100 anatomy concepts

8/20/2019 100 Anatomy Concepts

1/228

Dr. Mavrych, MD, PhD, DSc [email protected]

100 must importantGA conceptions

Dr. Mavrych, MD, PhD, DSc

Dr. Bolgova, MD, PhD

Understand first, then memorize and apply


2/228


Dear students, youcanusethis presentationlikeaguideduring yourpreparing for GA exams.

It does NOT cover all material of theGross Anatomy course. TocompleteGA material youshouldwork with ALL professor’s

presentations.

GoodLuck andAll thebest!Dr . Mavrych


3/228


1. Lumbar puncture (tap) and

Epidural anesthesia When lumbar puncture isperformed, the needleenters the subarachnoidspace to extractcerebrospinal fluid (CSF)or to inject anesthetic to

epidural space. The needle is usually

inserted between L3/L4 orL4/L5. Level of horizontalline through upper pointsof iliac crests.

Remember, the spinal cord

may ends as low as L2 inadults and does end at L3in children and dural sacextends caudally to level ofS2.


4/228



5/228


Patients typically have historyof back pain that may radiatedown to the lower limb.

Herniation of disc usuallyoccurs in lumbar (L4/L5 or L5/S1) or cervical regions(C5/C6 or C6/C7) ofindividuals younger than age50.

Herniated lumbar disc usuallycompreses the nerve root onenumber below: traversing root(e.g., the herniation L4/L5 willcompress L5 root).

The pain begins soon afterpatient lifted some heavy thing.

Lower limb reflexes aredecreased on the affected

side

2. Herniated IV disc


6/228


3. Abnormal curvatures of the

spine Kyphosis is an exaggeration of

the thoracic curvature that may

occur in elderly persons as a result

of osteoporosis (multiply

compression fracture of vertebralbodies) or disk degeneration.

Lordosis is an exaggeration of the

lumbar curvature that may be

temporary and occurs as a result

of pregnancy, spondylolisthesisor potbelly.

Scoliosis is a complex lateral

deviation, or torsion, that is

caused by poliomyelitis, a leg-

length discrepancy, or hip disease.


7/228


4. Upper l imb fractures:

Humerus fracturesSites of potential injury to major

nerves in fractures of the humerus:

1. Axillary nerve and posterior

humeral circumflex artery at thesurgical neck.

2. Radial nerve and profunda brachii

artery at midshaft. Midshaft

fracture affect origin of brachialis

muscle.

3. Brachial artery and median nerve

at the supracondylar region.

4. Ulnar nerve at the medial

epicondyle.


8/228


Fracture of distal radius: Transverse fracture within the distal 2 cm of

the radius. Most common fracture of the

forearm (after 50).

Smith's fracture results from a fall or a blowon the dorsal aspect of the flexed wrist

and produces a ventral angulation of the

wrist. The distal fragment of the radius is

ANTERIORLY displaced.

Colles' fracture results from forced

extension of the hand, usually as a result oftrying to ease a fall by outstretching the

upper limb. Distal fragment is displaced

DORSALLY - “dinner fork deformity”.

Often the ulnar styloid process is avulced

(broken off)


9/228


Scaphoid fracture Occurs as a result of a fall onto

the palm when the hand isabducted

Pain occurs primarily on thelateral side of the wrist,especially during wrist extensionand abduction

Scaphoid fracture may not showon X-ray films for 2 to 3 weeks,but a deep tenderness will bepresent in the anatomicalsnuffbox.

The proximal fragment mayundergo avascular necrosisbecause the blood supply isinterrupted.


10/228


Boxer’s fracture Necks of the metacarpal

bones are frequently

fractured during fistfights.

Typically, fractures of 2d

and3d metacarpals are seen in

professional boxers, and

fractures of 5th and sometimes

4th metacarpals are seen in

unskilled fighters.


11/228


Mallet or Baseball Finger This deformity results from the DIP joint suddenly

being forced into extreme flexion (hyperflexion)

when, for example, a baseball is miscaught or a

finger is jammed into the base pad.

These actions avulse the attachment of theextensor digitorum tendon to the base of the

distal phalanx. As a result, the person cannot

extend the DIP joint. The resultant deformity bears

some resemblance to a mallet.


12/228


5. Rotator cuff muscles – SITS Support the shoulder joint by

forming a musculotendinous

rotator cuff around it

Reinforces joint on all sides

except inferiorly, where

dislocation is most likely

Rotator cuff muscles are:

Supraspinatus

Infraspinatus

Teres minor

SubscapularisRight humerus


13/228


6. Abduction of the upper limb (0°-15°) Abduction of the

upper extremity is initiatedby the supraspinatusmuscle (suprascapular nerve).

(15°-110º) Further abductionto the horizontal position is afunction of the deltoidmuscle (axillary nerve).

(110°-180°) Raising theextremity above thehorizontal position requiresscapular rotation by actionof the trapezius (accessorynerve CNXI) and serratusanterior (long thoracic

nerve).


14/228


Subacromial bursitis &

Tearing of supraspinatus tendon Subacromial bursitis (inflammation of

the subacromial bursa) is often due to

calcific supraspinatus tendinitis,

causing a painful arc of abduction.

The same symptoms will be in case ofinflammation or trauma of the

supraspinatus tendon (MRI→ torn

tendon)


15/228


7. Three Elbows: Student's elbow

(Subcutaneous olecranon bursitis) The olecranon, to which the triceps

tendon attaches distally, is easilypalpated. It is separated from theskin by only the olecranon bursa,

which allow the mobility of theoverlying skin.

Repeated excessive pressure and

friction may cause this bursa to

become inflamed, producing a

friction subcutaneous olecranon

bursitis.


16/228


Tennis elbow

(Lateral epicondylitis) Lateral epicondyli tis: repeated

forceful flexion and extension of thewrist resulting strain attachment ofcommon extensor tendon and

inflammation of periosteum oflateral epicondyle. Pain felt over lateral epicondyle and radiatesdown posterior aspect of forearm.Pain often felt when opening adoor or lifting a glass

Origins of following muscles may

be affected:1. Extensor Carpi Radialis

Longus & Brevis

2. Extensor Digitorum

3. Extensor Digiti Minimi

4. Extensor Carpi Ulnaris


17/228


Golfer’s elbow

(Medial epicondylitis) Medial epicondyli tis is

inflammation of the common

flexor tendon of the wrist

where it originates on the

medial epicondyle of thehumerus.

Origins of following musclesmay be affected:

1. Pronator Teres

2. Flexor Carpi Radialis3. Palmaris Longus

4. Flexor Carpi Ulnaris


18/228


8. Arterial anastomoses

around the scapula Blockage of the

Subclavian or Axillaryartery can be bypassedby anastomoses

between branches ofthe Thyrocervical andSubscapular arteries:

Transverse cervical

Suprascapular

Subscapular

Circumflex scapular


19/228


9. Cubital fossa Contents from lateral to medial:

1. Biceps brachii tendon

2. Brachial artery

3. Median nerve

Subcutaneos structures from lateral tomedial:

1. Cephalic vein

2. Median cubi tal vein: joins cephalicand basilic veins

3. Basilic vein

Sites of venipuncture is usually mediancubital vein because: Overlies bicipital aponeurosis, so deep

structures protected

Not accompanied by nerves


20/228


10. Carpal Tunnel Syndrome Results from a lesion that

reduces the size of the carpaltunnel (fluid retention, infection,dislocation of lunate bone)

Median nerve – most sensitive

structure in the carpal tunneland is the most affected

Clinical manifestations: Pins and needles or anesthesia

of the lateral 3.5 digits

palm sensation is not affectedbecause superficial palmar

cutaneous branch passessuperficially to carpal tunnel

Apehand deformity - absentof OPPOSITION


21/228


11. Test of the proximal and

distal interphalangeal joints

PIP – FDS

DID - FDP


22/228


12. Lesion of UL nerves

Upper Brachial Palsy Injury of upper roots and trunk

Usually results from excessiveincrease in the angle between theneck and the shoulder stretching or

tearing of the superior parts of thebrachial plexus (C5 and C6 roots orsuperior trunk)

May occur as birth injury fromforceful pulling on infant's headduring difficult delivery


23/228


Upper Brachial Palsy

(Erb-Duchenne palsy) In all cases, paralysis of the muscles of the

shoulder and arm supplied by C5 and C6 spinal

nerves (roots) of the upper trunk.

