THORACIC VISCERA 1

1. Describe the orientation of the heart in situ particularly in relation to thoracic wall landmarks.
-

2. Describe the surface features of the heart.
-Fibrous pericardial sac = collagenous and non-distensable, firmly attached to diaphragms central
tendon. Sac lined with parietal layer of serous pericardium while heart lined with visceral layer of serous
pericardium (epicardium)
-pericardial cavity = btwn parietal and visceral layers of serous pericardium
-Cardiac tamponade = excess fluid in pericardial cavity, red ability of ventricles to fill causing pain, diff
breathing, compromised cardiac efficiency
-Sternocostal surface of heart::
-L to R = pulmonary trunk, ascending aorta, SVC
-Right border = rt atrium
-Inf border = r atrium, R ventricle, and L ventricle
-L border = L ventricle, auricle of L atrium
-Heart shaped like top with base (top) and apex (bottom) which projects to the L anteriorinferiorly
-Apex @ 5
th
LICS along mid-clavicular line
-grooves carry major coronary vessels
-coronary (atrioventricular) sulcus = atria sep from ventricles
-interventricular sulcus = shallow, sep ventricles

7. Trace the major coronary arteries and cardiac veins
-Sternocostal Surface:
-L main coronary artery bifurcates into L circumflex and Anteriorinterventricular/Left Anterior
Descending/ Wido-Maker in shallow IV sulcus (Widow-maker bc #1 occluded by atherosclerotic
plaque)
-R coronary artery becomes R marginal
-also note SVC, ascending aorta, and pulmonary trunk
CAD = circ not redundant despite anastomoses supplying myocardium. Sudden occlusion of
coronary artery will infarct area necrosis. #1 cause is atherosclerosis of coronary arteries bc
lumens are narrowed, red blood flow and causing ischemic heart dis
-Diaphragmatic Surface:
L Circumflex leads to L marginal (supplies L ventricle, most abundant bc lgst chamber with
thickest wall to pump under high P to systemic circ)
Posterior IV (Posterior Descending)
RCA leads to R Marginal
Note L Coronary sinus (drains myocardium to R atrium) and IVC
-Interatrial septum = sep atria
-IV septum = sep ventricles with thin membranous and thick muscular parts
-heart thicker twds apex and thinner posteriorly






THORACIC VISCERA 2

-Congenital Heart Defects = most are atrial or ventricular septal defects due to blood flow from high P
chamber to lower P chamber
-ASD = usually bc foramen ovale not closed completely so blood shunted btwn atria in either dir,
us asymptomatic (in babies R atrium L atrium pulmonary artery
-VSD = incomplete ventricular partitioning, blood flow L ventricle R ventricle, can become
heart failure if not surgically corrected

-Valvular heart disease
Valvular insuff = incompetent valve which cant close completely, prod regurgitation
Valvular stenosis = patho narrowing orifice bc valve cant open completely
Stenosis and regurgitation causes turbulence, prod murmurs
Back inf (rheumatic fever, strep throat) and subsequent inflam of valves prod scarring which
thickens and rigidifies elastic cusps

1. Trace the course of blood through the heart and pulmonary circulation to the aorta.
-DeOx blood enters R atrium from:
Sup vena = Head and upper extrem
Inf = All below diaphragm
Coronary = into R atrium, whole myocardium
-Fetus:
IVC foramen ovale, mostly blood returning from placental mem (O2 blood). Umbilical vein bc it
brings blood twds heart
SVC rt ventricle
-Cardiopulmonary circ = functional segmentation bc branching L and R pulmonary arteries and
formation of paired pulmonary veins draining ea organ, gas exch in alveoli (double cap bed)

