Supracolic compartment: Esophagus, Stomach, Spleen, Liver, Pancreas & Biliary Tree, Celiac artery and its branches

Describe the external notches of the stomach

CARDIAC: Notch between junction of esophagus and funds ANGULAR INCISURE: Sharp angulation of lesser curvature at the junction of body and pyloric portion

Describe Congenital Hypertrophic Pyloric Stenosis

(1-4/1000 live births; 4:1 male/female) Grossly increased muscle layer (mainly circular) at the pylorus which does not open enough to pass stomach contents It is palpable in the RUQ just to the right of the midline and is usually identified in the first 3-6 weeks of life after episodes of progressive vomiting Can be surgically dilated

Describe the visceral surface anatomy of the liver

**NOTE: Continuity of the visceral and diaphragmatic surfaces occurs anteriorly at the sharpened inferior border, while posterosuperiorly, this continuity is rounded Directed inferiorly and posteriorly PORTA HEPATIS: Located at the center of the visceral surface, this area marks the ENTRANCE AND EXIT of such structures as the HEPATIC ARTERIES, PORTAL VEIN, THE HEPATIC BILE DUCTS, NERVES OF THE HEPATIC PLEXUS, AND LYMPHATICS OF THE LIVER - The porta is surrounded by attachment of the lesser omentum Located immediately to the left of the porta is a SAGITTAL FISSURE which contains inferiorly the LIGAMENTUM TERES HEPATIS (round ligament of the liver derived from the umbilical vein) and superiorly the LIGAMENTUM VENOUS To the right of the porta, two shallow fossa exist, also in the sagittal plane, parallel to the left sagittal fissure - The inferior fossa contains the gall bladder; the superior fossa (caval fossa) contains the IVC **NOTE: The porta, together with the two sagittal landmarks creates an "H" on the visceral surface of the liver. The "H" is the basis for division of the liver into four ANATOMICAL lobes

Describe the muscular wall of the stomach

**SMOOTH MUSCLE** 1) Outer longitudinal 2) Inner circular - Greatly thickened segment which forms the pyloric sphincter 3) Innermost oblique - Modified circular fibers often forming an incomplete layer

What structures lie anterior to the stomach?

1) Anterior abdominal wall 2) Diaphragm 3) Left lobe of the liver

Where are the sites of potential constriction of the esophagus?

1) At the junction of the pharynx and esophagus, cricopharyngeus muscle (upper esophageal sphincter) 2) Aortic arch 3) Left primary bronchus 4) Esophageal hiatus

Describe the regions of the stomach

1) Cardia: Indefinite area around esophageal entrance 2) Fundus: Portion more superior than cardia 3) Body: Area between funds and pyloric antrum 4) Pyloric portion - Pyloric antrum: expanded portion proximal to pyloric canal - Pyloric canal - Pylorus: thickened muscular portion forming sphincter between stomach and duodenum, located to the right of the midline at LV1-LV2

Describe the fourth (ascending) part of the duodenum

5 cm in length Retroperitoneal (except for extreme terminal end) Ascends along the left side of the aorta to LV2 Turns abruptly, becomes peritonealized and joins the jejunum Relations - Anterior: L side of the root of the mesentery and coils of small intestine - Posterior: Aorta, L gonadal vessels, L psoas - Medial: Head of the pancreas (uncinate process) **NOTE: The duodenal-jejunal flexure is attached via a fibromuscular band, the SUSPENSOR MUSCLE OF THE DUODENUM (LIGAMENT OF TREITZ) to the posterior body wall in the area of the right crus of the diaphragm near the esophageal hiatus

Describe the third (horizontal) part of the duodenum

6-8 cm in length Runs horizontally from right to left across LV3 Retroperitoneal Relations: - Anterior: superior mesenteric vessels and coils of the small intestine and the root of the mesentery - Posterior: posts major, IVC, aorta, right gonadal vessels and right ureter - Superior: head of the pancreas