Combination lesions of axillary, suprascapular

and musculocutaneous nerves with loss of theshoulder mm and anterior arm.

As result patient has “ waiter’s tip” hand:

adducted shoulder

medially rotated arm

extended elbow

loss of sensation in the lateral aspect of the

upper limb


24/228


Lower Brachial Palsy

(Klumpke paralysis) Injury of lower roots and

trunk

May occur when the upper

limb is suddenly pulled

superiorly: stretching ortearing of the inferior parts

of the brachial plexus (C8

and T1 roots or inferior

trunk)

E.g., grabbing supportduring falling f rom height

or as a birth injury, or

TOS – thoracic outlet

syndrome


25/228


Lower Brachial Palsy

(Klumpke paralysis) All intrinsic muscles of the hand

supplied by the C8 and T1 roots ofthe lower trunk affected.

Combination lesions of ulnar nerve (“claw hand”) and mediannerve (“ape hand”)

Loss of sensation in the medialaspect of the upper limb andmedial 1,5 fingers.

May include a Horner syndrome


26/228


Injury to musculocutaneous

nerve Usually results from lesions

of lateral cord

Greatly weakens f lexion ofelbow (biceps and brachialismuscles) and supination offorearm (biceps muscle)

May be accompanied by

anesthesia over lateralaspect of forearm


27/228


Cutaneous innervation

of the hand

Dorsum: 1,5-U and 3,5 R Palm: 1,5-U and 3,5 M

In reality, in case of superficial branch of

radial nerve lesion it will be skin deficitbetween 1 & 2 digi ts on the dorsum of the

hand ONLY because of nerve overlapping


28/228


13. Cardiac catheterization

The femoral artery isused for cardiaccatheterization

It can be cannulatedfor left cardiacangiography & alsofor visualizing thecoronary arteries – along, slender catheteris insertedpercutaneously and

passed up theexternal iliac artery,common iliac artery,aorta, to the leftventricle of the heart


29/228


14. Injury of the gluteal region

Fractures of Femoral Neck

A common fracture inelderly women withosteoporosis is fracture of the femoral neck.

Fractures of the femoral

neck cause shortness andlateral rotation of the lowerlimb.

Fractures of the femoralneck often disrupt the bloodsupply to the head of thefemur.

At present time the best wayin case of femoral neckfracture is hip replacement.


30/228


Avascular necrosis

of femoral head

Transcervical fracturedisrupts blood supply tothe head of the femur viaretinacular arteries (frommedial circumflex femoral

artery) and may causeavascular necrosis of thefemoral head if bloodsupply through the ligamentto the head is inadequate.


31/228


Injury to sciatic nerve

Weakened hipextension and kneeflexion

Footdrop (lack ofdorsiflexion)

Flail foot (lack ofboth dorsiflexion andplantar flexion)

Cause of injury:

caused byimproperly placedgluteal injectionsbut may result fromposterior hipdislocation


32/228


Posterior hip dislocations They are most common. A head-on

collision that causes the knee to

strike the dashboard may dislocate

the hip when the femoral head is

forced out of the acetabulum.

The joint capsule ruptures inferiorly

and posteriorly (fracture of ishium),

allowing the femoral head to pass

through the tear in the capsule

(tearing of ishiofemoral lig.) and

over the posterior margin of the

acetabulum onto the lateral surface

of the ilium, shortening and

medial rotating the limb.


33/228


Superior gluteal

nerve injury The superior gluteal nerve

may be injured during surgery,posterior dislocation of thehip or poliomyelitis.

Paralysis of the gluteus

medius and gluteus minimusmuscles occurs so that theability to pull the pelvis upand abduction of the thighare lost.

Trendelenburg sign:

If the superior gluteal nerve on

the right side is injured, the leftpelvis falls downward when thepatient raises the left foot off theground.

Note that side is contralateral tothe nerve injury.

Right

superior

gluteal nerve

injury

Normal


34/228


Injury to inferior gluteal nerve

Weakened hip extension(gluteus maximus), mostnoticeable when climbing

stairs or standing from aseated posit ion

Cause of in jury: posteriorhip dislocation, surgery inthis region


35/228


Injury of obturator

nerve

Difficulty adducting th igh

(e.g., crossing legs while

sitting)

Decreased sensation

over upper medial thigh

Cause of injury: anterior

hip dislocation, radical

retropubic prostatectomia


36/228


Avulsion fractures occurwhere muscles areattached - ischialtuberosities

Hamstrings muscles:

1. Biceps femoris

2. Semitendinosus

3. Semimembranosus

Action: extension of hip

joint and flexion of knee joint

Nerve supply – Tibialnerve (short head ofbiceps femoris is suppliedby the common fibular nerve)

15. Avulsion fractures

of the hip bone and

hamstrings muscles


37/228


16. Structures under inguinal

ligament:

From lateral tomedial side:

Iliopsoas muscle

Femoral nerve Femoral artery

Femoral vein

Femoral canal


38/228


Femoral hernia

A femoral hernia passes below

inguinal ligament through the femoral

ring into the femoral canal to form a

swelling in the upper thigh inferior andlateral to the pubic tubercle

The hernial sac may protrude through

the saphenous hiatus into the

superficial fascia

A femoral hernia occurs more

frequently in females and is dangerousbecause the hernial sac may become

strangulated

An aberrant obturator artery is

vulnerable during surgical repair

Inguinal lig .


39/228


17. Knee joint injuries:

Unhappy triad

Because the lateral side of theknee is struck more often(e.g., in a football tackle), thetibial collateral ligament is

the most frequently tornligament at the knee.

The unhappy triad of athleticknee injuries involves:

1. Tibial collateral l igament

2. Medial meniscus

3. Anterior cruciate ligament


40/228


Tibial collateral ligament

(medial collateral ligament)

Broad flat band

extending from medial

epicondyle of femur to

medial condyle andshaft of tibia

Blends with capsule and

firmly attaches to

medial meniscus

Limits extension and

abduction of leg at

knee


41/228


Fibular collateral l igament

(lateral collateral ligament)

Rounded cord between

lateral epicondyle of femur

and head of fibula

Does NOT blend with jointcapsule and does NOT

attach to lateral meniscus

Limits extension and

adduction of leg at knee


42/228


Rupture of the

cruciate ligaments

With rupture of the anteriorcruciate ligament, the tibiacan be pulled forwardexcessively on the femur,

exhibiting anterior drawersign.

In the less common rupture ofthe posterior cruciateligament, the tibia can bepushed backward excessively

on the femur, exhibitingposterior drawer sign.


43/228


Prepatellar bursa

Suprapatellar bursa

Prepatellar bursa: between

superficial surface of patella

and skin. May become

inflamed and swollen

(prepatellar bursitis).

Suprapatellar bursa: superior

extension of synovial cavity

between distal end of femur

and quadriceps muscle and

tendon. Usual place for intra-

articular injections. May

become inflamed and swollen

(suprapatellar bursitis).


44/228


Knee jerk reflex

The patellar reflexis tested by tappingthe patellarligament with a

reflex hammer toelicit extension atthe knee joint. Bothafferent andefferent limbs ofthe reflex arch arein the femoral

nerve (L2-L4).

Knee jerk reflex:tests spinal nervesL2-L4.


45/228


18. Ankle joint injuries:

Ankle sprains

Sprains are the most commonankle injuries

A sprained ankle is nearlyalways an inversion injury,

involving twisting of the weight-bearing plantarflexed foot.