2. Describe the clinical significance of DVTs and pulmonary emboli.

3. Identify the distinctive features of each of the hearts chambers.
-R atrium = sm walled part cont with vena cavae, corrugated pectinate muscle cont with auricle, parts
sep by crista terminalis (SA node pacemaker above this), and fossa ovalis (in interatrial septum, remnant
of foramen ovale which shunted fetal blood around pul circ), Ostium of coronary sinus (most venous
blood drained from myocardium enters atrium here), and AV orifice (blood passes out of R atrium)
-R ventricle = Traveculae carnae (Thick wall w/irreg endocardial sur), tricuspid valve, tapers to smooth
conus arteriosus (dir blood to pul trunk)
Tricuspid with nipple-shaped papillary mus attached to cusps via chordae tendinae
Tricuspid passively closes but actively closes in systole. Pap mus contraction tenses chordae
tendinae to prev regurgitation and prolapse of cusps in R atrium during systole
-L atrium = smooth rel featureless wall w/ fossa ovalis, rec drainage of pulmonary veins, bicuspid (mitral)
valve delivers blood to L ventricle
-L ventricle = thickest wall, prominent traveculae carnae, 2 robust papillary muscles, blood flowing thru
AV orifice makes sharp turn to ascending aorta in systole

4. Describe the function of the atrioventricular, pulmonary and aortic valves.
-AV:
-Diastole = ventricle wall relaxed and AV valves opened so blood flows from atria to ventricles
-Then as ventricles fill, thin elastic cusps rise twd AV orifices, cusps appose, and valves closed
passively
-Systole = myocardium contraction raises ventricular pressure and tightens cordae to keep
valves closed
-SL
Systole = ventricular contraction pumps blood twds pul trunk and AA, sep thin elastic SL cusps
and opens valves
Diastole = ventricles relax, P dec in aortic and pul trunk. Blood falls back twds heart and cusps
forced away from vessel walls and into apposition, closing walls
Note sinuses of valsalva = little pockets at base of aortic and pul trunk
SL valves open and close passively. As aortic valve closes, blood in aortic sinuses fill coronary
arteries

5. Identify the points of auscultation for the atrioventricular, pulmonary and aortic valves.
-Put stethoscope downstream from valve projections bc listening for turbulence in flow from passage of
blood thru valve with problems aka heart murmur
-Aortic = 2nd RICS parasternally
-Pulmonary = 2nd LICS
-Tricuspid = 4th or 5th LICS parasternally
-Mitral = 5th LICS 6 cm. lateral to sternal

6. Describe the conduction system of the heart.
-SA node (pacemaker:: >65% supplied by RCA branch) sends signal thru R atrium walls to AV node (in
interatrial septum, distributes signal to ventricles thru AV bundle)
-AV bundle (Either R or LCA branch from crux of heart variable bc anastomosis) = L and R bundle
branches which discend along mus part of IV septum and ramify into Purkinje fibers (subendocardial
branches) that extend into apex and 2 ventricle walls
-If both compromised, need a pacemaker
-Purkinje fibers innervate papillary mus to tighten chordae tendinae so ventricles contract

7. Describe the organization of the sympathetic and parasympathetic divisions of the ANS.
-
-
-
affective (hunger, satiety, nausea, anxiety, stress), referred pain, visceral reflexes
-Visceral efferent neurons of ANS under control of higher CNS centers
-both 2 neuron system, ANS div to::
-sympathetic
Arousal
fight or flight
catabolic to deal w/challenge
widely dis EXCEPT to avascular tissues (nails, cartilage)
thoraco-lumbar system
-parasympathetic
Conserves energy
restores bodys res
anabolic
restricted dis to head/viscera of trunk/erectile tissues
craniosacral sys
-Thoracocolumbar T1-L2 carry away from CNS (pregangliionic, sympathetic ganglion with acetylcholine,
postganglionic neuron, then norepinephrine at target organ at postganglionic terminal - adrenergic).
Craniosacral with parasympathetic ganglion with preganglionic neuron, acetylganglion, postgangliionic
neuron, acetylcholine at target organ at postganglionic terminal - cholinergic)
-preganglionic neuron in CNS leaves and terminates by synapsing on postganglionic neuron loc in
autonomic ganglion that leaves ganglion and innervates sm muscle, gland, or heart
-sympathetic ganglion with short preganglionic axon loc in paravertebral or prevertebral ganglion rel
near CNS
-parasympathetic with long preganglionic axon loc on/in target organ walls
-symp/parasymp
1. Heart = elevate HR/slow
2. Lungs = dec bronchial secretions and bronchial dilation for more O2/opp
3. Dec secretions and motor activity bc busy/opp
4. Pancreas = dec secretion from endocrine part bc busy/opp
-ANS fx extrinsic heart thru superficial and deep cardiac plexus from both ANS div
Parasympathetic:
1. Dec heart rate and force of myocardial contraction
2. Vasoconstrict coronary arteries less demand for O2
Sympathetic: - arise from ganglia
1. Inc heart rate (fight or flight) and myocardial contraction
2. Vasodilate coronary arteries
-sympathetic cardiac nerves also convey visceral afferent fibers from heart back to cervical and upper
thoracic spinal nerves and spinal cord segments. GVA may stim somatic afferents in dorsal rt and dorsal
horn = referred cardiac pain
-lack of O2 to cardiac mus (myocardial ischemia) can prod cardiac pain why referred cardiac pain from
angina pectoris to substernal and pectoral reg, shoulder, and medial upper limb

