connects an intraperitoneal organ to the body wall and contains the neurovascular supply to the organ. Allows for mobility of the intraperitoneal organ What is THE Mesentery: THE mesentery (aka the "small intestine mesentery") is a fan-shaped fold that suspends the jejunum and ileum from the posterior body wall; its "root" attaches to the posterior body wall along a diagonal line from the duodenojejunal junction to the ileocecal junction.

In this same image you see also a hypodense structure in the liver (blue arrow). Is this a normal anatomic structure or a pathology? What could you do to better characterize this structure? (Please name two possibilities.)

Pathology.. Could be: Hemangioma in liver cause hypodense tissue (pathology) causing hypotenuse hepatic lesion tissue - liver should be uniform. To better characterize: Use contrast in cystic ducts (non-toxic) or IV contrast, or MRI with IV contrast.

Describe the motor and sensory innervation of the diaphragm:

Phrenic nerves, from C3-C5 spinal cord levels, provide all motor innervation to diaphragm and sensory fibers to central part. Lower 6 or 7 intercostal nerves supply additional sensory fibers to peripheral areas of diaphragm

• How do axons of preganglionic parasympathetic axons that innervate the ileocecal junction reach their targets?

Posterior vagal trunk → celiac branch → superior mesenteric plexus → SMA → ileocolic artery → cecal branches → enteric NS

• How do axons of preganglionic parasympathetic axons that innervate the duodenojejunal junction reach their targets?

Posterior vagal trunk → celiac branch → superior mesenteric plexus → SMA → inferior pancreaticoduodenal artery → enteric NS

• What are the locations of the postganglionic parasympathetic neurons that receive the preganglionic parasympathetic fibers described in the previous two sentences?

Submucosal and myenteric plexi (aka. enteric NS)

There is normally a small gap between the sternal and costal attachments of the diaphragm - what passes through this opening?

Superior epigastric vessels and lymphatics from diaphragmatic surface of liver.

GARQ 10: pre-reading:

There are three clinically important sites of obstruction of the extrahepatic biliary passageways by gallstones —within the cystic duct, within the common bile duct, and at the hepatopancreatic ampulla. Results of lodged calculi in the biliary passageways can include cholecystitis, jaundice and pancreatitis.

What is the central tendon?

Thin but strong aponeurosis situated near the center of the diaphragm. In the center it lies immediately below the pericardium, with which it is partially blended.

• Which vascular territory is shown in this image? Please name the major branches that are labeled A through C. Which major abdominal vessel do these ultimately originate from? Why is that major abdominal vessel not seen in the image?

This is the celiac trunk; the common hepatic part. - A: left hepatic artery - B: right hepatic artery - C: gastroduodenal artery - Come from Aorta, not seen because dye was injected into start of celiac trunk

What is the lumbocostal triangle?

Triangular region of diaphragm without muscular tissue located between its lumbar and costal parts and superior to the lateral arcuate ligament.

Radiology for GARQ 5: The figure below (figure 5) is a splenoportogram performed with MRI. Does this highlight venous or arterial structures in the abdomen? Please name the anatomic structures which are labeled with the letters A through G in this image.

Venous structures from spleen to portal system. - A: hepatic Portal Vein - B: abdominal aorta - C: IVC - D: Splenic Vein - E: IMV - F: SMV - G: Left Common Iliac Vein Image of figure 5:

GARQ 5 pre-reading:

When fibrosis from cirrhosis of the liver obstructs the hepatic portal vein, pressure rises in this vessel and its tributaries, producing portal hypertension. At the sites where tributaries of the hepatic portal vein anastomose with tributaries of the systemic veins (the superior and inferior venae cavae), portal hypertension can produce blood flow from the portal system into the caval system and can produce enlarged varicosities (tortuous vessels with thinned walls). The veins may become so enlarged and thin-walled that they rupture, resulting in serious hemorrhage.

Which abdominal organs possess a mesentery? Which abdominal organs DO NOT possess a mesentery?

Which abdominal organs possess a mesentery? ● Pancreas (just the tail) ● Small intestine ● Colon ● Liver ● Gallbladder ● Spleen Which abdominal organs DO NOT possess a mesentery? ○ Suprarenal ○ Aorta and IVC ○ Duodenum (2nd-4th parts) ○ Pancreas (except tail) ○ Ureters ○ Colon (descending and ascending) ○ Kidneys ○ Esophagus (thoracic portion) ○ Rectum - stomach

GARQ 11 radiology: Below is an image obtained from a CT of the liver (figure 10): • Identify the liver segments 1, 3, 4, 5 and 6 on the image. • Identify the portal vein, the hepatic veins and the IVC. • Identify the stomach (St), colon (C) and spleen (Sp) in this image. • Is this image acquired with intravenous contrast?

Yes - image was acquired with IV contrast

Using the illustration provided, indicate four possible sites where anastomosis between the portal and systemic venous systems can occur; for each site, illustrate and label the vessels that are involved.

the 4 possible sites: 1. Gastroesophageal junction: Esophageal branches of L. gastric vein (portal) and esophageal branches of azygos vein (caval) 2. Paraumbilical: Paraumbilical veins (portal) and superficial epigastric veins (caval) 3. Rectum: Superior rectal vein (portal) and middle and inferior rectal veins (caval) 4. Intrahepatic: hepatic portal vein (portal) and hepatic veins --> IVC (caval)

Which of these nerves (cardiac nerves, splanchnic nerves, gray rami) utilize paravertebral ganglia?

● Cardiac ● Gray

• In general, what are the functions of the visceral motor axons in the vagal fibers in the abdominal cavity?

● Stimulate smooth muscle contraction and glandular secretions ● Relax sphincters