The lateral ligament (anteriortalofibular ligament) is injuredbecause it is much weaker thanthe medial ligament.

In severe sprains, the lateralmalleolus of the fibula may befractured.


46/228


Pott’s fracture

It is fracture-dislocations of

the ankle joint Reason - forced eversion

(abduction) of the foot

The Deltoid ligamentavulses the medialmalleolus and after thatfibula fractures at ahigher level

Pott's fracture


47/228


Ankle jerk reflex

Achilles tendon reflex is

tested by tapping the

calcaneal tendon to elicit

plantar flexion at the ankle joint.

Both afferent and efferent

limbs of the reflex arc are

carried in the tibial nerve

(S1, S2).

Ankle jerk reflex: tests

spinal nerves S1-S2.


48/228


19. Injures of the leg and foot:

Fracture of the fibular neck May cause an injury to the common

peroneal nerve, which windslaterally around the neck of thefibula.

This injury results in paralysis of allmuscles in the anterior and lateralcompartments of the leg(dorsiflexors and evertors of thefoot) and loosing sensation on thedorsum of the foot.

Causing foot drop.


49/228


Rupture of the Achilles tendon

and Triceps surae muscle

Avulsion or rupture of the calcaneal

( Achilles) tendon disables the triceps

sure muscle (gastrocnemius & soleus)

so that the patient cannot plantar flexthe foot.

Triceps surae muscle:

2 Heads of Gastrocnemius m.

1 Head - Soleus muscle

Plantaris

small fusiform belly with long thintendon;

sometimes may becomehypertrophy


50/228


Plantar Fasciitis (calcaneal spur)

Plantar fasciitis is the

most common hindfoot

problem in runners. It

causes pain on the

plantar surface of thefoot and heel.

Point tenderness is

located at the proximal

attachment of the plantar

aponeurosis to themedial tubercle of the

calcaneus and on the

medial surface of this

bone.


51/228


20. Injury of tibial nerve

In popliteal fossa: loss ofplantar flexion of foot (mainlygastrocnernius and soleusmuscles) and weakened

inversion (tibialis posteriormuscle), causingcalcaneovalgus.

Inabili ty to stand on toes

Loss of sensation andparalysis of intrinsic musclesof the sole of the foot Popliteal fossa from superficial to

deep, contains:

Tibial nerve

Popliteal vein

Popliteal artery


52/228


On soil of the foot there are two terminal

branches of tibial n:

Medial plantar nerve supplies:

1. Abductor hallucis,2. Flexor hallucis brevis

3. Flexor digitorum brevis

4. 1st lumbrical muscles

skin of medial 3.5 digits

Lateral plantar nerve supplies: All intrinsic plantar muscles which

are not innervated by medial plantar

nerve

skin of lateral 1.5 digits


53/228


21. Breast:

Carcinoma of the Breast

Carcinomas of thebreast are malignanttumors, usuallyadenocarcinomasarising from theepithelial cells of thelactiferous ducts in themammary glandlobules

1. It enlarges, attachesto suspensory(Cooper‘s) ligaments,and producesshortening of theligaments, causingdepression or dimplingof the overlying skin.


54/228


Lymphatic drainage

of the breast

It is important becauseof its role in themetastasis of cancercells.

Most lymph (> 75%),especially from thelateral breastquadrants , drains tothe axillary lymphnodes, initially to theanterior (pectoral)nodes for the most

part. Most of the remaining

lymph, particularly fromthe medial breastquadrants, drains to theparasternal lymphnodes or to theopposite breast.

75% 25%


55/228


Mastectomy

Radical mastectomy, a more extensive surgicalprocedure, involves removal of the breast, pectoralmuscles, fat, fascia, and as many lymph nodes aspossible in the axilla and pectoral region.

1. During a radical mastectomy, the long thoracicnerve may be lesioned during ligation of the lateral

thoracic artery. A few weeks after surgery, the

female may present with a winged scapula and

weakness in abduction of the arm above 90°

because serratus anterior m. paralysis.

2. The intercostobrachial nerve may also be

damaged during mastectomy, resulting in skin

deficit of the medial arm.


56/228


Breast infection

Mastitis is an infection of the tissue

of the breast that occurs most

frequently during the time of

breastfeeding (1 to 3months after the

delivery of a baby).

This infection causes pain, swelling,

redness, and increased temperature

of the breast.

It can occur when bacteria, often from

the baby's mouth, enter a milk ductthrough a crack in the nipple.

It can occur in women who have not

recently delivered as well as in women

after menopause.


57/228


22. Thoracic wall & Diaphragm:

Intercostal spaces

Intercostal blood vesselsand nerves:

run between theinternal intercostal andinnermost intercostal

muscles in the costalgroove

arranged from superiorto inferior as vein,artery, nerve

Most vulnerablestructures – intercostalnerve and posteriorintercostal arterybecause they are notcovering by ribs.


58/228


Diaphragm:

Paralysis of half and ruptures

Paralysis of the halfof the Diaphragmmay result from injuryor operative division of

the phrenic nerve ofsame side

It can be detectedradiologically .

Paradoxicalmovement: dome ofdiaphragm of injuredside pushed superiorlyby abdominal visceraduring inspirationinstead of descending


59/228


Phrenic nerve

Arises from the anteriorbranches C3-C5 nerves andlies in front of the anteriorscalene muscle.

Runs anterior to the root ofthe lung, whereas the vagusnerve runs posterior to theroot of the lung.

Innervates the fibrouspericardium, themediastinal anddiaphragmatic pleurae(sensory innervation), andthe diaphragm for motor and its central tendon forsensory.


60/228


Diaphragmatic ruptures

Diaphragmatic injuries are

relatively rare and result from

either blunt trauma or

penetrating trauma.

Presently, 80-90% of blunt

diaphragmatic ruptures resultfrom motor vehicle crashes.

The majority (80-90%) of blunt

diaphragmatic ruptures have

occurred on the left side.

Blunt trauma typically produceslarge radial tears measuring 5-15

cm, most often at the

posterolateral aspect of the

diaphragm.


61/228


23. Cardiac hypertrophy Left atrial enlargement

(hypertrophy) secondary to

mitral valve failure may

compress on theesophagus and manifest

as dysphagia (difficulty in

swallowing).

It may be observed as a

filling defect in the

esophagus by barium

swallow on the lateral

thoracic X-Ray

P A j ti


62/228


Cardiac Shadow

Right border is formed by:

1. SVC,2. Right atrium

Left border is formed by:

1. Aortic arch2. Pulmonary trunk

3. Left auricle

4. Left ventricle

P-A projection


63/228


24. Auscultation of Heart

Valves

Right 2 ICS

PSL

Left 5 ICS

MCL

Left 4 ICS

PSL

Left 2 ICS

PSL


64/228


Auscultation sites for

mitral and aortic murmurs

A heart murmur is heard downstream from the valve: stenosis is orthograde direction from valve

insufficiency is retrograde direction from valve


65/228


25. Conducting System

of the Heart Sinoatrial (SA) node site where contraction of heart muscle is

initiated (pacemaker of the heart)

situated in the upper part of the sulcusterminalis just near to the opening ofthe SVC

Atrioventr icular (AV) node the AV node receives impulses from the

SA node; situated in the lower part ofthe atrial septum near coronary sinus

Atrioventr icular bundle of His

descends from the AV node to themembranous portion of the ventricularseptum where it divides into the left andright bundle branches

Right bundle branch – passes down toreach the moderator band - rightventricle

left bundle branch – passes down leftside of ventricular septum


66/228


26. Blood supply of the Heart:

Right coronary artery (RCA) It supplies major parts of the right

atrium and the right ventricle.

