ABDOMINAL CAVITY the second lecture

Esophagus Abdominal aorta Celiac trunk Celiac plexus Esophagus Fibromuscular tube Extends from the pharynx to the stomach Approximately 25 cm long Average diameter of 2 cm Usually flattened anteroposteriorly Descends through the neck, superior and posterior mediastinum, abdominal cavity (short part) Conveys food from the pharynx to the stomach Food passes rapidly because of the peristaltic action of its musculature Esophagus Initially inclines to the left but is moved by the arch of the aorta to the median plane opposite the root of the left lung Inferior to the arch again deviates to the left Passes through the esophageal hiatus in diaphragm at the level of T10 vertebra Esophagus – cervical part

Extends from the level of inferior border of C6 and inferior border of the cricoid cartilage. Esophagus -thoracic part (superior mediastinum)

Enters the superior mediastinum between the trachea and vertebral column Lies anterior to the bodies of the vertebrae T1 through T4 Esophagus- thoracic part (superior mediastinum)

Adjacent to the posterior surface (membranous wall) of the trachea Esophagus - thoracic part (superior mediastinum)

The thoracic duct usually lies on the left side of the esophagus, deep (medial) to the arch of the aorta Esophagus - thoracic part (inferior mediastinum)

Passes posterior to the pericardium and the left atrium Esophagus - abdominal part

Short, trumpet-shaped Approximately 1.25cm long Extends from the diaphragm to the cardiac orifice of the stomach to the left of the midline at the level of the 7th left costal cartilage and T11 vertebra The right border- continuous with the lesser curvature of the stomach The left border- is separated from the fundus of the stomach by the cardiac notch Esophageal hiatus Esophagus- constrictions Normally has four constrictions where adjacent structures produce impressions: The upper esophageal sphincter- at the beginning, approximately 15 cm from the incisor teeth and caused by the cricopharyngeus muscle Where is crosed by the arch of the aorta, 22.5cm from the incisor teeth Where is crossed by the left main bronchus, 27.5cm from the incisor teeth The lower esophageal sphincter- where passes through the diaphragm, approximately 40 cm from the incisor teeth Esophagus- constrictions (impressions) May be observed as narrowings of the lumen in oblique chest radiographs that are taken as barium is swallowed At these sites- the slower passage of substances The impressions indicate: -where swallowed foreign objects are most likely to lodge -where a stricture may develop following the accidental drinking of a caustic liquid such as lye Esophagus- musculature Layers of muscle: internal circular external longitudinal

- in the superior third consists of skeletal muscles (voluntary, striated) - in the middle third is made up of smooth and skeletal muscles (a mixture of striated and smooth) - in the inferior third is composed of smooth muscle (involuntary) The phrenoesophageal (membrane)

An extension of inferior diaphragmatic fascia Attaches the esophagus to the margins of the esophageal hiatus in the diaphragm Stabilizes and maintains the esophagogastric junction in intrabdominal position Permits independent movement of the diaphragm and esophagus during respiration and swallowing Esophagogastric junction Lies to the left of T11 vertebra on the horizontal plane that passes through the tip of the xiphoid process The diaphragmatic musculature forms the esophageal hiatus- a physiological esophageal sphincter that contracts and relaxes Surgeons and endoscopists designate as the Z-line- a jagged line where the mucosa abruptly changes from esophageal to the gastric Physiological esophageal sphincter

Prevents reflux of gastric contents into esophagus The lumen of the esophagus when one is not eating is normally collapsed above this sphincter Esophagus- the arterial supply

Esophageal branches (from the thoracic aorta) Left gastric artery (from celiac trunk) Left inferior phrenic artery (from the abdominal aorta) Esophagus- the venous drainage

To the portal venous system through the left gastric vein To the systemic venous system through esophageal veins entering the azygos vein Esophagus- the venous drainage Esophageal varices Esophageal varices, hiatus hernia, stricture and esophagitis Esophagus- the lymphatic drainage

