ABDOMEN

Denver F. Sapo, MD

Regions
and
Quadrants
Quadrants
Transumbilical plane
Median plane
Duodenum lies above the umbilicus

Umbilicus
Vertebral levelL4

Bifurcation of the aorta

Iliac crest

Dermatomal levelT10
Weeks AOG20 weeks

Regions
Midclavicular plane
Subcostal planeL3

3rd part of the duodenum

Origin of IMA

Transtubercular planeL5

Transpyloric plane
xxx

ANTERIOR
ABDOMINA
L WALL
Fascial layers
Superficial fascia

Camper fascia
outer fatty layer

Scarpa fascia
inner membranous layer
continuos with the...
Dartos fascia (scrotum)
Colles fascia (superficial
perineal fascia)

External oblique
Inguinal (Poupart) ligament
External/superficial inguinal ring
External spermatic fascia

Internal oblique
Splits
Conjoint tendon
Middle (Cremaster) spermatic fascia

and muscle

Transversus
abdominis

Conjoint tendon

Transversalis fascia
Internal spermatic fascia

 Internal/deep inguinal ring (defect)

Strongest layer

Paracentesis
(Clinical
correlation)
Flank approach

Skin

Superficial fascia
Camper fascia
Scarpa fascia

External oblique

Internal oblique

Transversus abdominis

Transversalis fascia

Preperitoneal fat

Peritoneum (parietal)

 Midline approach

Skin

Superficial fascia
Camper fascia
Scarpa fascia

Linea alba

Transversalis fascia

Preperitoneal fat

Peritoneum (parietal)

Paracentesis
(Clinical
correlation)

Extravasation of urine
(Clinical correlation)
Where will the fluid accumulate?

Covering of the
testes and scrotum

Rectus sheath
Contents

Rectus abdominis

Pyramidalis

Anterior rami of the lower six thoracic

nerves
Superior and inferior epigastric vessels

 Linea alba
Linea semilunaris

Rectus sheath

Between xiphoid process and ASIS

Rectus sheath

Between ASIS and pubis

Rectus sheath
Arcuate line (of Douglas)
What covers the rectus abdominis

posteriorly muscle below the arcuate

line?

Rectus sheath
hematoma (Clinical
correlation)
MCC is trauma
MC on the right side, below the

umbilicus
Inferior epigastric VEIN

Rectus sheath
hematoma (Clinical
correlation)
Fothergill sign (Classic)

palpable abdominal mass that remains

unchanged with contraction

Dx: CT
Will the hematoma cross the

midline?

INGUINAL
Region
Inguinal canal
Connection between the superficial

and deep inguinal rings

Contents

Spermatic cord (male)

Round ligament of uterus (female)

Ilioinguinal nerve

Inguinal canal
Boundaries: M-A-L-T

Roof
internal oblique Muscle
transversus abdominis Muscle

Anterior wall
Aponeurosis of external oblique
Aponeurosis of internal oblique

Floor
inguinal Ligament
lacunar Ligament

Posterior wall
Transversalis fascia
conjoint Tendon

Spermatic fasciae
External oblique fascia External

spermatic fascia
Internal oblique fasciaCremaster

fascia/muscle
Transversalis fascia Internal

spermatic fascia

Varicocele (Clinical
correlation)
MC on the left side
Examine the left kidney for

malignancy
bag of worms

Descent of testis
Parietal peritoneum tunica vaginalis
Gubernaculum

Bell clapper deformity

(Clinical correlation)
Poor gubernacular fixation torsion
Homologue of gubernaculum in

females?

Persistent processus
vaginalis (Clinical
correlation)
Females?
Associations

hydrocele

What type of hernia?

Hesselbach
triangle
Inguinal triangle
Boundaries

Inferior epigastric vessels

Rectus abdominis muscle

Inguinal ligament

Relationship of the deep inguinal ring

to the inferior epigastric vessels?

Inguinal hernia
(Clinical
correlation)

Most common type of hernia?

Most common in males?

 Most common in females?

More prone to

obstruction/strangulation?

Indirect inguinal hernia

(Clinical correlation)

Direct inguinal hernia

(Clinical correlation)

Epididymitis
(Clinical
correlation)
Differentiate between epididymitis

versus testicular torsion

What maneuver to differentiate?

A positive sign means pain relief =

epididymitis

Femoral hernia
Femoral triangle?
Femoral sheath?
Femoral canal?
Femoral ring?

Femoral sheath

 Continuous with the transversalis

fascia
Three compartments

Medial = femoral canal

Lymphatic vessels

Middle
Femoral vein

Lateral
Femoral artery

In which compartment is the femoral

nerve situated?

Femoral ring
Upper opening of the femoral canal
Relationships

Anterioringuinal ligament

Posteriorpectineal ligament

Mediallacunar ligament

Lateralfemoral vein

Inguinal hernia vs femoral

hernia(Clinical correlation)
Most common in females?
More common in FEMales?