It anastomoses with the marginalbranch of the left coronary arteryposteriorly

Branches:

1. Anterior cardiac branches – supplies the right atrium

2. Nodal branch – supplies the (1) SAnode, (2) AV node

3. Marginal artery – supplies the rightventricle

4. Posterior interventricular artery – supplies (1) diafragmatic (inferior)surface of both ventricles and (2)posterior 1/3 of the IV septum


67/228


Left coronary artery

(LCA)Branches:

1. Anterior (descending)

interventricular artery – most

common place of MI descends in the

anterior interventricular sulcus and

provides branches to the (1) anterior

heard wall, (2) anterior 2/3 of IV

septum, (3) bundle of His, and (4)

apex of the heart.

2. Circumflex artery – winds around the

left margin of the heart in theatrioventricular groove to anastomose

with the right coronary artery

posteriorly; supplies the left atrium

and left ventricle


68/228


Blood supply of the conducting

system SA node – RCA

AV node – RCA

AV bundle (andmoderator band)- LCA


69/228


27. Congenital cardiac defects:

Atrial Septal Defect (ASD) It is less frequent than

VSD

It results from failure toclose of the foramenovale after birth (failure ofthe septum primum andseptum secundum tofuse)

Postnatally, ASDs resultin left-to-right shunting(between right and left

atrium) and are non-cyanotic conditions.

If it is small, has noclinical significance & iflarge - necessary surgicalrepair


70/228


Ventricular Septal

Defect (VSD) Ventricular septal defect

(VSD) is the most commonof the congenital heart defects

It may be found in the

membranous part of theventricular septum andresults from failure to fuse ofthe membranous portion withthe muscular portion of theventricular septum

In this case, present left–to-

right shunt (right ventricularhypertrophy (RVH)) andagain non-cyanotic.

Necessary surgery for largedefects


71/228


Patent Ductus Arteriosus (PDA) It results from failure of the ductus

arteriosus (a connection between thepulmonary trunk and aorta) to constrict andclose after birth.

Prostaglandin E and low O2 tension sustainpatency of the ductus arteriosus in the fetalperiod.

PDA is common in premature infants and incases of maternal rubella infection.

Left –to-right shunt increased pressure inpulmonary circulation (pulmonary

hypertension) and is non-cyanotic Treatment: surgical division and ligation

imperative. In great danger is left recurrentnerve (wrapping aorta arch). Injure of thisnerve results in hoarseness.


72/228


Aneurysm of the aorta

Aneurysm of the aortic arch:compresses the left recurrentlaryngeal nerve, leading tocoughing, hoarseness, andparalys is of the ipsilateral vocal

cord. It may cause dysphagia(difficulty in swallowing), resultingfrom pressure on the esophagus,and dyspnea (difficulty inbreathing), resulting frompressure on the trachea, root ofthe lung, or phrenic nerve

Aneurysm of the thoracic aortamay compress and tug on thetrachea with each cardiac systoleso that the aneurysm can be feltby palpating the trachea at thesternal notch (T2).


73/228


Abdominal aortic aneurysm

It is a localized dilatation of the

aorta. It is typically happened

just above of the bifurcation at

level of L4 and crossed by 3rd

part of duodenum.

Pulsations of a large aneurysm

can be detected to the left of

the midline at the umbilical

region.

Acute rupture of an abdominal

aortic aneurysm is associated

with severe pain in theabdomen or back (mortality rate

is nearly 90%).

Surgeons can repair an

aneurysm by opening it and

inserting a prosthetic graft.


74/228


Coarctation of the Aorta It results from congenital

narrowing of the aorta distal to theoffshoot of the left subclavianartery.

Cardinal clinical sign: higher blood

pressure in the upper limbscompared to the lower limbs.

Coarctation of the aorta results inthe intercostal arteries providingcollateral circulation between theinternal thoracic artery and thethoracic aorta to provide blood

supply to the lower parts of thebody

Coarctation of the Aortacharacteristic X-ray picture:serrated appearance of inferiorborders of ribs (rib notching)


75/228


28. Aspiration of Foreign

Bodies & Bronchopulmonary

segments Aspiration of Foreign Bodies:

Inhalation of FB’s (e.g. pins,parts of teeth, screws, nuts,bolts, toys) into the lowerrespiratory tract is common,especially in children

More likely to enter the rightprimary bronchus and pass intothe middle or lower lobebronchi

If the vertical position of thebody, the foreign body usuallyfalls into the posterior basalsegment of the right inferiorlobe.


76/228


Right lung:

10 bronchopulmonary segments

Superior lobe:

1. Apical2. Anterior

3. Posterior Middle lobe:

4. Lateral5. MedialInferior lobe:

6. Superior 7. Anterior basal8. Posterior basal9. Lateral basal10.Medial basal

1

8

97

6 4

5

2

3

10


77/228


Left lung:

9 bronchopulmonary segments

Superior lobe:

1. Apicoposterior 2. Anterior 3. Superior lingular 4. Inferior lingular Inferior lobe:

5. Superior 6. Anterior basal

7. Posterior basal8. Lateral basal9. Medial basal

1

3 5

7

89

6

2

4


78/228


29. Lung diseases:

Pneumonia Pneumonia is an inflammation

of the lung, caused by an

infection or chemical injury to the

lungs.

Three common causes are

bacteria, viruses and fungi.

Symptoms: cough, chest pain,

fever, and difficulty in breathing.

Chest x-rays: areas of opacity

(seen as white) of the lungparenchyma and enlargement of

bronchomediastinal lymph

nodes (mediastinal widening).


79/228


Bronchogenic Carcinoma

Arises in the mucosa of thelarge bronchi

Produces as persistent,

productive cough orhemoptysis

Early metastasis to thoracic(bronchomediatinal) lymphnodes

Hematogenous spread to thebrain, bones, lungs,

suprarenal glands A tumor at the apex of the

lung (Pancoast tumor ) mayresult in thoracic outletsyndrome


80/228


Bronchogenic carcinoma

may lead to:1. Thoracic outlet syndrome (TOS)

It can cause pressure on the lowertrunk of the brachial plexus C8-T1and subclavian artery by cervical

rib or pancoast tumor. It results inpain down the medial side of theforearm and hand and atrophy ofthe intrinsic hand muscles)

2. Horner syndrome:

miosis - constriction of the pupildue to paralysis of the dilator

pupillae muscle ptosis - drooping of the eyelid due

to paralysis of the superior tarsalmuscle

hemianhydrosis - loss of sweatingon one side

11

22


81/228


Bronchogenic carcinoma

may lead to:3. Superior vena cava

syndrome, which causesdilation of the head andneck veins, facial swelling,and cyanosis

4. Dysphagia as a result ofesophageal obstruction

5. Hoarseness as a result ofrecurrent laryngeal nerveinvolvement

6. Paralysis of the

diaphragm as a result ofphrenic nerve involvement33


82/228


Qs about Auscultation

and penetrated wounds To listen to breath sounds of the

superior lobes of the right and left

lungs, the stethoscope is placed on

the superior area of the anterior

chest wall (above the 4th rib for the

right lung & above 6th for the left

one).

For breath sounds from the

middle lobe of the right lung, the

stethoscope is placed on the

anterior chest wall between the 4th

and 6th ribs

For the inferior lobes of both

lungs, breath sounds are primarily

heard on the posterior chest wall.

4

6


83/228


30. Open pneumothorax &

pleura It is entry of air into a pleural

cavity causing lung collapse.

Open pneumothorax – due to stabwounds of the thoracic wall whichpierce the parietal pleura so thatthe pleural cavity is open to theoutside air via the lung or throughthe chest wall.

Air moves freely through thewound during inspiration andexpiration. During inspiration, airenters the chest wall and the

mediastinum will shift toward otherside and compress the oppositelung. During expiration , air exitsthe wound and the mediastinummoves back toward the affectedside.


84/228


Pleura & Pleural Cavity 1. Cervical p leura may be affected in

case of improper subclavianvenipuncture.