Into the posterior mediastinal lymph nodes Into the left gastric nodes (efferent lymphatic vessels from these nodes drain mainly to the celiac nodes) Esophagus- the innervation

The vagal trunks The thoracic sympathetic trunks The splanchnic nerves (the greater and lesser) The esophageal nerve plexus around the left gastric and inferior phrenic arteries Peritoneum

A continuous, glistening, transparent Peritoneum

Lines the and invests the viscera Two continuous layers: - parietal peritoneum - visceral peritoneum Both layers of peritoneum consist of (a layer of simple squamous epithelial cells) Peritoneal cavity

Within the abdominal cavity which is continuous with the Potential space of capillary thinness between the parietal and visceral layers of peritoneum Contains peritoneal fluid which lubricates the peritoneal surfaces, enabling the organs to move each other without friction and allowing the movements of digestion Peritoneal cavity

Completely closed in males A communication pathway in females to the exterior of the body through the uterine tubes, uterine cavity and vagina (potenthial pathway of infection from exterior) Peritoneal fluid

Contains leukocytes and antibodies that resist infection Absorbed by lymphatic vessels on the inferior surface of diaphragm Embryology of the peritoneal cavity Early the embryonic body cavity is lined with mesoderm (the primordium of the peritoneum) Later, the primordial abdominal cavity is lined with parietal peritoneum derived from mesoderm, which forms a closed sac The peritoneal cavity- the lumen of the peritoneal sac The organs invaginate to varying degrees into the peritoneal sac, acquiring a peritoneal covering- the visceral peritoneum Peritoneum – the relationship of organs to the peritoneum Intraperitoneal organs-almost completely covered with visceral peritoneum (invaginate into the closed sac) Extraperitoneal (retroperitoneal) organs- outside the peritoneal cavity- external or posterior to the parietal peritoneum - primarily retroperitoneal - secondary retroperitoneal Peritoneum – the relationship of organs to the peritoneum

Primarily extraperitoneal- do not have a peritoneal covering, already retroperitoneal when formed, embedded primarily in the connective tissue of the Secondarily extraperitoneal- become extraperitoneal during the course of embryonic development, attached secondarily to the wall of the peritoneal cavity by peritoneal fusion Relationships of the organs to the peritoneum Intraperitoneal organs: Secondary retroperitoneal organs: Stomach (without ampulla) Ampulla of duodenum Ascending and descending colon Jejunum Pancreas Ileum Cecum with appendix Primarily retroperitoneal organs: Transverse colon Kidneys Sigmoid colon Ureters Suprarenal glands Spleen Urinary bladder (subperitoneal) Prostate (subperitoneal) Uterine tubes Vagina (subperitoneal) The peritoneal of the liver and the stomach

Consist of a double layer of peritoneum that connects an organ with another organ or to the The

A double layer of peritoneum A result of the invagination of peritoneum by an organ Constitutes a continuity of the visceral and parietal peritoneum that provides a means for neurovascular communication between the organ and the body wall Connects the organ to the posterior abdominal wall Has a core of connective tissue containing blood and lymphatic vessels, nerves, lymph nodes and fat Mesocolon

The mesentery of the large intestine The omentum

Double-layered extension or fold of peritoneum Passes from the stomach and proximal part of the duodenum to adjacent organs in the abdominal cavity or to the abdominal wall Divides into: - the lesser omentum - the The lesser omentum

Connects the lesser curvature of the stomach and the proximal part of the duodenum to the liver

The and are continuous parts The greater omentum

Prominent peritoneal fold

Hangs down like an apron from the greater curvature of the stomach and the proximal part of the duodenum

Folds back and attaches to the anterior surface of the transverse colon and its mesocolon The greater omentum

Prevents the visceral peritoneum from adhering to the parietal peritoneum lining the anterolateral abdominal wall „Abdominal policeman” wraps around an inflamated organ walling it off and thereby protecting other viscera from this organ Cushions the abdominal organs against injury Forms insulation against loss body heat Peritoneal fold and peritoneal recess

