Download 25 -celiac_T2009-01-27 12:361.2 MB

Coeliac Trunk
It is the artery of foregut, it supplies
GIT from lower 1/3 of esophgus down
as far as the middle of second part of
duodenum.
Origin : is very short and arises from
front of abdominal aorta at level of
lower border of T12 vertebra.
It is surrounded by the celiac plexus
of nerves.
It lies behind the lesser sac of
peritoneum.
It has 3 terminal branches :
1-Left gastric artery.
2-Splenic artery.
3-Hepatic artery.
1- Left gastric artery
It is the smallest branch of celiac
trunk.
It passes upwards and to left side
to reach cardiac end of stomach.
It then passes downwards between
the 2 layers of lesser omentum along
lesser curvature of stomach.
It ends by anastomosing with right
gastric artery.
Branches :
1-Esophageal branches to lower
end of esophagus.
2-Gastric branches : to supply both
surfaces of stomach along lesser
curvature.
2- Splenic Artery
It is the largest branch of celiac
trunk.
It runs behind the stomach to the
left side in a wavy course along upper
border of pancreas.
On reaching left kidney , it enters
splenico-renal ligament to reach the
hilum of spleen.
2- Splenic Artery
Branches :
1-Pancreatic branches.
2-Left gastroepiploic artery :
arises near hilum of spleen and
passes in the gastro-splenic omentum
(ligament) to supply the stomach
along greater curvature of stomach
and anastomoses with right gastroepiploic artery.
3-Short gastric arteries : arise from
splenic artery at the hilum of spleen,
and pass in the gastro-splenic
omentum to supply fundus of
stomach. They anastomose with left
gastric & left gastroepiploic arteries.
3- Hepatic Artery
It is one of the 3 branches of
celiac trunk.
It runs to the right and ascends
between 2 layers of lesser omentum
to lie in front of the opening into
lesser sac., to the left of bile duct and
in front of portal vein.
At the porta hepatis, it divides
into Rt. & left branches to supply the
corresponding lobes of liver.
3- Hepatic Artery
Branches :
1-Right gastric artery : arises from the
hepatic artery at the upper border of pylorus
to pass to the left in the lesser omentum
along lesser curvature of stomach to
anastomose with the left gastric artery.
2-Gastrodudenal artery : is a large
branch that descends behind 1st part of
duodenum. It divides into :
-Right gastro-epiploic artery : that runs
along greater curvature of stomach between
the layers of greater omentum.
&
-Superior pancreatico-duodenal artery :
that descends between 2nd part of duodenum
& head of pancreas.
3-Right & left hepatic arteries :
enter the porta hepatis of liver. Right hepatic
artery gives off cystic artery, which run to
neck of gallbladder.
Small intestine
It extends from the pylorus of stomach to the
ileocecal junction.
It is divided into 3 parts : duodenum, jejunum,
& ileum.
Duodenum
It is a C-shaped tube, about 10 in.(25cm) long,
that joins stomach to jejunum. It lies in epigastric
& umbilical regions.
It receives openings of bile & pancreatic ducts.
It curves around the head of pancreas.
It has 4 parts, /its 1st inch (2,5 cm) as the
stomach in that it is covered completely anterior &
posterior with peritoneum and has lesser omentum
& greater omentum.
Remainder of duodenum is retroperitoneal.
Jejunum and Ileum
They are about 6 meter long
The jejunum begins at duodenojejunal
flexure and ileum ends at ileocecal junction .
The coils of jejunum & ileum are freely
mobile and are attached to posterior
abdominal wall by a fan-shaped fold of
peritonium known as mesentry of small
intestine which has a root along a line that
extends downward and to right /from the
left side of 2nd lumbar vertebra to the region
of right sacroiliac joint.
The root of mesentry contains superior
mesenteric vessels.
Lymph drainage : into superior
mesenteric nodes.
N.supply : sympathetic + parasympathetic
(vagal) from the superior mesenteric
plexuses
Jejunum and Ileum
Jejunum
Ileum
It lies in the upper part of peritoneal
cavity.