Describe the second (descending) part of the duodenum

7-10 cm in length Descends anterior to the right lateral border of LV 1, 2, and 3 Retroperitoneal Receives the common bile duct and main pancreatic duct Relations: - Anterior: Right lobe of the liver, gall bladder, transverse colon and its mesocolon, coils of small intestine - Posterior: hilum of the right kidney, right renal vessels, right ureter, right posts major, IVC - Medial: head of the pancreas, gastroduodenal artery, common bile duct and main pancreatic duct

Describe the general components of the pancreas

Accessory gland of digestion - Exocrine portion: elaborates digestive enzymes secreted directly into the gut - Endocrine portion: elaborates hormones important in sugar metabolism (insulin, glucagon) which are secreted into the blood Approximate weight - 85 gas; approximate length - 20 cm

Describe the quadrate lobe of the liver

Anatomical subdivision of the dorsal surface of the right lobe Situated between the inferior limbs and crossbar of the "H"

Describe the caudate lobe of the liver

Anatomical subdivision of the dorsal surface of the right lobe Situated between the superior limbs and the crossbar of the "H" A "caudate process" separates the gall bladder fossa from the caval fossa **CLINICAL NOTE: Although the quadrate and caudate lobes are described as anatomic subdivisions of the right lobe, internal functional segments do not completely correlate with established external markings. By virtue of the distribution of hepatic arteries, portal veins, and hepatic ducts (hepatic triad) they FUNCTIONALLY belong to the left lobe. These "vascularly defined" segments have greater import when considering surgical interventions, i.e. lobectomies

Describe the abdominal course of the esophagus

Approximately 2.5 cm in length Only peritonealized portion (mesoesophagus) Joins cardiac portion of the stomach at approximately the level of the 11th thoracic vertebra

Describe the left lobe of the live

Area directly to the left of the falciform ligament Impressions: 1) Esophageal 2) Gastric

What structures lie posterior to the stomach?

Area known as the STOMACH BED - area related to the stomach that directly "cradles" it, including retroperitoneal structures behind the posterior wall of the omental bursa 1) Left hemidiaphragm 2) Spleen 3) Body and tail of pancreas 4) Superior pole of left kidney 5) Splenic artery 6) Transverse colon & transverse mesocolon 7) Left suprarenal gland 8) Left colic flexure **CLINICAL CORRELATION: Erosion of the posterior wall of the stomach due to GASTRIC/PEPTIC ULCER can erode into ANY of the above structures. Erosion of the splenic artery as it courses through the substance of the pancreas can result in severe hemorrhage pancreatitis, and peritonitis

Describe the head of the pancreas

Area that lies within the concavity formed by the duodenum UNCINATE PROCESS: Inferior hook-shaped process which lies in contact posteriorly with the aorta and is crossed anteriorly by the superior mesenteric vessels Relations: - Anterior: pylorus, transverse mesocolon, and coils of the small intestine - Posterior: LV1-LV2, IVC and renal veins, aorta and right renal artery, and the bile duct which may be partially embedded within it

Describe the anterior superior pancreaticoduodenal artery

Arises from the gastroduodenal artery Courses anterior to the head of the pancreas at the junction of the 3rd portion of the duodenum providing pancreatic and duodenal branches Will anastomose with the anterior inferior pancreaticoduodenal artery (from superior mesenteric artery)

Describe the right gastro-omental

Arises from the gastroduodenal artery Travels within the gastrocolic ligament along the inferior border of the greater curvature Provides gastric branches to the anterior and posterior surfaces of the stomach as well as epiploic branches to the greater momentum Anastomoses with the left gastroepiploic artery

Describe the right gastric artery

Arises from the proper hepatic artery Branches from the proximal portion of the proper hepatic artery Descends to cours along the lesser curvature (from the pyloric end) between layers of lesser momentum providing gastric branches to the anterior and posterior surfaces of the stomach Anastomoses with the left gastric artery (celiac trunk artery)