Peritoneal fold- a reflection of peritoneum that is raised from the body wall by underlying blood vessels, ducts and obliterated fetal vessels Peritoneal recess (fossa)- a pouch of peritoneum that is formed by a peritoneal fold The transverse mesocolon

Mesentery of the transverse colon Divides the abdominal cavity into: - supracolic compartment - infracolic compartment The infracolic compartment

Lies posterior to the greater omentum

Divides into right and left infracolic spaces by the mesentery of the small intestine The paracolic gutters (sulci, recesses, fossae) The grooves between the lateral aspect of the ascending or descending colon and the posterolateral abdominal wall

Free communication between the supracolic and infracolic compartments

Provide pathways for the flow of ascitic fluid and the spread of intraperitoneal infections

Provide pathways for the spread of tumor cells Peritoneal cavity the the main and larger part of the peritoneal cavity the lesser sac (omental bursa) lies posterior to the stomach and adjoining structures Omental bursa- development

Between the fourth and fifth weeks the stomach starts rotation

The stomach rotates and displaces the dorsal mesogastrium The omental bursa

An extensive saclike cavity that lies posterior to the stomach and adjacent structures and the lesser omentum

Permits free movement of the stomach

Communicates with the greater peritoneal sac through the The recesses of the omental bursa

A superior recess limited superiorly by the diaphragm and the posterior layers of the of the liver An inferior recess between the superior part of the layers of the greater omentum The omental foramen (epiploic foramen, foramen of Winslow) An single physiological opening situated posterior to the free edge of the lesser omentum (hepatoduodenal ligament) Can be located by running a finger along the gallbladder to the free edge of the lesser omentum The boundaries of the omental foramen (epiploic foramen, foramen of Winslow)

Anteriorly hepatoduodenal ligament Posteriorly: inferior vena cava right crus of diaphragm Superiorly: caudate lobe of the liver Inferiorly: superior part of the duodenum Stomach

Expanded part of the digestive tract between the esophagus and the small intestine In the most of people the shape resembles the letter J Acts as a food blender and reservoir The chief function is enzymatic digestion The gastric juice gradually converts a mass of food into a liquid mixture- chyme- that passes fairly quickly into the duodenum Stomach

An empty stomach is only of slightly larger caliber than the large intestine Capable of considerable expansion and can hold two to three liters of food A newborn infant’s stomach can hold about 30ml of milk Stomach- curvatures Lesser: the shorter concave border, passes from the right side of the cardia to the pyloric antrum.

- the angular incisure (notch)- the sharp indentation approximately two-thirds of the distance along this curvature indicates the junction of the body and the pyloric part, lies just to the left of the midline

Greater: the longer convex border, passes to reach the pyloric antrum Stomach – the shape and the position

Varies in different persons and even in the same individual because of diaphragmatic movements during respiration, the stomach’s contents (heavy meal) and the position of the person In the erect postion the stomach moves inferiorly In asthenic (thin, weak) persons the body of the stomach may extend into the pelvis Stomach- regions

Epigastric region Left hypochondriac region Umbilical region Left lateral region Stomach- quadrants

Right upper quadrant Left upper quadrant Stomach- parts Cardia surrounds the cardiac orifice Fundus dilated superior part related to the left dome of the diaphragm limited inferiorly by the horizontal plane of the cardiac orifice Body between the fundus and the pyloric antrum Pyloric part funnel-shaped region the pyloric antrum- wide part the pyloric canal- narrow part Pylorus

Normally in tonic contraction At irregular intervals gastric peristalsis passes the chyme through the pyloric canal and pyloric orifice into the duodenum for futher mixing, digestion and absorption Pylorospasm (spasmodic contraction)- a failure of the smooth muscle fibers; resulting in vomiting Congenital hypertrophic pyloric stenosis- severe stenosis, overgrown pylorus is hard Pylorus