PERITONEU
M AND
PERITONEA
L CAVITY
Peritoneum

 Lining epithelium?

Parietal
peritoneum
Patent urachus
(Clinical
correlation)
Reveals when urethral obstruction is

present

Congenital urethral obstruction

Prostate enlargement

Visceral
peritoneum
Viscera

Peritoneal
Have mesentery
Mobile

Retroperitoneal
Immobile or fixed

Peritoneal organs
Peritoneal cavity
Peritoneal cavity

Is it an open or closed cavity?

Peritoneal fluid: 50 mL (Moore)

 Greater sac
Lesser (Omental) sac

Epiploic foramen
(of Winslow)
Connection between the greater and

lesser sac
Relationships

Anteriorly
Hepatoduodenal ligament
Hepatic artery
Hepatic vein
Portal vein

Posteriorly
IVC

Pringle maneuver
(Clinical correlation)

Compressed?

Morrison pouch
(Clinical
correlation)
Hepatorenal recess
Most dependent portion of the

abdominal cavity in the supine

position

Douglas pouch
(Clinical
correlation)
Rectouterine pouch

Most dependent area in the upright

position

Posterior fornix???

Gastrointes
tinal
VISCERA
Derivatives of the
developing gut
Pharynx
Compartments

Nasopharynx

Oropharynx

Laryngopharynx

Function?

Zenker diverticulum
(Clinical correlation)
Most common esophageal

diverticulum
Between the transverse and oblique

fibers
Pseudodiverticula
Traction diverticula?
Pulsion diverticula?

Esophagus
(Histology)
Lining epithelium?
No serosa

Esophagus

 10 inches
C6 cardia
Parts

Cervical

Thoracic

Abdominal

Course in the mediastinum?

Esophagus
Blood supply

Cervical esophagus
Inferior thyroid artery

Thoracic esophagus
Bronchial arteries
Aorta

Abdominal esophagus
Left gastric artery
Inferior phrenic artery

Esophagus
Constrictions

Anatomic
Cervical constriction (UES)
Cricoid cartilage?
Bronchoaortic constriction
Diaphragmatic constriction

Physiologic
LES!!!

Birds beak sign

(Clinical
correlation)
Diagnosis?
Pathology?

Esophageal hernia
(Clinical correlation)

What type will produce reflux?

GERD (Clinical
correlation)

24-hour pH monitoring is the gold

standard in the diagnosis

Stomach

 Openings
Curvatures
Notches

Stomach
(Histology)
Cardia

Mucus

Fundus and Body

Parietal cellIF and HCl

Chief cells pepsin

Pyloric region

Pyloric antrum
G cells Gastrin

Pyloric canal

Stomach
Innervation

THINKLARP

Left/anterior vagus nerve

Hepatic branch
Nerves of Laterjet (anterior)

Right/posterior vagus nerve

Celiac branch
Nerves of Laterjet (posterior)

Criminal nerve of Grassi (50%)

Stomach
Innervation

Nerves of Laterjet
Fundus and Body

Crows foot
Antrum

Vagotomy (Clinical
correlation)

Peptic ulcer disease

(Clinical correlation)
Modified Johnson Classification

THINK
One is one
Two is two
Three is pre
Four is door
Type 5--NSAIDs

Upright CXR
(Clinical
correlation)

gastric bubble = fundus of the

stomach

Upright CXR
(Clinical
correlation)
Diagnosis?

Upright CXR
(Clinical
correlation)
Diagnosis

Duodenum
10 inches!!!
Portions

First partduodenal cap/bulb

PosteriorGDA
L1 vertebra

Second part-descending
Duodenal papillae

Third parthorizontal
Anteriorsuperior mesenteric vessels
L3 vertebra

Forth part

Which is intraperitoneal?
Vertebral level of duodenojejunal

flexure?

UGIB and LGIB

(Clinical
correlation)
Ligament of Treitz/Suspensory

ligament of the duodenum

MCC of UGIB?
MCC of LGIB?

Pediatric?

Adult?

UGIB or LGIB?

Melena

Hematochezia

Mesenteric small
bowel
Jejunum versus
ileum
Ls of the iLeum

Less in everything else

Lymphoid tissue (Peyers patches)

Loops (Arcades)

Longer (3/5th)

Lipid (more fat in the mesentery)

Double bubble sign

(Radiologic sign)
Diagnosis?

Colon
Unique features

Taenia coli
Rectosigmoid junction

Appendices epiploicae

Haustra

What segments are intraperitoneal?

Colon
Cecum

Most dilated portion

Ascending colon
Transverse colon

 Descending colon
Sigmoid colon

MC site of volvulus

MC site of diverticulosis

Rectum

Colon
Blood supply

SMA
Cecum splenic flexure

IMA
Descending colon upper rectum

Marginal artery (of Drummond)

Arc of Riolan

meandering mesenteric artery

Middle colic artery and left colic artery

Apple core deformity

(Clinical correlation)
Diagnosis?
Most common site?