8. Identify and describe the significance of the contents of the posterior mediastinum.
-maj contents of sup mediastinum = brachiocephalic veins (Venous plane, deep to manubrian with SVC
inf), aortic arch & 3 branches, trachea, esophagus, phrenic nerves, vagus nerves, arch of azygos vein, and
thoracic duct
-Plane of sternal < div thoracic aorta into aortic arch, ascending aorta, and descending aorta
-3 lg vessels arise from aortic arch in sup mediastinum: L common carotid, L subclavian, and
brachiocephalic trunk (rt)
-Recurrent larynegeal nerves innervate all intrinsic laryngeal mus except cricothyroid. Inj means
ipsilateral paresis or parlysis horseness and fixed vocal cord. L goes further so worse things happen
like upper lobe lung tumors. Note its near CNX and ligamentum arteriosum at bottom (remnant of
ductus arteriosus. R atrium R ventricle pulmonary trunk aortic artery to rest of body)
-post mediastinum =
esophagus (whole l, runs with vagus nerves)
-
1. Cervical constriction = pharynx cont with esophagus. Cricopharyngeal sphincter closes
when we breathe and opens when talks
2. Broncho-aortic constriction
3. Diaphragmatic constriction
esophageal plexus (autonomic fibers) and vagal trunks (inf)
des thoracic aorta
azygous venous sys = arch of azygos vein drains into SVC. Azygos sys (Along post ab wall before
ascending into post mediastinum, extensive anastomses with IVC and renal veins) drains post
thoracic and abdominal walls and posterior mediastinal viscera, Prov collateral pathways of VR
to R side of heart if IVC or SVC obstructed
thoracic duct, = Thoracic duct very far back on thoracic spine with cisterna chyli (collect lymph
fluids from ab organs and branches to R and L to drain into venous system), Drains into
confluence of L subclavian and internal jugular.
sympathetic trunks
thoracic splanchic nerves = Drainage cryptic, can be in supraclavicular nodes, Also
pharyngeal/lingual/palatine tonsils, thymus, axillary/cervical/intestinal/inguinal l nodes, spleen,
cisterna chyli, ileum peyers patches, bone marrow, and affferent peripheral lymphatics
-CNX course bilaterally thru sup mediastinum and post to rts of lungs
-3 pairs posterior intercostal arteries:
1. Esophageal = supply mediastinal portion of esopohagus. IVNB Biggest near vertebral column
bc off spinal nerves in IV foramina
2. Bronchial = give O2 to parenchymal lung tissues along bronchial tree
3. Azygous sys
9. Bone stuff
-pelvis formed by sacrum and 2 hip bones (os coxae formed by postnal fusion of 3 bones at
acetabulum .. Sup and broadest ilium, antero-inf pubis, and posteroinferior ischium sit on this
prominent part). Fuse in late teens, earlier in fem
-note iliac crest, ASIS, and pubic tubercle. Heart-shaped pelvic inlet/brim sep false/greater pelvis and
true/lesser pelvis thats lgr in fem for childbirth
-ab wall w/ mult layers inc skin, fascia, muscle, and peritoneum (serous mem). Dev in 3 layers like
thoracic mus. 1 single vertical mus anteriorly in fetuses
-Anterolateral ab mus = resist downward and fwd slumping of ab viscera as diaphragm descends in
inspiration; works w/ diaphragm and pelvic floor mus to reg intra-abdominal P, assist forced
expiration, and execute valsalva for coughing, defection, urination, and childbirth; ant and lat trunk
flexion and rot spine; maintain standing and sitting posture
-linea alba = marks anterior ab wall midline, formed by decussation of aponeurotic fibers of 3 pairs
of AL ab mus
-linea semilunaris = lat boarder of long vertical strap mus, rectus abdominis encased in aponeurotic
rectus sheath
-rectus abdominis = orig from pubis and insert on xiphoid and costal cartilages 5-7, div into
segments by tendinous inscriptions
-ext ab obliques (V)= most superficial. Inginal ligament runs from inf edge of ext mus from ASIS to
pubic tubercle
-int ab obliques deep to ext, perpendicular to ex but vary in orientation along l of mus, Attaches to
spine via thoracolumbar fascia posteriorly
-deep to int is transversus abdominis, also attaches post to thoracolumbar fascia. Inf fibers of
aponeuroses of int oblique and transversus forms conjoint tendon aka falx inguinalis as they
approach midline attachments to pubis. Can sports hernia (mus and tendon tears from pubic
bone rectus ab or conjoint tendon)
-rectus abdominis encased ant and post on e side by rectus sheath formed by aponeuroses of 3 mus
-aponeuroses of ext and int oblique contribute to ant rectus sheath thruout length. Int oblique also
in post rectus sheath thruout length. Transversus varies
Sup plane = transversus and int oblique in post rectus sheath. Inf, all 3 aponeuorses ant to rectus
abdominus (CHANGE IN ROLE!) @ 2/3 btwn pubis and umbilicus so inf ab weaker than superior
-arcuate line = line transition btwn transversus aponeurosis and formation of rectus sheath,
Consequences for strength and structureal integrity esp w/inc age.
-Sandwich analogy: rectus ab is meat, bread is ext oblique and transversus ab .. Condiments int
oblique on both sides ant and post
-inf to arcuate line, only transversalis fascia and parietal peritoneum itervene btwn deep sur of
rectus and ab viscera, hernia can happen here
-epigastric vessels in rectus sheath deep to rectus abdominus. Internal mammary arteries (int
thoracic) at costal <. Pathway for collateral flow down ant wall, can be lg and sig if blockage of des
aorta or aortic obstruction of lower of body
-if IVC obstucted, azygous sys can help out, often in fetus