Describe the right hepatic artery

Arises from the proper hepatic artery One of the terminal branches of the proper hepatic artery -**NOTE: 14% of the time this artery originates from the superior mesenteric artery Courses to the right behind the common hepatic duct (64%) and anterior to the portal vein (94%) where it breaks up into smaller branches which enter the right side of the hilum of the liver Provides the CYSTIC ARTERY to the cystic duct as it passes between the common hepatic and cystic ducts (cystohepatic angle)

Describe the common hepatic artery and list major branches

Arises from the trunk at the 9 o'clock position Courses in a retroperitoneal position along the superior border of the pancreas Reaching the superior portion of the 1st portion of the duodenum, it divides into the GASTRODUODENAL and PROPER HEPATIC ARTERIES

How is the esophagus attached to the diaphragm?

Attached to the margins of the esophageal hiatus via the PHRENIC-ESOPHAGEAL LIGAMENT (dorsal mesentery) It attaches to the esophagus both superior and inferior to the hiatus, allowing independent movement of the esophagus and diaphragm during breathing

What structures lie inferior to the spleen

Base rests on phrenjicocolic ligament (Sustentaculum lines - L. to prop, to hold upright)

What is the origin of the esophagus?

Begins at the cricoid cartilage opposite CV6

Describe the visceral hepatic circulation

Blood from the organs of digestion and their accessory glands reaches the liver via the portal vein - Portal vein "branches", within the liver, also course parallel to the bile duct network Branches of hepatic arteries and portal veins BOTH feed into hepatic sinusoids Hepatic sinusoids are drained by CENTRAL VEINS which coalesce to form tributaries which will eventually form HEPATIC VEINS Three hepatic veins drain the liver to the IVC within the caval fossa

Describe the proper hepatic artery

Branches from the common hepatic artery passing superiorly to enter the hepatoduodenal ligament Ascends parallel and to the common bile duct and anterior to the moral vein to provide the RIGHT GASTRIC ARTERY and terminates as the LEFT AND RIGHT HEPATIC ARTERIES **CLINICAL NOTE: in 42% of individuals, an ACCESSORY or ABERRANT HEPATIC ARTERY is present - An accessory artery is defined as an additional arterial supply from any origin that DOES NOT REPLACE an existing artery - An aberrant artery is defined as an artery that originates from any source which REPLACES an artery of traditional distribution

Describe the left gastro-omental artery

Branches from the splenic artery inferiorly near its termination Reaches the stomach by traversing the gastrosplenic ligament Travels within the gastrocolic ligament inferior ward along the middle portion of the greater curvature Provides gastric branches to the anterior and posterior surfaces of the stomach as well as epiploic branches to the greater momentum Anastomoses with the right gastro-mental artery

What is the arterial supply of the esophagus?

Cervical portion: Inferior thyroid artery Thoracic portion: branches from the bronchial arteries and from the aorta directly Abdominal portion: esophageal branch of the left gastric artery

What structures lie lateral to the spleen

Contact diaphragm inferior & medial to the costodiaphragmatic recess

Describe the neck of the pancreas

Continuous with superior portion of the head May appear somewhat constricted Relations: - Anterior: transverse mesocolon - Posterior: grooved by the superior mesenteric vessels **NOTE: Posterior to the neck of the pancreas, the superior mesenteric vein receives the splenic vein thereby forming the portal vein

Describe the body of the pancreas

Continuous with the neck Ascends slightly to the left Triangular in cross-section (apex directed anteriorly) Relations: - Anterior - stomach (through the omental bursa) and posterior body wall peritoneum - Posterior: aorta, L suprarenal gland, L kidney and its vessels and the splenic vein which may course through the substance of the gland