2. Costodiaphragmatic Recess isdeepest place in pleural cavity, aroundthe chest wall, there are two ribinterspaces separating the inferiorlimit of parietal pleural reflections fromthe inferior border of the lungs andvisceral pleura:

1. Midclavicular line - between ribs 6-82. Midaxillary line - between ribs 8-10

3. Paravertebral line between ribs 10-12

2


85/228


Nerve supply of the pleuraParietal Pleura – sensitive to general

sensibilities (pain, temperature, touch,and pressure) - somatic sensoryinnervation:

costal pleura – intercostal nervesblock may be used to decreasethoracic pain

mediastinal pleura – phrenic nerve

diaphragmatic pleura – phrenic nerveover the domes and lower 6 intercostalnerves around the periphery

Visceral Pleura – sensitive to stretch butinsensitive to general sensibilities;autonomic nerve supply from thepulmonary plexus


86/228


31. Mediastinum

Superior mediastinum Improperly done

sternal puncturemay affectstructures related

to the posteriorsurface of themanubriumsternum:

In upper part – Leftbrachiocephalic

vein In lower part –

Aort ic arch


87/228


Thoracic duct

Function – conveys to theblood all lymph from thelower limbs, pelvic cavity,abdominal cavity, left side

of the thorax, left side ofthe head & neck, and leftupper limb (3/4 of thebody)

Tributaries – at the root of theneck

Left jugular lymph trunk Left subclavian lymph

trunk

Left bronchomediastinallymph trunk


88/228


Constrictions of the esophagusThere are sites where ingested

foreign bodies can lodge orwhere strictures may developfollowing ingestion of causticfluids, common sites of

esophageal carcinoma

1. C6 - where the pharynx joinsthe upper end (6" from theupper incisors)

2. T4-T5 - where the aortic archand left main bronchus cross

its anterior surface (10" from theupper incisors)

3. T10 - where it passes throughthe diaphragm into thestomach (16" from the upperincisors)

1

2

3


89/228


32. Anterior abdominal wall

The liver and gallbladder are in the right upperquadrant;

The stomach and spleen

are in the left upperquadrant;

The cecum and appendixare in the right lowerquadrant;

The end of the descendingcolon and sigmoid colonare in the left lowerquadrant.


90/228


Referred abdominal pain

Pain arising out of theforegut derived structuresis referred to the

epigastric region.

Pain arising out of themidgut derived structuresis referred to theumbilical region.

Pain arising out of thehindgut derivedstructures is referred tothe hypogastric region.

Nerve supply of the


91/228


Nerve supply of the

anterior abdominal wall

Therefore totally 7 nerves:lower 5 intercostals, 1subcostal and L1(iliphypogastric andilioinguinal) nerves supply

the anterior abdominal wall. L1 can be anaesthetized by

injecting 1 inch (2.5 cm)superior to the anteriorsuperior iliac spine.

All nerves and deep blood

vessels lie in theneurovascular plane:between internal obliqueand transversus muscles

Arterial supply of the anterior


92/228


Arterial supply of the anterior

abdominal wall:

Important SUPERFICIAL

ARTERIES (supply skin) are:

1. Superficial epigastric

2. Superficial circumflex iliac

Important DEEP ARTERIES lie inthe neurovascular plane:

1. Superior epigastric

2. Posterior intercostals arteries

3. Lumbar arteries

4. Deep circumflex iliac artery

5. Inferior epigastric

33 Herniations


93/228


33. Herniations

Hernia consist of 3 parts:

Hernial sac is a pouch(diverticulum) of peritoneum andhas a neck and a body

Hernial contents may consist ofany structure found in the

abdominal cavity (more offen – loops of small intestine andpiece of omentum major)

Hernial coverings are formedfrom the layers of the abdominalwall through which the hernial

sac passes

T li f i i th FIRST


94/228


Transversalis fascia is the FIRST

STRUCTURE which is crossed by

any abdominal hernia


95/228


Indirect Inguinal Hernia

Indirect inguinal hernia is the mostcommon form of hernia and is believedto be congenital in origin (boys 0-3years).

It passes through the deep inguinal ring

lateral to the inferior epigastricvessels, inguinal canal, superficialinguinal ring and descend into thescrotum.

An indirect inguinal hernia is about 20times more common in males than infemales, and nearly 1/3 are bilateral.

It is more common on the right(normally, the right processus vaginalisbecomes obliterated after the left; theright testis descends later than the left).


96/228


Direct Inguinal Hernia

Direct inguinal hernia composesabout 15% of all inguinal hernias.

During a direct inguinal hernia,the abdominal contents willprotrude through the weak area of

the posterior wall of the inguinalcanal medial to the inferiorepigastric vessels in the inguinal[Hesselbach's] triangle and afterthat through superficial inguinalring. It never descends into thescrotum.

It is a disease of old men withweak abdominal muscles. Directinguinal hernias are rare in women,and most are bilateral.

34 P it l t t


97/228


34. Peritoneal structures:

Lesser omentum

Consist of 2 ligaments:

hepatogastric

hepatoduodenal

Contents : Right & Left gastric

vessels

Connective and fattytissue

and Portal triad:

Bile duct

Portal vein

Proper hepatic artery


98/228


Epiploic (winslow’s) foramen

Anteriorly: The freeborder of thehepatoduodenalligament, containingportal triad (DV A).

Posteriorly: IVC

Superiorly: Caudate

lobe of the liver .

Inferiorly: The 1st

part of theduodenum.


99/228


Douglas (rectouterine) pouch

Rectouterine pouch(pouch of Douglas):deeper point of

peritoneal space invertical position of thefemale body between therectum and the cervix ofuterus.

It is space of the pelvic

abscess location.


100/228


Culdocentesis

Culdocentesis isaspiration of fluid fromthe cul-de-sac ofDouglas (rectouterinepouch) by a needle

puncture of theposterior vaginalfornix near the midlinebetween the uterosacralligaments

Because therectouterine pouch is

the lowest portion ofthe female peritonealcavity, it can collectinflammatory fluid(pelvic abscess).


101/228


35. Smart Table

FOREGUT MIDGUT HINDGUT

Esophagus

Stomach

Duodenum (1st and

2nd parts)

Liver

Pancreas

Biliary apparatus

Gallbladder

Duodenum (2nd, 3rd,

4th

parts)

Jejunum

Ileum

Cecum (with

Appendix)

Ascending colon

Transverse colon(proximal 2/3)

Transverse colon

(distal 1/3)

Descending colon

Sigmoid colon

Rectum (anal canal

above pectinate line)



102/228



Artery: CA Artery: SMA Artery: IMA

Parasympathetic

innervation: vagus

nerves, CNX

Parasympathetic

innervation: vagus

nerves, CNX

Parasympathetic

innervation: pelvic

splanchnic nerves, S2-S4

Sympathetic

innervation:

•Preganglionics: greater splanchnic nerves, T5-T9

•Postganglionics:

celiac ganglion

Sympathetic

innervation:

•Preganglionics: lesser splanchnic nerves, T10-

T11

•Postganglionics:

superior mesenteric

ganglion

Sympathetic

innervation:

•Preganglionics: lumbar splanchnic nerves, L1-L2

•Postganglionics: inferior

mesenteric ganglion

Sensory Innervation:DRG T5-T9

Sensory Innervation:DRG T10-T11

Sensory Innervation:DRG L1-L2

Referred Pain:

Epigastrium

Referred Pain:

Umbilical

Referred Pain:

Hypogastrium


103/228


36. Posterior gastric ulcer

1. Posterior gastric ulcer mayerode through the posteriorwall of the stomach into the

Omental bursa (Lesserperitoneal sac) and affectpancreas resulting inreferred pain to the back.

2. Erosion of splenic artery is

very common in posteriorgastric ulcers as wellbecause of the proximity ofthe artery to this wall.

37 Congenital diaphragmatic


104/228


37. Congenital diaphragmatic

hernia

Hernia of stomach orintestine through aposterolateral defect

in diaphragm(foramen ofBochadalek).