Lecture 9. Abdominal Viscera I and ANS II

*Gonads
-gonads form prenatally in extraperitoneal layer of post ab wall and descend along gubernaculum and
drag neurovasculature with them
-ovaries descend into pelvic cavity and stops and testes cont thru ab wall to enter scrotum
-entry and exit pts offset bc dont want abd struc near gubernaculum and descend further
-in both sexes, inguinal canal tunnels thru ab wall on ea side to transmit gubernaculum. Transmits
spermatic cord in males and round ligament of uterus (remnant of gubernaculum) in fem. Transmits ilio-
inguinal nerve in distal portion in both sexes-superficial inguinal ring = defect in aponeurosis of ext
oblique forms superficial end
-deep inguinal ring = evagination of tranversalis fascia forms opp end
-put finger at supeficial ing ring = exit inguinal canal, ask to cough. If weak, then Dr. feels P as contents of
abdomen bulge out here
-ant wall formed by ext oblique thruout w/ int oblique and transversus lat. Floor of canal formed by
inguinal ligament
-Guided by gubernaculum, testes descend thru inguinal canal behind processus vaginalis (ext of parietal
peritoneum) to reach scrotum (evagination superficial body wall). Kidneys ascend (R lower bc of liver)
and gonads descend
-processus vaginalis normally pinches off around ea testis in scrotum to form fluid-filled sac tunica
vaginalis that holds testes (collection of serous fluid = hydrocele). If processus vaginalis fails to pinch off,
open comm btwn ab cavity and scrotum persists and a congenital inguinal hernia may happen
-external spermatic fascia forms ext oblique, cremaster mus (elevates testes for thermoreg) and fascia
form int oblique, internal spermatic fascia forms transversalis fascia. Stim skin of inner thigh can raise
cremaster mus (L1 spinal cord segment)
-contents of spermatic cord = ductus deferens (moves spermatozoa prod by testes, mature in
epididymus), testicular artery, pampiniform venous plexus, lymphatics, sympathetics, and genital branch
of genitofemoral nerve (L1, L2). Sympatheitc autonomic nerves for emission and ejaculation
-inf epigastric contributes to boundaries of inguinal (hesselbachs triangle) and inf epigastric vessels. With
age, ab wall sus to tearing = hernia
-indir hernia: enters the deep inguinal ring lat to inf epigastric artery, distends the spermatic
cord, exits the superficial ring, Causes inc chronic inc intra-ab P due to cough, constipation,
prostate enlgment, or colon cancer, or valsalving when lifting heavy wts
-dir hernia: prod thru wall in inguinal triangle medial to inf epigastric artery, may or may not exit
superficial ring