Describe the mucosa of the esophagus

Demonstrates an epithelial transitional zone (stratified squamous to simple columnar, aka, "Z" line) **NOTE: Although not anatomic, a functional physiologic sphincter exists at the esophageal cardiac junction (L.E.S. - lower esophageal sphincter) which appears to be important in regulating the entrance of food into the stomach and in preventing esophageal reflux

Describe the gastroduodenal artery

Descends posterior to the 1st portion of the duodenum Provides SUPRA and RETRODUODENAL branches to those respective regions of the upper duodenum Provides the POSTERIOR SUPERIOR PANCREATICODUODENAL ARTERY which courses to the left following the curvature of the 3rd portion of the duodenum, providing pancreatic and duodenal branches; will anastomose with the posterior inferior pancreaticoduodenal artery (from superior mesenteric artery) Divides at the inferior border of the 1st portion of the duodenum into RIGHT GASTRO-OMENTAL and ANTERIOR SUPERIOR PANCREATICODUODENAL ARTERIES

What structure lies superior to the stomach?

Diaphragm

Describe the first (superior) part of the duodenum

Direct continuity with pylorus 3-5 cm in length Located approximately at the anterior and right lateral side of LV1 Completely peritonealized (surrounded by hepatoduodenal ligament) Relations: - Anterior: gallbladder and quadrate lobe of the liver - Posterior: common bile duct, gastroduodenal artery and portal vein - Superior: Neck of the gallbladder and cystic duct - Inferior: Head of pancreas **NOTE: Due to lack of internal mucosal folds, the first part of the duodenum is thin-walled. Because of this, it is easily visualized through the use of radiopaque material and therefore radiologists refer to this area s the DUODENAL BULB or CAP

What structures lie medial to the spleen

Displays gastric, renal, and colic impression Tail of pancreas contacts hilum

Describe a sliding hiatal (esophageal) herniation

Due to elongation of the mesenteric attachments of the esophagus to the diaphragm, a portion of the lesser curvature and funds "slide" through the esophageal hiatus into the thoracic cavity The gastro-esophageal junction (cardia) will be located SUPERIOR to the diaphragm Associated with heartburn

Describe the venous drainage of the esophagus

Esophageal submucosal veins are drained by venue comitantes of the arterial supply These veins drain to systemic (brachiocephalic and azygous veins) and viscera venous systems (portal vein)

Describe the location of the pancreas

Except for tail, completely retroperitoneal (posterior to omental bursa) Lies transversely across the posterior abdominal wall, from duodenum to spleen, posterior to the stomach (forms a significant portion of the stomach bed)

Describe the main pancreatic duct (Wirsung)

Extends from tail to head Joined by minor ducts in a "herring bone" pattern Lies toward the posterior surface of the gland and courses midway between the superior and inferior borders of the gland In the head, curves inferior ward and courses more posteriorly within the gland Joins the common bile duct at the HEPATOPANCREATIC AMPULLA Opens into the distal 1/3 of the second portion of the duodenum via the GREATER DUODENAL PAPILLA **NOTE: Often (15%) a highly variable ACCESSORY PANCREATIC DUCT (Santorini) drains a portion of the head of the pancreas. It usually opens PROXIMAL to the greater duodenal papilla on the posterior wall of the second part of the duodenum via the lesser duodenal papilla

What is the general function of the stomach

First organ of digestion; mixes food with digestive juices Typically J-shaped, however, shape varies with stature and content Fastened securely to the diaphragm superiorly (TV11) via the GASTROPHRENIC LIGAMENT; inferiorly to the posterior body wall via its continuity with the retroperitoneal portion of the duodenum (LV1-LV2) **NOTE: Since the remainder of the stomach is only loosely secured by the omenta (greater and lesser), it is highly mobile, so much so, that when sufficiently filled may extend into the major pelvis

Describe the general characteristics of the celiac trunk artery, and what are the major branches