It lies in the lower part of abdominal
cavity.
It has wider lumen.
It has narrower lumen.
Its wall is thicker due to presence of
larger & numerous circular folds of the
m.m, the plica circularis.
Its wall is thinner since the circular
folds are smaller & fewer, and may be
absent in its lower part.
It is more vascular and redder.
It is less vascular and paler.
Jejunum and Ileum
Jejunum
Its mesentry is attached to posterior
abdominal wall above & to left of aorta.
Ileum
Its mesentry is attached below & to right
of aorta.
Its mesenteric vessels form a series of 3-4
Its mesenteric vessels form only one or
or more arcades, that send numerous short
2 archades, with long & infrequent
terminal vessels.
branches passing to the intestinal wall.
It has a great amount of mesenteric fat.
It has scanty of mesenteric fat.
Aggreggations of lymphoid tissue (Peyer ‘s
It has No lymphoid follicles.
patches) are present in the m.m of lower
ilum along antimesenteric border
Large Intestine
It extends from ileocecal junction
to anus.
It includes cecum, appendix,
ascending colon, transverse colon,
descending colon, sigmoid colon,
rectum & anal canal.
It is about 1 ½ meters.
Differences between Large & Small intestines
Large intestine is 150-180 cm. long, while
small intestine is 6 meters long.
It is wider than small intestine.
Most of large intestine is fixed in position
(retroperitoneal), while most of small intestine
is mobile.
It has 3 longitudinal muscle bands on its
surface, the toenia coli ( but form a continuous
longitudinal muscle layer in the small intestine).
Teniae coli are shorter than the length of
colon, leading to sacculation of the colon
(sacculation is absent in small intestine).
It has (except caecum, appendix & rectum)
small peritoneal folds filled with fat called
appendices epiploicae (but absent in small I.).
Its m.m. has No Peyer’s patches as
in the small intestine.
Its m.m is smooth, but the small I. has villi.
Cecum
It is a blind-ended pouch (6cm.), lies in the right
iliac fossa.
Peritoneal covering : it is completely covered
with peritoneum, except at its upper part of its
post. wall, so it has a considerable range of
mobility.
The opening of the ileum : lies at the
posteromedial side of the junction of cecum with
ascending colon. It is a horizontal opening which is
gaurded by ileo-cecal valve. It plays No role but
the circular ms. of lower end of ileum is thickened
in the region of the valve, forming the ileo-cecal
sphincter acts as a sphincter to control the flow of
contents from ileum into colon.
The opening of appendix : lies 1 inch below
and behind the ileocecal opening.
anteriorly : coils of small intestine, greater
omentum, anterior abd.wall. Posteriorly : psoas &
iliacus ms.+ lateral cut. N.of thigh + femoral N.
Appendix
It is a muscular tube containing a large amount of
lymphoid tissue, about 10cm.long.
Its base is attached to postero-medial surface of
cecum below the ileocecal valve.
It has a complete peritoneal covering.
It has mesentry, the mesoappendix, which contains
appendicular vessels & nerves.
Lymph Drainage of
cecum & appendix :
superior mesenteric L.Ns.
Nerve Supply of cecum &
appendix : sympathetic &
parasympathetic (vagal)
nerves from superior
mesenteric plexus.
It lies in right iliac fossa, in relation to anterior abd.
wall. Its base lies one third of the way up the line
joining the right anterior superior iliac spine to
umbilicus (McBurney’s point).
The teniae coli of cecum collect at the base of
appendix to become continuous with the longitudinal
muscle coat of appendix.
Common position of the tip of appendix : 1 & 2
1-Hanging down into the pelvis.
2-Coiled up behind cecum (retrocecal).
3-Passing upward along lateral side of cecum
(subcecal) 4-Front of or behind terminal part of
Ascending Colon
It is about 15 cm.long, lies in right lower
quadrant, extending from cecum to inferior
surface of right lobe of liver.