Guards the pyloric orifice The distal sphincteric region of the pyloric part projects into the first (superior) part of the duodenum Thickened (contains more circular smooth muscle) to form the pyloric sphincter, which controls discharge of the stomach contents into the duodenum Surface anatomy of the stomach (supine position) The cardiac orifice usually lies posterior to the 6th left costal cartilage, 2 to 4cm from the median plane at the level of T11 The fundus usually lies posterior to the left 6th rib in the midclavicular plane The pyloric part usually lies at the level of the 9th costal cartilages at the level of L1 vertebra The pylorus usually lies on the right side; its location varies from L2 through L4 vertebrae Hiatus hernia

A protrusion of a part of the stomach into the mediastinum through the espohageal hiatus of the diaphragm In people after middle age (most often), possibly because of weaking of the muscular part of the diaphragm and widening of the esophageal hiatus Distressful and cause pain Hiatus (hiatal) hernia Two main types: sliding hiatus hernia the abdominal part of the espohagus, the cardia and parts of the fundus of the stomach slide superiorly through the esophageal hiatus into the thorax paraesophageal hiatus hernia the cardia remains in its normal position a pouch of peritoneum, often contains part of the fundus, extends through the esophageal hiatus anterior to the esophagus Stomach - intraperitoneal organ

Covered by visceral peritoneum, except where blood vessels run along its curvatures Two layers of the lesser omentum extend around the stomach and leave its greater curvature as the greater omentum Stomach- intraperitoneal organ Stomach - ligaments

Gastrocolic Hepatogastric Gastrophrenic Gastrosplenic (gastrolienal) Stomach - anterior surface

Related to: diaphragm, left lobe of liver anterior abdominal wall The bed of the stomach Formed by the structures forming the posterior wall of the omental bursa: Left dome of the diaphragm Spleen Left kidney Left suprarenal gland Splenic artery Pancreas Transverse mesocolon Stomach- muscles Stomach

Mucous layer is reddish-brown during life, except in the pyloric part where is pink Gastric folds (rugae)- most marked toward the pyloric part as a longitudinal ridges and along the greater curvature, formed by gastric mucosa Gastric canal- between the longitudinal gastric folds along the lesser curvature, formed temporarily during swallowing Stomach- gastric canal

Can be observed radiographically and endoscopically Forms because of the form attachment of the gastric mucosa to the muscular layer, which does not have an oblique layer at this site Saliva and small quantities of masticated food and other fluids pass through it to the pyloric canal Mucosa of stomach Gastroscopy Abdominal aorta

Descends anterior to the bodies of T12 through L4 vertebrae

Begins at the aortic hiatus in the diaphragm

Ends at the level of the L4 by dividing into the right and left common iliac arteries (aortic bifurcation- 2 to 3 cm inferior and to the left of the umbilicus) Abdominal aorta Branches: unpaired visceral branches: -celiac trunk -superior mesenteric artery -inferior mesenteric artery paired visceral branches: -suprarenal arteries -renal arteries -gonadal arteries unpaired parietal branch -median sacral artery paired parietal branches: -subcostal arteries -inferior phrenic arteries -lumbar arteries The celiac trunk

Unpaired branch of the abdominal aorta

Just distal to the aortic hiatus of diaphragm

Soon divides into left gastric, splenic and common hepatic arteries The arteries of the celiac trunk

Left gastric artery ascendens retroperitoneally to the esophageal hiatus, where it passes between layers of hepatogastric ligament

Common hepatic artery passes retroperitoneally to reach hepatoduodenal ligament and passes between its layer to porta hepatis Splenic artery

Runs retroperitoneally along superior border of pancreas; it then passes between layers of splenorenal ligament to hilum of the spleen Arterial supply to the stomach Left gastric Left gastro- omental passes between layers of to the greater curvature Right gastro- omental passes between layers of greater omentum to greater curvature of stomach Right gastric runs between layers of hepatogastric ligament Short gastric pass between layers of to fundus of stomach Stomach- arterial supply