First unpaired branch of the abdominal aorta just after it emerges from the aortic hiatus of the diaphragm; located approximately TV12-LV1 Artery of the forges; supplies the distal esophagus to the middle of the 2nd portion of the duodenum and upper half of the pancreas (beginning of mid-gut) The trunk is short (1 cm); its 3 major branches traveling in a RETROPERITONEAL plane to their respective destinations -**NOTE: Branches of all subdivisions of the celiac trunk course to their respective destinations either in a retroperitoneal position or within peritoneal ligaments Branches: 1) Left gastric 2) Common Hepatic 3) Splenic

Describe the short gastric arteries

Four or five in number Branch from the terminal portion of the splenic artery superiorly Travel within the gastrosplenic ligament to reach the superior portion of the greater curvature and fundus of the stomach Provides gastric branches to the anterior and posterior surfaces of the stomach Anastomoses with the left gastro-mental and left gastric arteries

Describe the general characteristics of the duodenum

Function: - Absorption of nutrients - Site of openings of hepatopancreatic ducts for the addition of digestive enzymes and bile C-shaped loop of small intestine in continuity with the stomach proximally and jejunum distally Named for its length - approximately 12 finger breadths (25 cm) Firmly affixed to the posterior abdominal wall (retroperitoneal) Divided into four parts

Describe cholelithiasis

Gallstones Can be located anywhere along the hepatobiliary tract and can compromise the flow of bile from the liver as well as compromise the outflow of bile and pancreatic enzymes due to blockage of the duodenal papillae at the HEPATOPANCREATIC AMPULLA Blockage of the main pancreatic duct leads to back-up of pancreatic enzymes resulting in PANCREATITIS

Describe cholecystitis

Gallstones can erode the gallbladder wall due to their abrasive action → leads to inflammation of the gall bladder and make CHOLECYSTECTOMY (gallbladder removal) necessary Sometimes gallstones can erode the gallbladder wall to enter the duodenum (chole-cystoenteric fistula) and become lodged, usually at the ILEOCECAL JUNCTION, causing intestinal blockage (ILEUS)

Describe hepatomegaly

Increase in overall size of the liver due to: - CHF resulting in backing-up of blood due to increased resistance to blood flow through the lungs - Hepatitis (inflammation due to various causes) - Metastatic carcinoma **NOTE: Increases in the amount of blood housed in the liver at any one time is the result of the lack of valves within the hepatic veins and the IVC - Increase in central venous pressure causes the liver to become engorged with blood - Pooling of blood within the liver can be demonstrated by pushing on the RUQ resulting in distention of neck veins

Describe the gallbladder

Inferior most portion (funds) contacts the anterior abdominal wall near the junction of the right semilunar line and the 9th costal cartilage Located in the gall bladder fossa of the right lobe immediately to the right of the quadrate lobe Usually covered with peritoneum on its posterior and inferior surface, however, it may be completely peritonealized and suspended by a mesentery Contacts the transverse colon inferiorly and the first and second portion of the duodenum posteriorly Pear shaped, 7-10 cm in length, 2.5 cm at its broadest point Capacity: approximately 35 cc Divided into fundus, body, and neck - Fundus: Most anterior inferior portion - Body: contacts the visceral surface of the liver, transverse colon, and superior duodenum - Neck: Tapered, S-shaped curve, continuous with the cystic duct **NOTE: Folds of mucosa within the neck and proximal cystic duct form the SPIRAL FOLD (VALVE OF HEISER) which is important in maintaining potency of the cystic duct Function: Concentrate and dehydrate bile

Describe pancreatitis

Inflammation of the pancreas due to: 1) Blocked hepatopancreatic ampulla/main pancreatic duct causing reflux of bile and/or pancreatic digestive enzymes resulting in autolysis of pancreatic tissue Causes: - Trapped gallstone in ampulla or main duct - Trauma - Alcoholism (binge drinking)