It is seen in infantsand the mortality rate ishigh because of left

lung hypoplasia.


105/228


38. Sliding hiatal hernia

A sliding hiatal hernia which

occurs in individuals past

middle age is caused by

the hernia of cardia of thestomach into the thorax

through the esophageal

hiatus of the diaphragm.

This can damage the vagal

trunks as they pass throughthe hiatus and resulting in

hyposecretion of gastric

juice.


106/228


39. Meckel's diverticulum

Meckel's diverticulum is a congenitalanomaly representing a persistent portion ofthe vitellointestinal duct.

This condition is often asymptomatic butoccasionally becomes inflamed if it containsectopic gastric, pancreatic, or endometrial

tissue, which may produce ulceration. Meckel's diverticulum is located on the

Ileum about 2 feet (61 cm) before theileocecal junction and SMA supply it. Itoccurs in 2% of patients and is about 2 inches(5 cm) long.

The diverticulum is clinically importantbecause diverticulitis, liberation, bleeding,perforation, and obstruction are complicationsrequiring surgical intervention and frequentlymimicking the symptoms of acuteappendicitis.

40 Features of the large


107/228


40. Features of the large

intestine

Features of the large intestine:

1. Appendices epiploic

2. Sacculations(haustrations)

3. Taeniae coli

The taeniae coli meettogether at the base ofthe appendix where theyform a complete

longitudinal muscle coatfor the appendix.


108/228


Colon

The ascending colon liesretroperitoneally and lacks amesentery.

It is continuous with thetransverse colon at the right(hepatic) flexure (1) of colon.

The transverse colon (3) hasits own mesentery called thetransverse mesocolon(intraperitoneal position).

It becomes continuous with thedescending colon at the left

(splenic) flexure (2) of colon. The sigmoid colon (4) is

suspended by the sigmoidmesocolon (intraperitonealposition).

1

3

4


109/228


41. Pain of Appendicitis

In appendicitis, first pain isreferred around the umbilicus.Visceral pain in the appendix isproduced by distention of itslumen or spasm of its muscle.

The afferent pain fibers enterthe spinal cord at the level ofT10 segment, and a vaguereferred pain is felt in the regionof the umbilicus.

Later if parietal peritoneum

gets involved, and then the painis shifted laterally to the McBurney’s point. Here the painis precise, severe, and localized(second pain)


110/228


Mc Burney's point

This point indicatesthe surface markingof the base of theappendix.

It is a point at the

junction between thelateral 1/3 andmedial 2/3 of a line

joining the rightanterior superior iliacspine with theumbilicus.


111/228


42. Volvulus

Because of its extreme mobility,

the Jejunum, Ileum and

Sigmoid colon sometimes

rotates around its mesentery.It results in avascular necrosis

corresponding part of interstine.

This may correct itself

spontaneously, or the rotation

may continue until the blood

supply of the gut is cut off

completely.


112/228


43. Hirschsprung's Disease

It is a rare congenital abnormality thatresults in obstruction because theintestines do not work normally.

It is commonly found in Down Syndromechildren.

The inadequate motility is a result of anaganglionic section (congenital absentsof postganglionic parasympatheticneurons inside of the intestinal wall) of theintestines resulting in megacolon.

In a newborn, the main signs andsymptoms are failure to pass a

meconium stool within 1-2 days afterbirth, reluctance to eat, bile-stained(green) vomiting, and abdominaldistension.

Treatment is removal of the aganglionicportion of the colon.

44 Branches of Abdominal aorta


113/228


44. Branches of Abdominal aorta

and Mesenteric ischemia

Celiac trunk (CA) originatesfrom the aorta at the lowerborder of T12 vertebra

Superior mesenteric arteryoriginates at the lower

border of L1 vertebra Renal arteries originate at

approximately L2 vertebra

Inferior mesenteric arteryoriginates at L3 vertebra

Two terminal branches are

common iliac arteries atthe level of L4 vertebra


114/228


CELIAC ARTERY (TRUNK)

Origin: T12, just below the

aortic opening of the

diaphragm.

The CA passes above the

superior border of thepancreas and then divides

into three retroperitoneal

branches:

Left gastric artery (1)

Common hepatic artery (2) Splenic artery (3)

2

3

1


115/228


Left gastric artery

The left gastric artery (1)

courses upward to the left to

reach the lesser curvature of

the stomach and may be

subject to erosion by a

penetrating ulcer of thelesser curvature of the

stomach.

Branches:

Esophageal branches (2) - tothe abdominal part of theesophagus

Gastr ic branches (3) supply

the left side of the lesser

curvature of the stomach and

make anastomosis with right

gastric artery.

2

3

1


116/228


Common hepatic artery

The common hepatic artery

(1) passes to the right to

reach the superior surface of

the first part of the duodenum,

where it divides into its two

terminal branches:

Proper hepatic artery (2)

Gastroduodenal artery (3)

1

2

3


117/228


Proper hepatic artery Proper hepatic artery (1) gives

off right gastric artery (2) and

then ascends within the

hepatoduodenal ligament of the

lesser omentum to reach the

porta hepatis, where it divides

into the right (4) and left (3)hepatic arteries.

The right and left arteries enter the

two lobes of the liver , right

hepatic artery gives cystic artery

(5) to the gallbladder .

Right gastric artery (2) suppliesthe right side of the lesser

curvature of the stomach where it

anastomoses the left gastric

artery.

54

3

21


118/228


Gastroduodenal artery

Gastroduodenal artery (1)

descends posterior to the first

part of the duodenum (may be


penetrating ulcer in this place)

and divides into two branches:

Right gastroepiploic artery (2)

(supplies the right side of the

greater curvature of the

stomach where it anastomoses

the left gastroepiploic)

Superior pancreaticoduodenal

arteries (3) (supply the head of

the pancreas, where they

anastomoses the inferior

pancreaticoduodenal arteries

from the SMA).

1

2

3


119/228


Ligature of the hepatic artery:

The hepatic artery may beligated proximal to the originof its gastroduodenal branch,a collateral circulation to theliver is established throughthe left and right gastric

arteries, left and rightgastroepiploic andgastroduodenal arteries.

The right hepatic arterymay be mistakenly ligatedduring holecystectomy in

Calot triangle together withthe cystic artery, right lobehepatic necrosis commonlyoccurs.


120/228


Splenic artery

Splenic artery (1) runs a

tortuous horizontal course to

the left along the upper border

of the pancreas, behind the

peritoneum of the posterior

wall of the lesser sac, forming apart of the stomach bed.

The splenic artery may be


penetrating ulcer of the

posterior wall of the stomach

into the lesser sac.

N.B. The splenic vein runs amore straight course below theartery and behind of thepancreas.

1


121/228


Splenic artery

Splenic (1) a. is retroperitoneal

until it reaches the tail of the

pancreas, where it enters the

splenorenal ligament to enter

the hilum of the spleen.

Branches: Branches to the spleen (2)

Branches to the neck, body, and

tai l of pancreas (3)

Left gastroepiploic (4) artery that

supplies the left side of the

greater curvature of the stomachwhere it anastomoses the right

gastroepiploic

Short gastric (5) branches that

supply fundus of the stomach

5

43

1 2


122/228


SMA Branches:

(1) Inferiorpancreaticoduodenalarteries

(2)Jejunal and (3)Ileal branches

(4) Ileocolic artery

Ascending branch

Anterior cecal artery

Posterior cecal artery

(5) Appendicularartery

(6) Right colic artery

(7) Middle colic artery

17

6

5

4

3

2


123/228


IMA Branches:

(1) Left colic artery

(2) Sigmoid arteries

(3) Superior rectal artery

3

2

1


124/228


Mesenteric ischemia Atherosclerosis, which slows the

amount blood flowing through arteries, isa frequent cause of chronic mesentericischemia.