*ABDOMEN
-ab cavity bounded by diaphragm and lower thoracic cage sup, cont w/ pelvic cavity and bounded by
pelvic diaphragm inf, lined by serous peritoneal sac
-cut innervation of abdominal achieved prim by intercostal nerves (thoracoab nerves T7-T11) and note
T12 and branches of L1, umbilicus in T10, inguinal in L1, xiphoid is T6
-superficial veins in superficial fascia imp for comm with gut veins. all veins above transumbilical plane
drain sup twd axilla. below drains twds thigh and eventually to IVC to heart
-lympatic vessels above plane twds axilla, below twds thigh nodes around inguinal ligament and ant thigh
-Planes::
-midclavicular lines
-L1 = transpyloric plane, approx loc of pt cont btwn stom and duodenum
-L3 = subcostal plane, tangent to costal margins
-L4 = interiliac (intercristal) plane
-L5 = transtubercular plane
-after passing thru diaphragm, esophagus disch contents to stom which empties in sm intestine
(duodenum, jejunum, and ileum) that is cont with cecum (proximal part of lg intestine or colon). Distal to
cecum we find ascending, transverse, des, and sigmoid colon. Finally, rectum and anal canal
-falciform ligament from ventral mesentary of embryonic ligament. Round ligament = obliterate oxy-
umbilical vein. Greater omentum derived from dorsal mesentery of stom (peritoneum, lymph tissue, and
fat)

1. Trace the course of a bolus of food from the esophagus to the rectum.

2. Identify and describe the significance of the peritoneum and mesenteries.
-mesentery = double layer of pertioneum. Abdominopelvic cavity lined w/ serous mem (parietal
peritoneum). Most GI struc peritonealized. Retroperitoneal is outside, sub is inside sac
-GI tract and derivatives covered by visceral peritoneum, mobile GI viscera suspended by mesenteries,
pot space btwn parietal and visceral layers of peritoneum = peritoneal cavity
-viscera suspended by mesentery are peritonealized and transmit:
1) Arterial supply from branches of abdominal aorta
2) Venous drainage to hepatic portal sys
3) Autonomic nerves
4) Lymphatics
-most of GI tract attached to post ab wall via dorsal mesentery. In dev, some lose suspensory
mesenteries and are fixed to post ab wall so covered by peritoneum only on ant and lat = secondarily
retroperitoneal.
-pushed against ab wall, become sec retroperitoneal (Distal duodenum, Ascending and descending
colon, and rectum). sm recess adj note circle = internal hernia bc mobile viscera get stuck
3. Identify the derivatives of the embryonic foregut.
-derivatives of ventral mesentery suspended the embryonic gut are assoc in adult w/ foregut derivatives
only (initially attached by ventral and dorsal but dorsal disappears)

4. Identify the major branches of the celiac artery.
--mesenteries are conduits from 3 arteries from ant abdominal aorta = celiac (foregut) L1-- superior
mesentic (midgut) L3-- inferior meseneric (hindgut). Des aorta terminates to common iliac at L4
-these vessels supply organs derived from 3 ab div of embryonic gut