Describe the splenic artery

Largest branch of celiac trunk Arises from the left side of the celiac trunk inferior to the left gastric artery Follows a highly tortuous course posterior to the omental bursa partially embedded within the superior portion of the pancreas Passes within the lienorenal ligament and over the superior pole of the left kidney Before entering the hilum of the spleen, divides into 4 or 5 branches which enter the spleen as END ARTERIES Branches of the splenic artery include: 1) Pancreatic branches - Dorsal pancreatic - greater pancreatic (pancreatic magna) - Arteries of the tail 2) Left gastro-mental 3) Short gastric arteries

Describe pancreatic cancer (head of pancreas)

Largest cause of extra hepatic biliary obstruction Cancer compresses common bile duct and/or hepatopancreatic ampulla Results in obstructive jaundice; due to backing up of bile pigments, body's tissues become stained yellow/green

Describe the general characteristics of the liver

Largest gland in the body; weighs approximately 2% of adult body weight As a gland, the liver elaborates and secretes bile, important for digestion of fats Provides a storehouse for nutrients gained by digestion (via portal circulation) as well as an area for anabolic synthesis Carries out the process of deamination of amino acids Detoxifies agents harmful to the body (formation of urea utilizing ammonia)

Describe the right lobe of the liver

Largest lobe of the liver, approximately 6x larger than the left lobe Separated from the left lobe on the diaphragmatic surface by the falciform ligament, and on the visceral surface by the left sagittal fissure Fossa: - Gall bladder fossa - Caval fossa - Portal fossa (porta hepatis) Impressions: - Renal (right) - Colic (hepatic flexure) - Duodenal (1st and 2nd parts)

Describe the general components of the spleen

Largest single mass of lymphatic tissue in the body; function: 1) Reservoir of red and white cells 2) Removes old RBC's and waste products 3) Elaborates lymphocytes (immune surveillance & response) Located in the LUQ within the dorsal mesentery suspended between the greater curvature of the stomach (gastrosplenic ligament) and the diaphragm (phrenicolienal ligament) at ribs 9, 10, 11. - The spleen rests on the phrenjicocolic ligament (sustentaculum lines: shelf for the spleen) **CLINICAL NOTES: 1) The spleen can expel its reservoir of blood in time of need, i.e. decreased volume or increased demand, through contraction of smooth muscle located in the capsule 2) The spleen normally does not extend inferior to the costal margin and therefore is not palpable through the abdominal wall (needs to be at least 3x normal size to palpate: SPLENOMEGALY)

Where does the esophagus pierce the diaphragm?

Level of the 10th thoracic vertebra

Describe the tail of the pancreas

Lies within the lineorenal ligament (only portion of the pancreas to be peritonealized) Contacts the hilum of the spleen

Describe the internal anatomy of the duodenum

Microscopic surface modifications, villi, provide increased surface area for absorption Macroscopic circular folds of mucosa and submucosa (place circulars) extend from the 2nd-4th part of the duodenum Two papillae, nipple-like projections, may be raised on the mucosa of the posteromedial wall of the second part - The common bile duct and the major pancreatic duct join to form a dilated tube (hepato-pancreatic ampulla) prior to opening through the GREATER DUODENAL PAPILLA - A lesser papillae may be seen proximal to the greater papilla if an accessory pancreatic duct is present

Describe a splenic rupture/splenectomy

Most frequently injured organ in the abdomen Susceptible to direct compression, laceration from broken ribs, blunt trauma elevating intra-abdominal pressure resulting in capsular rupture Capsule can be sutured; if injured too severely, splenectomy is performed to prevent fatal bleeding - Adults tolerate splenectomy well since the liver and bone marrow can assume the spleen's functions Splenectomy can also be performed as a result of splenomegaly due to hypertension and various leukemias and anemias where the spleen becomes engorged & clogged due to increased white cell product or increase red cell destruction, respectively

Describe a duodenal (peptic) ulcer

Most occur in part I where stomach acid concentration is highest Erode the posterior wall Can erode the gastroduodenal artery, resulting in significant blood loss, peritonitis, formation of adhesions between organs located in the area, and pancreatitis

Describe the gastro-esophageal junction

Right border: Continuous with the lesser curvature of the stomach Left border: Separated from the funds of the stomach by the cardiac notch

Where will referred pain from the gallbladder be located?