Coffee bean sign

(Radiologic sign)
Bent inner tube sign
Kidney bean sign
Diagnosis?
Intraperitoneal or retroperitoneal?

Intussusception
(Clinical
correlation)
Most common type?

 Intraperitoneal or retroperitoneal?

Vermiform
appendix
Blood supply

Ileocolic artery-->posterior cecal

artery-->appendicular artery

Most common location?

Appendicitis
(Clinical
correlation)
First manifestation?
Migration of pain?

Dermatomal level?

McBurney's point?

 How can the base of the appendix be

identified?
Left-sided?

Small intestine
versus colon
Liver
Anatomic division

Falciform ligament

Physiologic division

Cantlie line

LiverAnatomic
division
Right lobe

Caudate lobe

Quadrate lobe

 Left lobe

LiverPhysiologic
division
Right lobe
Left lobe

Caudate lobe

Quadrate lobe

Couinaud segments

Planes
Right hepatic vein
Middle hepatic vein
Left hepatic vein
Right and left portal veins

Couinaud
segments

Liver
Blood supply

Hepatic artery (75%)

Postal vein (25%)

Biliary Tree
Cystic duct

Valves of Heister

Right and left hepatic ducts

CBD
Ampulla of Vater
Drainage

Posteromedial wall of the 2nd part of

the duodenum

Gallbladder
Parts
Function

Mercedes-Benz
sign
gallstones

Pancreas
Parts

Head

Uncinate process

Body

Neck

Tail

Embryology
Ventral pancreas

Head, inferior

Uncinate process

Major pancreatic duct

 Dorsal pancreas

Head, superior

Neck

Body

Tail

Minor pancreatic duct

Pancreas
Ducts

Main pancreatic duct (Wirsung) major

duodena papilla
Accessory pancreatic duct (Santorini)
minor duodenal papilla

Necrotizing pancreatitis
(Clinical correlation)
Grey-Turner sign

Flank

Double duct sign

Pancreatic head mass

Inverted-3 sign
Diagnosis?

Whipple procedure
(Clinical correlation)

Spleen
THINKSpleen is a very odd organ

1, 3, 5, 7, 9, 11
Spleen size is 1 x 3 x 5
Spleen is 7 oz
Between ribs 9 to 11

Accessory spleen
(Clinical correlation)

 Splenorenal ligament

Splenic vessels

Tail of the pancreas

Gastrosplenic ligament

Short gastric vessels

Greater or lesser omentum?

Posterior
Abdominal
wall
Kidneys

 T12-L3
Hilum (anterior to posterior)

Renal vein

Renal artery

Ureter

Kidneys
Coverings

Renal capsule

Perirenal fat

Renal (Gerota) fascia

Encapsulates the adrenal glands and

kidneys

Pararenal fat

Kidneys (Histology)
Cortex

Glomeruli

PCT

DCT

Renal column

Medulla (10-18)

Loop of Henle

Collecting duct

Drainage?

Kidney stones
(Clinical
correlation)
90% seen on AXR
Unseen = Uric acid

Left renal vein

Left renal vein

Left adrenal vein

Left gonadal vein

Longer?

Varicocele (Clinical
correlation)
Left renal tumor
Dilation of what venous plexus?
Description?

Ureter
Constriction

Ureteropelvic junction

External iliac artery and/or pelvic brim

Bladder wall-most common site*

Adrenal glands
(Histology)
Cortex

 Medulla

chromaffin cells

Embryologic origin

cortex?

medulla?

Adrenal glands
Blood supply?

Superior adrenal artery

Middle adrenal artery

Inferior adrenal artery

Venous drainage?

Ureter
Blood supply?

UpperRenal artery

MiddleGonadal artery

LowerSuperior vesical artery

Suprapubic
aspiration (Clinical
correlation)

Retropubic (Retzius) space

VASCULATU
RE
Abdominal aorta

First branch of the abdominal

aorta?

Nutcracker
syndrome

(Clinical
correlation)

renal vein entrapment syndrome

Superior
mesenteric artery
(Clinical
correlation)

compression of the third part of

the duodenum

Inferior vena cava

Formed at L5

Abdominal aortic
aneurysm (Clinical
correlation)
MC site of aneurysm?
Most important risk factor?

Hepatic portal
system
Portal vein = SMV + Splenic vein
Behind the neck of the pancreas

Vertebral level?

Drain lower 1/3 of esophagus to

upper 1/2 of anal canal

Tributaries of the splenic vein

short gastric vein

left gastroepiploic vein*

Inferior mesenteric vein

pancreatic vein

Sites of anastomoses
between portal and caval
systems