5. Complete their understanding of the ANS with specific reference to the preaortic ganglia and plexi,
the vagal trunks and pelvic splanchnics.
*Sympathetics
-sympathetic = preganglionic neuron cell bodies loc in intermediolateral horns of T1-L2 segments, they
leave spinal cord in ventral roots of T1-L2 spinal nerves, then exit vertebral canal on T1-L2 aka
thoracolumbar sys, head for bilateral chains of interconnected ganglia aka sympathetic trunks that lie in
paravertebral gutters along ea side of spine, ext from base of skull to coccyx (paravertebral ganglia on
both sides)
-note thoracic parts of sympathetic trunks inf. After traversing IV formina, T1-L2 spinal nerves send
pregangliionic sympatthetic fibers to chain via wt rami communicates
-4 fates for preganglionic sympathetic fibers reaching sympathetic chain via wt rami comm::
1) may enter chain and synapse at nearest ganglion
2) Ascend the chain and synapse at a more superior ganglion
3) Descend and synapse at a more inferior ganglion
4) Pass thru chain w/o synapsing
-if synapse occurs in chain, most postganglionic sympathetics rejoining spinal nerves for dis to body wall
(skin, 3 layers of mus, parietal pleura or peritoneum). Gray rami comm convey postganglionic
sympathetic fibers back to spinal nerves
-all spinal nerves rec some postganglionic sympathetic fibers via gr rami comm bc these fibers supply
body wall struc and req autonomic innervation
-body wall struc rec sympathetic innervation:: sweat glands, arrectores pilli, vascular sm mus
(vasoconstriction of peripheral vessels except coronary arteries so more O2 to heart). Turn off by
removing stimulus
-wt and gr in T1-L2, gray in all spinal nerves
-most postganglionic from cervical ganglia will leave sympathetic chains and form periarterial plexus on
carotid arteries and their branches to reach cranial and cervical viscera. Interruption = Horners
syndrome (ptosis, miosis, and anhidrosis)
-other postganglionic arising in cervical and upper thoracic ganglia leave chains as dir visceral branches to
cervical and thoracic viscera (heart, lungs, and esophagus)
-dir visceral branches also convey GVA fibers from viscera to cervical and upper thoracic spinal nerves via
wt comm rami
-if w/o synapsing, then called splanchic nerves, synapse in collateral or prevertebral ganglia loc ant to
abdominal aorta and common iliac arteries
-thoracic splanchic nerves contain preganglionic symp fibers for abdomen instead, note vagus nerves
over esophagus, sympathetic chainlike trunks on sides. Pierce diaphragm and synapse on preaortic
(prevertebral) ganglia
-Postganglionic symp fibers from prevertebral ganglia reach visceral targets thru periarterial plexus along
arteries from abdominal aorta
-postganglionic sympathetic fibers contribute to enteric nervous wys in GI struc walls from esophagus to
anal canal where they facilitate contraction of sm mus sphincters and inhibit both peristalsis and
glandular secretion
-in ab and pelvis, visceral afferents accompanying symp nerves also transmit pain from nocioceptors
(stim by excessive distension of part of GI tract or bladder) and strong contractions of sm mu ( in wall of
visceral struc like uterus)
-splanchics convey GVA from viscera to dorsal rts of spinal nerves T5-L2 via wt comm rami, can stim GSA
fibers in dorsal roots and prod abdominopelvic reffered pain in spec regions of body wall