Right epigastrium, right shoulder, anterior body wall at the intersection of the 9th rib where the right semilunar line and radiation posteriorly to the inferior angle of the scapula as well as between the scapulae

Describe the course of the esophagus

Neck: Slightly to the left of midline Upper thorax (TV4): Midline Middle thorax (TV8): Crosses to the left (anterior to aorta) Lower thorax (TV10): Left of the midline to penetrate the diaphragm

Describe the size and shape of the spleen

Normal weight range 100-250 gm (average 150) Wedge shaped or tetrahedral shaped, depending on: 1) Distribution of vessels within 2) Fullness of surrounding organs, i.e. stomach, transverse colon Surfaces: - Lateral surface: smooth and convex - Medial surface: triangular and somewhat concave; location of hilum → Anterior border, between anterior and posterior surface is deeply notched - Apex: Directed superiorly and medial ward - Base: Inferior

Describe the location of the liver

Occupies most of the RUQ directly below the dome of of the R hemidiaphragm, protected by ribs 5-9 On the midline lies behind the xiphisternal junction Extends into the LUQ to the fifth intercostal space below the apex of the heart Should not extend more than 1" inferior to the anterior rib margin

Describe the left hepatic artery

One of the terminal branches of the proper hepatic artery Branches from the proper hepatic artery to enter the left side of the hilum of the liver May provide a MIDDLE HEPATIC ARTERY (40% occurrence) to the middle segment of the liver

What is the muscular composition of the esophagus?

Outer longitudinal, inner circular smooth muscle **CLINICAL CORRELATION: The upper 1/3 (approx.) is composed of striated muscle continuous with the inferior constrictor and innervated by the recurrent laryngeal nerve. Weakness sometimes occurs in the area of the posterior pharyngo-esophageal junction. - Because fibers of the inferior portion of the inferior constrictor (cricopharynxgeus/upper esophageal sphincter) diverge, a small area is left where the mucosa and adventitia can be directly opposed without intervening muscle fiber - An out-pocketing of these two opposed layers can occur, referred to as a ZENKER'S DIVERTICULUM, which gathers food, fills the retrovisceral/retroesophageal space and impedes swallowing

Describe pancreatic rupture

Pancreas, located transversely across spine is susceptible to compression injures (rapid deceleration and compression via steering wheel) Results in bleeding and autolysis of pancreatic and surrounding tissues due to dissemination of pancreatic enzymes throughout the abdomen

Describe the greater pancreatic artery (pancreatic magna)

Pancreatic branch of the splenic artery Arises from the inferior surface of the splenic artery along its mid-course, descends into the substance of the pancreas where its branches parallel the main pancreatic duct

Describe the dorsal pancreatic artery

Pancreatic branch of the splenic artery Variable in origin, but most often arises from the proximal inferior portion of the splenic artery Descends through the neck of the pancreas **NOTE: The dorsal pancreatic artery provides a branch at the level of the uncinate process that crosses the head of the pancreas to anastomose with the anterior superior pancreaticoduodenal artery, thereby forming the pre-pancreatic arcade

Describe cirrhosis

Progressive hepatocellular change in the form of increased fibrosis and fat deposition due to the continued exposure to toxic substances, i.e. industrial solvents, alcohol (highest frequency) Results in "hobnail" appearance of liver surface and portal HTN

Describe a paraesophageal hiatal (esophageal) herniation

Protrusion of the fundus of the stomach through a defect in the diaphragm next to the esophagus The gastro-esophageal junction (cardia) remains INFERIOR to the diaphragm - this is more dangerous as the funds may strangulate