Ischemia occurs when blood cannot flowthrough arteries as well as it should, and

intestines do not receive the necessaryoxygen to perform normally. Mesentericischemia usually involves SMA and smallintestine.

Mesenteric ischemia primarily affectsorgans which locate far away fromanastomoses with CA & IMA. Usually

blood supply of the Jejunum and Ileum ismost compromised.

Mesenteric ischemia typically occurs inpeople older than age 60 with history ofsmoking and high cholesterol level.


125/228


45. Biliary system & gallstones

Bile is secreted by the liver cells,stored, and concentrated in thegallbladder and later it isdelivered to the duodenum.

The gallbladder lies in it’s fossa

on the visceral surface of theliver right side of quadrate lobe.

It stores and concentrates bile,which enters and leaves itthrough the cystic duct.

The cystic duct joins the

common hepatic (from leftand right hepatic) due to formthe common bile duct.


126/228


Biliary system

The common bile duct descends in

the hepatoduodenal ligament,then passes posterior to the firstpart of the duodenum

It penetrates the head of thepancreas where it joins the mainpancreatic duct and they form the

hepatopancreatic ampulla(sphincter of Oddi), which drainsinto posteromedial wall thesecond part of the duodenum at themajor duodenal papilla

Cholelithiasis (gallstones)


127/228


Cholelithiasis (gallstones)

The distal end of the hepato-

pancreatic ampul la (Bile duct) is the

narrowest part of the biliary passages

and is the common si te for impaction

of gallstones.

As result of common hepatic (1), bile

duct (2), or hepatopancreatic

ampulla (3) obstruction patient will

have yellow eyes and jaundice

Gallstones may also lodge in the

cystic duct. A stone lodged in thecystic duct (4) causes biliary colic

(intense, spasmodic pain in the

gallbladder) but doesn't produce

jaundice.

1

2

3

4


128/228


Gallstones

The fundus [1] of the gallbladder isin contact with the transverse colonand thus gallstones erode through theposterior wall of the gallbladder andenter the transverse colon. They arepassed naturally to the rectum

through the descending colon andsigmoid colon.

Gallstones lodged in the body [2] ofthe gallbladder may ulcerate throughthe posterior wall of the body of thegallbladder into the duodenum

(because the gallbladder body is incontact with the duodenum) and maybe held up at the ileocecal junction,producing an intestinal obstruction.

2

1

46. Nerve supply of the liver


129/228


and gallbladder

Sensory innervation of the liver: by the rightphrenic nerve (C3-C5). Pain may radiate to ther ight shoulder .

The liver receives parasympathetic innervation

from the vagi nerves (CNX), reaching it throughthe celiac plexuses around the supplying arteries.The preganglionic fibers synapse on the cells ofthe uxtramural plexuses in hilum of the liver andshot postganglionic fibers supply organs.

Sympathetic f ibers of preganglionic neurons

T5-T9 segments (IML) come through thesympathetic trunk and form greater splanchnicnerves. They contribute to the celiac plexus,where postganglionic neurons are located.Branches of celiac plexus reach the liver wrappingaround the branches of the celiac artery.

47. Portal Hypertension &


130/228


Portocaval shunts

Portal hypertension is acommon clinical condition, andfor this reason portal-systemicanastomoses should beremembered.

[1] Extrahepatic portocavalshunt for the treatment ofportal hypertension: thesplenic vein may beanastomoses to the left renalvein after removing the

spleen. [2] Intrahepatic portocaval

shunt : between portal veinand hepatic veins

Large intestine metastases &


131/228


Portocaval anastomosis

Metastases of the Large intestine

cancer typically rich the Liver via

portal venous system: Rectum -

IMV - splenic vein - portal vein -

Liver

If there is an obstruction to flowthrough the portal system (portal

hypertension), blood can flow in a

retrograde direction and pass

through anastomoses to reach the

caval system. Sites for these

anastomoses include:

(1) esophageal veins

(2) paraumbilical veins

(3) rectal veins


132/228


Esophageal anastomosis

Anastomosis between thetributaries of the left gastricvein (portal vein) and thetributaries of the azygousvein (SVC) in the wall of thelower end of the esophagus.

In portal hypertension theseveins enlarge in the wall of theesophagus and later burstinto the lumen of the

esophagus (esophagealvarices) resulting inhematemesis (vomiting redblood).


133/228


Umbilical anastomosis

Anastomosis between theparaumbilical veins (portalvein) and the superior andinferior epigastric veins(SVC and IVC) in anteriorabdominal wall around theumbilicus.

In portal hypertension, thisanastomosis gets enlargedand dilated veins form “caputMedussae” around theumbilicus.


134/228


Rectal anastomosis

Anastomosis between thesuperior rectal vein(inferior mesenteric veinand then portal vein) andinferior rectal vein whichdrains into the internal iliac

vein (from IVC system). In portal hypertension

(chronic alcoholics) thisanastomosis gets dilatedresulting in internalhemorrhoids and bleedingper anus from superior

rectal vein.

48. Pancreas:


135/228


Head and uncinate process

The head of the pancreasrests within the C-shapedarea formed by theduodenum and istraversed by the commonbile duct.

It includes the uncinateprocess which is crossedby the superiormesenteric vessels.

Cancer of the head


136/228


of the pancreas

Cancer of the head of thepancreas compresses the bileduct and results inOBSTRUCTIVE TYPE OFJAUNDICE.

Pain will be conveyed to sensoryneurons T5-T9 dorsal rootganglia via celiac plexus andgreater splanchnic nerve.

This type of jaundice is NOTusually associated with fever .

Hepatitis also causes jaundicebut is associated with thefever .


137/228


Neck of the pancreas

Posterior to theneck of thepancreas is the siteof formation of thePORTAL VEIN.

(1)Splenic vein joins with (2)superiormesenteric vein toform (3) portal vein.

3

2

1


138/228


Body of the pancreas

The body passes to theleft and anterior to the (1)aorta and the (2) leftkidney.

The (3) splenic arteryundulates along thesuperior border of thebody of the pancreas withthe splenic vein coursingposterior to the body.

3

2

1


139/228


Tail of the pancreas

The tail of the pancreasenters the splenorenalligament to reach thehilum of the spleen.

It is the only part of thepancreas that isintraperitoneal.

Tail of the pancreas maybe mistakenly removedduring spleenectomy(ligation of splenic artery

and vein) and resulting insugar diabetes because itcontains a lot endocrinecells.

Arterial supply of the


140/228


pancreas

Head and Duodenum:

(1) Superiorpancreaticoduodenal arteries -branches of gastroduodenalartery.

(2) Inferior pancreaticoduodenal

arteries - branches of SMA This region is important for

collateral c irculation becausethere are anastomoses betweenthese branches of the CA andSMA.

Neck, Body, and Tail of thepancreas:

Pancreatic branches of the (3)Splenic artery.

1

2

3


141/228


Annular Pancreas Annular pancreas is caused by

malformation during the

development of the pancreas,

before birth.

Occurs when the ventral and dorsal

pancreatic buds form a ring aroundthe duodenum, thereby causing an

obstruction of the duodenum and

polyhydramnios

Symptoms:

1. Feeding intolerance in newborns

2. Fullness after eating

3. Nausea and bile-stained vomiting

Half of cases are not diagnosed

until symptoms occur in adulthood.

49. Spleen:

R t f th S l


142/228


Rapture of the Spleen

Rapture of the spleen may beresult of the left 9th and 10th ribsfracture or blunt trauma of theleft upper abdomen.

The spleen is a peritoneal organ

in the upper left quadrant that isdeep to the left 9th, 10th, and 11th

ribs.

The spleen follows the contour ofrib 10 (axis of the spleen).

When blood collected deep to the

diaphragm phrenic nerveirritates and pain may irradiate toleft shoulder .

When spleen is ruptured, itcannot be sutured thereforeremoving is required.