It turns to left, forming right colic
flexure, and becomes continuous with the
transverse colon.
It is covered with peritonium in its
front & sides, binding it to the post.
abdominal wall.
Anteriorly : coils of small intestine,
greater omentum & anterior abd.wall.
Posteriorly : iliacus, quadratus
lumborum, origin of transversus
abdominis, right kidney, iliohypogastric &
ilioinguinal nerves.
Lymph drainage & Nerve supply : as
cecum & appendix.
Transverse Colon
It is about 50 cm. long, extending across
abdomen, occupying umbilical region.
It begins at right colic flexure, supended
by transverse mesocolon from the
pancreas, to end at left colic flexure below
the spleen.
Left colic flexure is higher than the right,
and is suspended from diaphragm by
phrenico-colic ligament.
Nerve supply : proximal 2/3 :
sympathetic & vagal parasympathetic
nrves through superior mesenteric plexus.
Distal 1/3 : sympathetic /&
parasympathetic pelvic splanchnic
(sacral)nerves through inferior mesenteric
plexus.
Anteriorly : greater omentum, anterior
abd.wall.
Posteriorly : 2nd part of duodenum,
head of pancres, coils of small intestine.
Lymph drainage :
proximal 2/3:
drain into superior mesenteric nodes.
Distal 1/3: drains into colic nodes and
then into inferior mesenteric nodes.
Descending Colon
It is about 25 cm.long, lies in left upper &
lower quadrants, extending downwards from
left colic flexure to the pelvic brim, where it
becomes continuous with the sigmoid colon.
The peritoneum covers the front & sides
and binds to post.abd. Wall.
Anteriorly : coils of small intestine +
greater omentum + anterior abd.wall.
Posteriorly : left kidney, origin of
transversus abdominis, quadratus lumborum,
psoas, iliacus. / Iliohypogastric, ilioinguinal,
lateral cutaneous N. of thigh, and femoral N.
Lymph drainage : colic & inferior
mesenteric L.Ns.
N.supply : sympathetic /&
parasympathetic pelvic splanchnic (S 2,3,4)
nerves through inferior mesenteric plexus.
Sigmoid Colon
It is about 40 cm.long, S-shaped loop.
It descends in the pelvic cavity as a
continuation of descending colon, to end at
the 3rd sacral vertebra to begin the rectum.
 it is completely covered with peritoneum
which form a fan-shaped sigmoid
mesocolon attached to posterior pelvic wall,
so it is freely mobile.
Anteriorly : in male : urinary bladder.
In female : uterus + upper vagina.
Posteriorly : rectum + sacrum.
Lymph drainage : the nodes along course
of sigmoid arteries drains into
inferior mesenteric nodes.
N. supply : sympathetic + parasympathetic
nerves from the inferior hypogastric plexus.
Factors contribute in appendix’s
infection



It is long, narrow, blind-ended tube, which leads
to stasis of large-bowel contents.
It has a large amount of lymphoid tissue in its
wall.
Its lumen has a tendency to becom obstructed
by hardened intestinal cotents, leading to further
stagnation of its contents,
Pain of appendicitis



visceral pain is produced by distention of its
lumen or/ spasm of its muscle.
Afferent pain fibres enter the spinal cord at the
level of T10 segment, and a vague referred pain
is felt in the region of umbilicus.
Later, the pain shifts to where the inflamed
appendix irritates the peritoneum, here pain is
precise, severe and localized in right lower
quadrant.
Variability of position of Appendix



It should be borne in mind for diagnosis of
appendicitis.
In retrocecal appendix, it is difficult to elicit
tenderness on palpation in right iliac fossa, irritation of
psoas ms., may cause the patient to keep his right hip
joint flexed.
An appendix hanging down in the pelvis may result
in absent right iliac region tenderness, but deep
tenderness may be revealed just above the symphysis
pubis, rectal or vaginal examination may reveal
tenderness of peritoneum in the right side of pelvis.