Describe a splenic needle biopsy/splenoportography

Recalling the position of the spleen related to the diaphragm, any intervention utilizing a sharp instrument has the potential to enter the thoracic cavity at the costodiaphragmatic recess resulting in PLEURITIC (inflammation of the pleura)

What are the major clinical correlations of the esophagus

Reversal of venous drainage due to circulatory blockage within the liver causes distention of the esophageal subvocal veins, resulting in the formation of ESOPHAGEAL VARICES which over time can rupture causing death GERD (gastroesophageal reflux disease) produces "heartburn" (pyrosis) - referred pain is to the substernal region; made worse by sliding hiatal hernia

Describe the systemic hepatic circulation

Right and left hepatic arteries branch from the proper hepatic artery within the aorta Each hepatic artery courses parallel to the bile duct network which drains functional right and left lobes

Describe the biliary tree

Right and left hepatic ducts join to form the common bile duct The common hepatic duct exits the aorta ventrally and to the right to course inferiorly within the hepatoduodenal ligament After a course of 4 cm, the common hepatic duct is joined by the CYSTIC DUCT from the gallbladder, their union forming the COMMON BILE DUCT - **NOTE: The area between the common hepatic duct, cystic duct, and visceral surface of the liver is known as the CYSTOHEPATIC TRIANGLE (CALOT) and contains the cystic artery The common bile duct descends behind the first portion of the duodenum, running to the right of and parallel to the gastroduodenal artery - It passes posterior to the head of the pancreas, often being embedded within int The common bile duct joins the MAJOR PANCREATIC DUCT and pierces the posterior medial wall of the second part of the duodenum, forming the HEPATOPANCREATIC AMPULLA The hepatopancreatic ampulla opens into the lumen of the duodenum at the GREATER DUODENAL PAPILLA Circular smooth muscle located at the distal end of the common bile duct forms the CHOLEDOCHAL SPHINCTER -**NOTE: Contraction of the choledochal sphincter prevents discharge of bile into the hepatopancreatic ampulla and forces bile in a retrograde fashion into the cystic duct and gall bladder for storage and concentration the HEPATOPANCREATIC SPHINCTER (ODDI) encircles the HEPATOPANCREATIC AMPULLA, controls discharge of bile and pancreatic digestive enzymes into the duodenum The PANCREATIC DUCT SPHINCTER controls the release of pancreatic enzymes from the main pancreatic duct into the hepatopancreatic ampulla

Describe the left gastric artery

Smallest major celiac branch; aries from the trunk at the 2 o'clock position courses superiorly and to the left deep to the posterior body wall peritoneum Reaches the posterior cardiac portion of the stomach where it gives off an ESOPHAGEAL branch which supplies the distal portion of the esophagus through the esophageal hiatus of the diaphragm -**NOTE: Here the left gastric artery may also provide an ABERRANT HEPATIC BRANCH (18%) to the left lobe of the liver Remainder of left gastric artery courses along the lesser curvature between layers of lesser momentum providing gastric branches to the anterior and posterior surfaces of the stomach Ends by anastomosing with the right gastric artery

Describe the diaphragmatic surface anatomy of the liver

Smooth due to conformity of the liver to the inferior surface of the diaphragm; diaphragmatic surfaces correspond to the following designations: 1) Superior (right and left) 2) Anterior (ventral) (right and left) 3) Right (lateral) 4) Posterior (dorsal)

Describe the accessory spleen

Usually small: 0.5-2.5 cm Most often located in gastrosplenic ligament near hilum Can be found in tail of pancreas, mesentery proper, in proximity to the ovary or testes

Describe the mucosa on the internal aspect of the stomach

When the muscular layers are contracted, the mucosa displays longitudinally oriented folds called RUGAE (magenstrassen - stomach streets) located predominantly along the LESSER CURVATURE; forms GASTRIC CANAL (temporarily visible during swallowing)