Relations of the Spleen and

L ft Kid


143/228


Left Kidney

The spleen followsthe contour of 10th riband extends from thesuperior pole of theleft kidney to just

posterior to themidaxillary line.

The border betweenspleen and upperpole of the left kidney

is 11th rib.

50. Kidney:


144/228


Dimensions and position

During life, kidneys arereddish brown and measureapproximately 11-12 cm inlength, 5-6 cm in width, and2.5-3 cm in thickness.

They are extending from thelevel of T12 to the level of L3,the right kidney lying about2-3 cm lower than the leftone.

The lateral border of thekidney is convex. Its medial

border is convex at both endsbut concave in the middlewhere there is the hilum ofthe kidney (L1).

Anterior relations

f th i ht kid


145/228


of the right kidney

1. Right suprarenal gland

2. 2nd part of theduodenum

3. Right lobe of the liver

4. Right colic flexure

5. Small intestine

Anterior relations

f th l ft kid


146/228


of the left kidney

1. Left suprarenal gland

2. Stomach

3. Spleen

4. Body of pancreas andsplenic vessels

5. Descending colon

6. Small intestine

R l (G t ) f i


147/228


Renal (Gerota) fascia

Enclosing the perinephric fat is

a membranous condensation

of the extraperitoneal fascia -

the renal fascia (3).

The suprarenal glands (4) are

also enclosed in this fascial

compartment, usually

separated from the kidneys by

a thin septum.

N.B. The renal fascia must

be incised in any surgicalapproach to this organ.

3

4

P i h i b


148/228


Perinephric abscess

Most infections of the perinephricspace occur as a result of extensionof an ascending urinary tractinfection, commonly in associationwith nephrolithiasis or tuberculosis.

Perinephric abscess typicallydescends down between 2 sheets ofthe renal fascia along the psoasmajor muscle.

In case if abscess locates behind ofthe psoas major muscle it descendsdown and may affect hip joint.

If abscess spreads up it’ll reach thediaphragm and irritate phrenicnerve. As result patient will feel painin shoulder region.

51 N h lithi i


149/228


51. Nephrolithiasis

Renal calculi are solid concretions

(crystal aggregations) formed in the

kidneys from dissolved urinary minerals.

There are several types of kidney

stones. The majority are calcium

oxalate stones, followed by calcium

phosphate stones.

Kidney stones typically leave the body

by passage in the urine stream, and

many stones are formed and passed

without causing symptoms. If stones grow to sufficient size before

passage (at least 2-3 mm), they can

cause obstruction of the ureter (renal

colic).

3 t i ti f t


150/228


3 constrictions of ureter:

Ureter located on the anteriorsurface of the Psoas majormuscle and has 3 constrictions:

1st constriction is at thepelviureteric junction (level of L1)

2d constriction lies at the level ofpelvic brim (level of the sacroiliac

joint)

3d constriction appears whereureter lies obliquely in the wall ofurinary bladder (level of ischial

spine)

1

2

Staghorn calc li


151/228


Staghorn calculi

Renal stone that develops in the

renal pelvis and greater calices,

and in advanced cases has a

branching configuration which

resembles the antlers of a stag.

Staghorn calculi are composed of

magnesium ammonium

phosphate, which forms in urine

that has an abnormally high pH

(above 7.2).

This high pH usually developsbecause of recurrent urinary tract

infection with microorganisms

such as Proteus mirabilis.

52 Suprarenal glands


152/228


52. Suprarenal glands

They are endocrine glands

having cortex and medulla.

The adrenal cortex [1]

secretes aldosterone,

corticosteroids and

genital hormones.

1

2

The chromaffin cells of the adrenal medulla [2]

secrete two catecholamines : epinephrine and

norepinephrine, which affect smooth muscle, cardiac

muscle, and glands in the same way as sympathetic

stimulation. Sympathetic stimulation or hypersecretion of

catecholamines (tumor of adrenal medulla orsympathetic chain ganglia) resulting in: episodes oftachycardia, sweating and high blood pressure.

Unpaired tributaries of IVC


153/228


Unpaired tributaries of IVC

The right renal (1) vein ismuch shorter than the left.Both veins lie anterior to thecorresponding artery inhilum of kidneys.

The long left renal vein (2)is joined by the leftsuprarenal (3) and leftgonadal (4) (testicular or ovarian) veins before itreached IVC.

Right suprarenal vein andright gonadal vein draindirectly to IVC (unpairedIVC tributaries).

1

2

3

4


154/228


53. Varicocele

It is enlargement of thepampiniform plexus thatproduces a wormlike scrotalmass and enlargement of thespermatic cord. Varicocelemay be reason of low spermcount.

Varicocele formation is usuallyon the lef t side and maydisappear in supine positionof the body.

Varicocele may indicatekidney disease or may signala retro peritoneal malignancyobstructing the testicularvein.

Pampiniform plexus


155/228


Each testicular or ovarian vein isformed by coalescence of apampiniform plexus: thetesticular at the deep inguinalring, the ovarian at the margin ofthe superior aperture of the

pelvis. The veins run accompanied by

the corresponding arteries. Theleft pampiniform plexus entersthe left renal vein; the right oneenters directly the IVC inferiorto the renal vein.

That is why varicocely(engorgement of the pampiniformplexus that produces a scrotalmass) is more often located onthe left.

54 Hydrocele


156/228


54. Hydrocele

The tunica vaginalis testis orother remnants of the processusvaginalis may form a hydroceleor hematocele.

In spermatic cord it is smooth

sausage-shaped structure thatpersists under gentlecompression and isn’t disappearin supine position.

In the scrotum withtransillumination, a hydroceleproduces a reddish glow,

whereas light will not penetrateother scrotal masses such as ahematocele, solid tumor , orherniated bowel.

55. Hemorrhoids:

V d i f t


157/228


Venous drainage from rectum

Above pectinate line: superior

rectal vein [1] into portal

system [2].

Below pectinate line: inferior

rectal vein [3] into inferior

vena cava [4].

1

2

3

4

E t l h h id


158/228


External hemorrhoids

Hemorrhoids are masses that

typically protrude from anus

during defecation.

Hemorrhoids are commonly

associated with constipation,extended sitting and straining at

the toilet, pregnancy, and

disorders that hinder venous return.

1. External hemorrhoids are

dilated tributaries of the inferior

rectal veins (IRV) BELOW THE

PECTINATE LINE and are painful

because the mucosa is supplied by

somatic afferent fibers of the

inferior rectal nerves (from

pudendal).

1

1


159/228


Internal hemorrhoids

2. Internal hemorrhoidsare dilated tributaries of thesuperior rectal veins(SRV) ABOVE THE

PECTINATE LINE and arenot painful because themucosa is supplied byvisceral afferent fibers.

Internal hemorrhoids

frequently develop inchronic alcoholicsbecause of liver cirrhosisand portal hypertensionsyndrome.

2

2

2

56. Perineal pouches:

Deep perineal pouch


160/228


Deep perineal pouch

The deep perineal pouch is

formed by the fasciae and

muscles of the urogenital

diaphragm.

It contains:1. Sphincter urethrae

muscle

2. Deep transverse

perineal muscle

3. Bulbourethral

(Cowper ) glands (inthe male only) - ducts

perforate perineal

membrane and enters

bulbar urethra.

Superficial perineal pouch1 I hi l l t d t th C f th


161/228


1. Ischiocavernosus muscle – related to the Crus of thepenis (Male) & Crus of the clitoris (Female)

2. Bulbospongiosus muscle – related to the Bulb ofvestibule (Female) & Bulb of the penis (Male)

3. Superficial transverse perineal muscle – related to thePerineal body (both genders)

1

2

3

Urine leaks


162/228


Urine leaks

After a crushing blow or a

penetrating injury, the spongy

urethra commonly ruptures

within the bulb of the penis, and

urine leaks into the superficialperineal pouch.

The superficial perineal fascia

keeps ur

100 anatomy concepts

Documents