*PARASYMPATHETIC
-Preganglionic neuron cell bodies in brainstem nuclei or e ventral horns of S2-S4. CN 3, 7, 9, and 10
-preganglionic axons leaving spinal cord in ventral rts of S2-S4 form pelvic splanchic nerves, nerves prov
parasympathetic innervation to lower GI, pelvic, and perineal organs
-4 diff ganglia parasymp synapse in head and neck
1) Pterygopalatine ganglion orbit innervate lacrimal gland for lacrimation and nasal/paranasal
mucus (red lacrimation in menopausal fem)
2) Chorda tympani submandibular ganglion for salivation of submandibular and sublingual
glands
3) Brainstem (CN 9) otic ganglion for salivation of parotic gland
4) Ciliary ganglion orbit, wonder about target!
-Vagus nerve does not do parasym
-pupil is central aperture of irus, funcitons like camera diaphragm. Diameter under active control of 2
antagonistic mus:: constrictor and ciliary mus w/ zonular fibers that runs to lens (parasympathetic,
controls shape and thickness of lens) and dilator (sympathetic get more lt in)
-pupillary constrictor and ciliary mus innervated by postganglionic parasympathetic arising from ciliary
ganglion
-contract ciliary mus = inc lens curvature for accomodation, they bulge. Also constrict pupil
-shine lt either eye = bilateral pupillary constriction. Anisocoria = unequil pupil sizes under changing lt
cond, means lesions in pupillary autonomic pathway, ex: occulomotor nerve ptosis
-postganglionic axons from 4 pairs of parasympathetic ganglia in head reach targets by piggybacking on
CNV (principal sensory nerve of face)
-many visceral afferent fibers convey sensations of visceral pain. Some also do physiologic sensations
from mechanoreceptors (distension of GI tract walls, res struc, ur bladder, barorec in arteries) and
chemoreceptors (changes in pO2 and pCO2, blood pH, and [H+] in stomach

Lecture 10. Abdominal Viscera II

*ABDOMEN
-most inf (diaphragmatic) of 3 pts of constriction is where esophagus is vulnerable to irritation and
pathology. Esophagus passes thru esophageal hiatus of diaphragm accompanied by vagal trunks and
esophogeal vessels
-contraction of diaphragm widens caval foramen in central tendon and dilates IVC in caval foramen,
assists VR via IVC
-aortic hiatus transmits thoracic duct from cisterna chyli and tributaries of azygos sys

1. Identify the derivatives of the embryonic midgut and hindgut.
**FOREGUT = distal esophagus, stomach, liver, gallbladder, pancreas, and proximal dudoenum. Blood
supply from celiac artery, pregangliion sympathetic from thoracic splanchic, preganglionic
parasympathetic from vagus nerves
-stomach with longitudinal, cricular, and oblique mus layers which churn food, liq, and saliva into chime
-Has cardia (gastroesophageal junction), fundus (most sup and post), body, and pylorus (inf). Also greater
(attached to greater omentum) and lesser curvature. Vertebral column presses ab contents twds ant ..
When move up no more vert so fundus falls more post
-GE junction = physioligcal IES, prev reflux of stom contents
-stom also w/ gastric folds (rugae), pyloric sphincter (squeeze chyme thru narrow pyloric canal)
-achalasia = excessive IES relaxation. Esohpagitis (gastric acids inflame esophagus) cicatrization (scar
esophageal lining), and stricture
-peptic ulcers = lesions ext thru gastric or duodenal mucosa
-diaphragmatic hernias from widening of esophageal hiatus due with age. Paraesophageal us inv fundus,
extreme inc transverse colon. Sliding is bell-shaped, most common hernia, slides up into mediastium
-remnant of ventral mesentary connects liver to stom and duodenum. Lesser omentum hepatogastric
and hepatopyloric attachments to liver
-free edge of lesser omentum contains hepatic triad (proper hepatic artery (superficial L, branch of
celiac), common bile duct (superficial R), and hepatic portal vein) and forms ant wall of epiploic foramen
-major branches of celiac trunk = L gastric, splenic artery (high P bc carries lots of blood, prod tortuous
vessels), and common hepatic
-beyond these 3 branches: esophageal (upper L), L and R gastrics (follows lesser curvvatrure to complete
circm), and L and R gastro-omentals (greater overture), pacretic, short gastrics (to stomach from L), and
proper hepatic (next to gr) and cystic artery ligated in cholescystectomy (gr far rt), gastroduodenal
(behind duodenum)
-duodenal ulcers will fx gastroduodenal artery = bleeding ulcer. Also supraduodenal ulcers
-hepatic portal vein drains GI tract from distal esophagus thru superior rectum, spleen, pancreas, and
gallbladder. suproaduodenal arteries = branches of celiac and superior mesenteric anastomose around
pancreas and duodenum
-liver, gallbladder, and pancreas also derived from embryonic foregut
-lesser sac/omental bursa is behind lesser omentum so stom can slide. Also note epiploic formaen where
intestines can enter and cause internal hernia
-duodenum w/ 4 parts:
1) @ L1, stomach drains into pyloric canal
2) Des portion gets secretions of common bild duct and major bile duct
3) Transverse part @ L3
4) Ascending part
-@ L2 = duodenaljejunojunction, 2-4 is sec retroperiotoneal
-duodenum wraps around pancreatic head. Note neck and body. Most sup is tail that dir twds spleen
-superficial loc of spleen couple with organs vascularity and its living consistency, predisposes spleen to
rel easy rupture by external trauma @ 10
th
rib
-note sm mus and canal of pyloric sphnicer
-cholelithiasis = inflame gallbladder bc gallstones
-cholecystitis, pancreatic adenocarcioma (in head, compression or obliterate common bile duct as tumor
grows)
-papilla maks boundary btwn foregut and midgut derivatives

