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Thoracic Cavity

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Thoracic Cavity Powered By Docstoc
					Visceral Anatomy
These notes were made by Hadley Wickham, hadley@technologist.com and are licensed under the Creative Commons NonCommercial-ShareAlike License. To view a copy of this license, visit http://creativecommons.org/licenses/nc-sa/1.0/ or send a letter to Creative Commons, 559 Nathan Abbott Way, Stanford, California 94305, USA.

Table of Contents
Table of Contents ........................................................................................................................................ 2 Thoracic Cavity ........................................................................................................................................... 3 Pleura, Trachea, Bronchii and Lungs ........................................................................................3 Pericardium ................................................................................................................................ 6 Heart ..........................................................................................................................................6 Great Vessels .............................................................................................................................9 Mediastinum ..............................................................................................................................9 Thoracic Diaphragm ................................................................................................................11 Lymphatics .............................................................................................................................. 13 Nerve System ...........................................................................................................................13 The Abdomen ............................................................................................................................................ 14 Overall Organisation ................................................................................................................14 Liver .........................................................................................................................................15 Gall Bladder .............................................................................................................................16 Pancreas ...................................................................................................................................17 Spleen ......................................................................................................................................17 Blood Supply of Gut ................................................................................................................18 Stomach ...................................................................................................................................18 Small Intestine .........................................................................................................................19 Large Intestine .........................................................................................................................19 Kidneys ....................................................................................................................................20 Suprarenal Glands ....................................................................................................................20 Posterior Abdominal Wall .......................................................................................................21 Development of the Gut ...........................................................................................................22 The Pelvis .................................................................................................................................................. 23 Pelvic Supply ...........................................................................................................................23 Pelvic Diaphragm ....................................................................................................................23 Rectum .....................................................................................................................................25 Anal Canal ............................................................................................................................... 25 Ischioanal Fossae .....................................................................................................................26 Urinary System ........................................................................................................................27 Male Internal Genitalia ............................................................................................................28 Male External Genitalia ...........................................................................................................29 Female Internal Genitalia ........................................................................................................30 Female External Genitalia .......................................................................................................31 Perineum ..................................................................................................................................32 Clinical Anatomy ...................................................................................................................................... 33 Myotonic Dystrophy ................................................................................................................33 COPD .......................................................................................................................................33 Polycystic Kidney Disease ......................................................................................................35 Congenital Heart Defects .........................................................................................................36

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Thoracic Cavity
divided into three sections: two pleura (lateral) and a mediastinum (medial)

Pleura, Trachea, Bronchi and Lungs
Pleura each lung is covered a pleural sac it has two layers: visceral (lines lungs, including fissures) and parietal (lines cavity walls) two pleura contact during inspiration reducing pleural cavity to very small space very thin layer of pleural fluid (secreted by pleura) lubricates the two pleura and allows easy sliding the two layers are formed as lung bud pushes its way into embryonic pleura pulling some with it PP named for part of body that it lines: costal, mediastinal, diaphragmatic and pleural cupula pleural cupula is the dome shaped apex of the PP, covers apex of lung, 3cm superior to clavicle, strengthened by suprapleural membrane (dense fascia) PP becomes continuous with VP at root of lung pulmonary ligament formed by a double layer of PP which passes down from root of lung, becomes continuous with the VP
Supply



each receives different blood, nerve and lymph supply:
Visceral (same as lung) Artery Vein Nerve Lymph bronchial a. pulmonary v. autonomic nn. hilum Parietal (same as thorax) intercostal aa. intercostal vv. intercostal nn. and phrenic n. (C35) on diaphragm axillary and sternal

Pleural Reflections

  

pleural reflection = area where pleura turns sharply from one wall to another pleura is higher anteriorly than posteriorly course of pleura follows rule of twos:
Rib 2 4 6 8 10 12 Course sternal angle runs inferiorly turns laterally and inferiorly crosses mid-clavicular line crosses mid-axial line most posterior