The arterial arch on the lesser curvature is formed by the larger left gastric artery and smaller right gastric artery

The arterial arch on the greater curvature is equally formed by the right and left gastro-omental (gastroepiploic) arteries The gastric veins Parallel the arteries in position and course The left and right gastric veins drain into the portal vein The short gastric veins and left gastro- omental vein drain into the splenic vein, which joins the superior mesenteric vein to form the portal vein The right gastro- omental vein empties in the superior mesenteric vein A prepyloric vein- ascends over the pylorus to the right gastric vein, is used for identifying the pylorus The lymphatic drainage of the stomach

The gastric lymphatic vessels accompany the arteries along the curvatures of stomach

Drain the lymph from anterior and posterior surfaces of stomach towards its curvatures to the right (inferior) and left (superior) gastric lymph nodes, pyloric lymph nodes and pancreaticosplenic (+superior pancreatic) lymph nodes The lymphatic drainage of the stomach

The efferent vessels from the lymph nodes accompany the large arteries to the celiac lymph nodes The lymphatic drainage of the stomach

Lymph from the superior 2/3 of the stomach drains along right and left vessels to the left gastric nodes

Lymph from the fundus and superior part of the body of the stomach drains along short gastric arteries and left gastro- omental vessels to the pancreaticosplenic nodes

Lymph from the right inferior part of the body drains along the right gastro- omental vessels to the right and pyloric lymph nodes

Lymph from the superior part of the pylorus drains to the pyloric lymph nodes Lymphatic vessels

The efferent vessels from the celiac nodes form the intestinal lymphatic trunk (single or multiple) The thoracic duct receives the lymph from the intestinal lymphatic trunk The chyle cistern – a sac at the inferior end of the thoracic duct The thoracic duct – ascends through the aortic hiatus in the diaphragm into the posterior mediastinum and ends by entering the venous system (the left venous angle)

Sympathetic part of the autonomic nervous system Abdominopelvic splanchnic nerves from the thoracic and abdominal sympathetic trunks Prevertebral sympathetic ganglia Abdominal autonomic plexuses Periarterial plexuses The sympathetic nerve supply of the stomach

The greater splanchnic nerve from T5 through T9 or T10 segments of the spinal cord (the main source of presynaptic sympathetic fibers serving abdominal viscera) Parasympathetic part of the autonomic nervous system

Anterior and posterior vagal trunks Pelvic splanchnic nerves Abdominal autonomic nerve plexuses Periarterial plexuses of nerves Intrinsic (enteric) parasympathetic ganglia Anterior vagal trunk

Usually enters the as a single branch that lies on the anterior surface of the esophagus Runs toward the lesser curvature of the stomach Leaves the stomach in the hepatoduodenal ligament Gives rise to anterior gastric branches Posterior vagal trunk

Derived mainly from the right vagus nerve Enters the abdomen on the posterior surface of the esophagus Passes toward the lesser curvature of the stomach Posterior vagal trunk

Gives off a celiac branch to the celiac plexus Stomach - innervation

The parasympathetic nerve from the anterior and posterior vagal trunks and their branches

The celiac plexus through the greater splanchnic nerve The celiac plexus (solar plexus) Surrounds the root of the celiac arterial trunk Contains irregular right and left celiac ganglia (approximately 2cm long) that unite superior and inferior to the celiac trunk The parasympathetic root - a branch of the posterior vagal trunk The sympathetic root - the greater and lesser splanchnic nerves Innervation of abdominal viscera Parasympathetic stimulation promotes peristalsis secretion and relaxation of sphincter

Sympathetic stimulation is inhibitory to the parasympathetic stimulation Visceral referred pain Visceral afferent fibers accompany the sympathetic fibers Radiates to the dermatome level Referred to the epigastric region because the stomach is supplied by pain afferents that reach the T7 and T8 (T9) spinal sensory ganglia and spinal cord segments through the greater splanchnic nerve THANK YOU !!!