**MIDGUT
-distal duodenum, jejunum, ileum, cecum, ascending colon, proximal 2/3 transverse colon, gets blood
from sup mesentic artery, preganglion sympathetic from thoracic splanchic, preganglionic
parasympathetic from vagal trunks
-jejunum = LUQ, wider, many circular folds, more vascular
-ileum = RLQ, narrower, few such folds, less vascular, peyers patches = lymphoid bodies only in ileum
-vasa recta = vascular networks, supplies both sides of gut
-colon w/ teniae coli (contract in peristalsis to move bolus thru colon to rectum), appendices epiploica
(fatty bodies), and haustra (saculated, prod by semilunar folds in intervals in lumen). Also note ascending
colon and hepatic flexure under R liver
-midgut vascularized by SMA and branches deep to neck of pancreas. Vascular arcades (anastomose,
redundancy, and collateration) and vasa recta

**HINDGUT
-Distal 1/3 transverse colon, des colon, sigmoid, and rectum. Get blood from IMA, preganglionic from
lumbar splanchic, preganglionic sympathetic from pelvic splanchics (S2-S4)
-note splenic flexture (L), des colon, sigmoid, cannons ring (minor narrowing lumen, div midgut and
hindugt, 2/3 across transverse colon before L colic flexure
-rectum

2. Identify the major branches of the superior and inferior mesenteric arteries.

3. Describe the applied anatomy of appendicitis.
-vermiform appendix suspended from cecum, appendicitis can by caused by hyperplasia of lymphatic
follicles or obstruction by fecolith. Thrombosis of appendicular artery and rupture of appendix prod
peritonitis, swelling appendix can infact self and cut out appendicular artery

4. Identify the major components of the biliary system and their clinical significance.
-biliary struc = R and L hepatic ducts lead to common hepatic duct (drains liver of bile, cystic duct meets
here too). This leads to common bile duct. Gallbladder with fundus (9
th
costal cart under costal margin)
and body. Infundibulum and neck leads to cystic duct. Liver prod bile, stored in gallbladder. Pancreas is a
C-shaped gland
-bile and pancreatic secretions drain into 2
nd
part of duodenum at major duodenal papilla, site of
hepatopancreatic ampulla (of vater)
-major pancreatic duct empties to duodenum

5. Describe the hepatic portal system and identify the location and clinical significance of portocaval
anastomoses.
-hepatic portal sys drains GI tract, spleen, pancreas, and gallbladder from lower esophagus thru sup
rectum
-hepatic portal vein formed deep to neck of pancreas by confluence of superior mesenteric and
splenic veins
- rtal HTN
-liver drained by hepatic veins entering IVC inferior to diaphragm. Portal vein ramifies w/in liver and
ends in hepatic sinusoids from which vessels converge to form hepatic veins
-sites of porto-caval anastomosis = esophageal, paraumbilical, rectus, and retro-peritoneal
-dilation from portal HTN from cirrhosis or hepetitis prod esophageal varices, caput medusa, and
hemorrhoids. Norm w/ ascites due to sinusoidal HTN, weeping of hepatic lymph and renal retention
of Na and H2O

6. Identify the adrenal glands, kidneys and ureters, as well as their associated vasculature in the
retroperitoneum.
7 Identify and describe the surgical vulnerability of the hypogastric plexus and nerves.