Pleural Recesses

   

three pleural recesses are formed where two layers of PP touch each other (potential spaces), only filled by lung during deep inspiration obliteration of cavity causes little functional loss but fluid can accumulate inside them costodiaphragmatic recess lies between ribs and diaphragm costomediastinal recess lies along anterior border of PP

 left recess larger because of cardiac notch
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 lingula slides in and out during breathing  
retroesophogeal recess behind oesophagus sternocostal recess

Trachea wide fibro-cartilaginous tube (reinforced by C-shaped cartilaginous rings) two ends of C are connected by trachealis muscle and connective tissue divides into two main bronchi at carina tracheo-oesophageal fistula

 

posterior surface flat

  

congenital condition, ranging in severity trachea and oesophagus connected by channel v. dangerous, as food can easily enter lung, but usually detected early and corrected

Bronchi 10 bronchus supplies one lung, 20 bronchus supplies one lobe, 30 bronchus supplies one bronchopulmonary segment main bronchial walls supported by irregular plates of cartilage, travel with pulmonary vein into hilum of lung where they both divide into a regular pattern of branchings right main bronchus wider, shorter (2.5cm) and more vertical than left (5cm) foreign bodies (esp. peanuts) are more likely to become stuck in the right bronchus if lying on side, usually becomes stuck in posterior branch of upper lobe broncho-pulmonary segments are indistinguishable at a macroscopic level, knowing location only useful to respiratory therapist to perform percussion and drainage Lungs function: oxygenate blood each lung has an apex (close to cupula), base (diaphragmatic surface), root (connection to heart) and hilum (where root attaches to lung) unsymmetrical, right lung larger, heavier, shorter and wider with more lobes (because heart decreases space on the left) left lung has a deep cardiac notch 24 degrees of branching when fully developed, 3 degrees at 8 weeks lungs divided into lobes by fissures

 

if lying down, usually becomes stuck in superior branch of lower lobe



oblique fissure divides lower lobe from upper (and middle) lobe(s)

 extends obliquely downwards from the 4th ICS, crosses the mid-axillary line at the 5th rib
and ends at the anterior border at the 6th costal cartilage



horizontal fissure (on right side only) divides middle from upper lobe,

 begins at the 4th ICS at the mid-axillary line, follows the course of the 4th rib and ends at
the sternal margin
Grooves

 

grooves left by structures that passes adjacent to lungs (only apparent in preserved) left lung (from left to right)
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                 

aorta oesophagus trachea 1st rib inferior vena cava superior vena cava subclavian a. trachea

(large) curving around root and running to bottom of lung (near pulmonary lig) (middle of apex of lung) (right side of apex, more inferior and posterior) (middle of base of lung) (wrapping around side of root)

left brachiocephalic v (right side of apex)

right lung (from left to right)

right brachiocephalic a.

Blood supply

bronchi and tissue of lung are supplied by bronchial a. left side 2 come straight from aorta, right side 1 comes from intercostal a. venous drainage to azygous v. and pulmonary v. named according to position (pulmonary, bronchopulmonary, superior tracheobronchial, tracheal and oesophageal) right side drains into right thoracic trunk left side drains into thoracic duct receives both sympathetic (T1-5) and parasympathetic (brainstem) supply (join in the pulmonary plexus, anterior and posterior to root of the lung)
Supply Efferent Sympathetic Parasympathetic Afferent Parasympathetic blood vessels, bronchioles, mucus glands, smooth muscle Effect vasoconstriction, bronchodilation, mucus secretion  vasodilatation, bronchoconstriction, mucus secretion  pain, sensation, cough reflex

Lymph nodes

Nerve Supply

Radiology x-ray can be very useful tool in diagnosing chest problems, but radiologist needs to know situation density changes in disease states usually reflected leakages (could be blood, water or pus)
Lung

     

oblique fissure visible on lat x-ray because 4 layers of pleura horizontal fissure visible on AP x-ray if perpendicular to x-ray beam (75% of people) large difference between inspiration and expiration – not pathological! before the availability of antibiotics many people died from lower lobe pneumonia after an operation because they don‟t take deep breaths and secretions etc. accumulated young lungs usually have many blood vessels – this can appear abnormal after looking at many old, sick lungs pulmonary angiograms used to visualise pulmonary circulation, especially in cases of suspect pulmonary embolism (PE)
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Pneumothorax (a.k.a. collapsed lung)

     

usually OK in a normal, healthy person because other lung can compensate can be life threatening in a person with unhealthy lungs (eg. smoker) and rapid treatment is required tension pneumothorax occurs when air is pumped into the pleural cavity hyperinflating it pneumothorax often accompanies a hydrothorax lymphatics are often forgotten about because they can‟t be seen but are absolutely crucial “Curly” B-lines (actually straight) indicate engorged lymph ducts implying that the lungs are filled with fluid

Lymphatics

Pericardium
double-walled fibro-serous sac: parietal (2 layers, fibrous and serous, autonomic nn.) and visceral (wrapped tightly around heart, phrenic n.) posterior to costal cartilages 2-6, anterior to T5-T8 vertebrae parietal pericardium protects the heart from sudden overfilling base fused with central tendon of diaphragm, attached to sternum by sternopericardial ligaments, fused with external coat of great vessels visceral pericardium is reflected onto the heart where it forms the epicardium potential space between the two layers (greater than in lungs) usually holds about 1-2 ml of pericardial fluid, but can hold up to 300ml! pericardial effusion occurs when the pericardial sac fills up with fluid (usually blood or water) cardiac tamponade occurs if heart is severely constrained by the fluid and can‟t pump effectively transverse (above) and oblique (below) sinuses formed by fusion of pericardium to great vessels



transverse sinus important clinically because used to tie off heart in surgery

Heart
size: clenched fist, double self-adjusting muscular pump weight: 250-350g location: middle inferior mediastinum, which it almost completely fills has base, apex, three surfaces (sternocostal, diaphragmatic, pulmonary) and four borders (right, interior, left and superior) base of heart quadrangular in shape, consists of mostly LA apex located in the right 5th intercostal space (formed by LV), apex beat is point of maximal pulsation sternocostal surface is formed by the right ventricle, diaphragmatic surface is formed by both ventricles, pulmonary surface is formed by the left ventricle and occupies the cardiac notch of the left lung the four borders of the heart are formed by the sternocostal surface

 

location: faces towards to right shoulder, opposite to T5-T9

   

right – formed by right atrium, slightly convex inferior – formed by right ventricle, nearly horizontal left – formed by left ventricle superior – formed by auricles
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three layers of heart muscle: epicardium (= visceral pericardium) , myocardium, endocardium wall thickness: RV = 0.5 cm, LV = 1.5 cm (reflect greater pressure in LV) all walls are smooth to prevent clot formation Blood Supply
Arteries

  

left and right coronary aa. come off aorta just above valve both run in interventricular sulci, left in anterior, right in posterior 80% of people are RCA (right coronary a.) dominant
Right Coronary Artery

 supplies: RV, post LV, RA, 1/3 IVS, both nodes  runs along coronary groove (between RA and RV), gives off right marginal branch at
inferior border, then turns to posterior part and gives off largest branch the posterior interventricular branch

 opposite the origin of the PIV, atrioventricular nodal a. is usually given off which supplies
AV node and bundle
Left Coronary Artery

 supplies: LV, LA, ant. 2/3 IVS  divides into two terminal branches (anterior interventricular branch, circumflex branch)
soon after entering coronary groove

 anterior interventricular branch (a.k.a. LAD), passes along ant. interventricular groove to
apex of the heart where it turns and anastomoses with the posterior interventricular branch

 circumflex branch follows coronary groove around left border to posterior surface,
terminates by giving off branches to LV and LA

 marginal branch of circumflex follows left border
Veins

  

more obvious externally than aa. coronary sinus (about 2cm long, located in posterior coronary groove) and anterior cardiac vv. empty into the RA great cardiac v. is its main tributary

 begins at apex of the heart and ascends in AIVG with AIVA  enters the left end of the coronary sinus through a valve  drains the areas of the heart supplied by the LCA    
middle cardiac v. also begin at apex but travels in PIVG with PIVA and enters the right side of the coronary sinus small cardiac v. runs in the coronary groove (with right marginal branch) and enters to the right of the middle cardiac vein thesbian vv. run inside of heart, can be life saving in MI because they can allow blood to flow from inside the heart out to the heart tissue major blood vessels lie on the surface but branch deep into the myocardium

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Parts of the Heart
Right Atrium

 

receives venous blood from venae cava (only rudimentary valve for IVC) and coronary sinus composed of two parts: smooth walled sinus venarum, and rough anterior part (with muscularis pectinati)

 separated from each other by crista terminalis, a thin band (opposite to sulcus terminalis)   
right auricle is a small, conical, muscular pouch that projects left over the aorta, separated from rest of atrium by sulcus terminalis intra-atrial septum forms thin post-med wall 25% of people have probe patent fossa ovalis, causing atrial septal defect but not of clinical importance unless it is large superior left angle tapers into a cone shaped pouch (the conus arteriosus) which leads into the pulmonary trunk papillary muscles are cone shaped projections of the myocardium

Right Ventricle

 

 attach to valve edges via chordae tendineae  prevent inversion of valve flaps  there are three: anterior (largest), posterior (smaller, may be several parts) and septal
(smallest, many parts)

 contract just before ventricular contraction  
the internal wall of the conus arteriosus is smooth while the remainder of the ventricle is roughened by trabecular carni (fleshy branches) and papillary muscles one trabeculae carni crosses the ventricle from the intraventricular septum to the anterior papillary muscle – it is called the septomarginal trabecula (or moderator band) and carries the right bundle branch

 ischaemia that damages this trabecula can cause conduction problems
Left Atrium

        

four pulmonary veins (2 from each side) enter posterior wall of LA left auricle is tube shaped and forms superior part of left border LA is slightly larger than the RA, and lies posterior to it smooth except in auricles which have muscularis pectinati left AV orifice is smaller than the right wall is about three times as thick as RV ascending aorta arises from superior part of LV has only two papillary muscles (anterior and posterior) which are larger than those in the RV aortic has three valve leaflets (left, right, and posterior), coronary sinus located behind left and right valve leaflets supply heart with blood four valves: two atrioventricular, one aortic and one pulmonary

Left Ventricle

Valves



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     

right AV valve has three valve and is also know as the tricuspid valve, the left has two and is known as the bicuspid (or mitral) valve (anterior valve is larger) listen to valve sounds downstream in the major aa. (aortic – aorta, 2nd ICS; pulmonary – PA, 2nd ICS; mitral, posterior to sternum, 4th left costal cartilage) most common cause of damage to the aortic and mitral valves is rheumatic fever valve replacements have been performed for quite a long time first used a ball and cage contraption, which damaged surrounding tissue current models use pig or synthetic valves, little immune problems because of the poor blood supply to the valves
Supply Efferent Afferent Sympathetic Parasympathetic Pain Cardiovascular reflexes myocardium, conduction system, coronary arteries rate  Effect rate , force , vasodilatation

Cardiac Plexus

Great Vessels
left & right brachiocephalic vv. combine to form the superior vena cava (SVC) azygous v. drains in to SVC just before it enters the heart 2 inferior thyroid vv. drain down into l. brachiocephalic v. superior intercostal v. drains into bottom of l. brachiocephalic v cardiac knuckle = bulge of aortic arch visible on x-ray thyroid ima a. is a small artery sometimes found between the brachiocephalic trunk and the r. common carotid, supplying the thyroid – watch out for in thyroid surgery Nerves left and right vagus nn. supplies lots of internal organs (left most) each gives of recurrent laryngeal n left loops under ligamentum arteriosus superior intercostal v. sandwiched between l. vagus and l. phrenic clinical: if patient presents with hoarseness but no physical symptoms, it could be a tumour pressing on the left recurrent laryngeal n. as it passes under the ligamentum arteriosus

 

right loops under subclavian a.

Mediastinum
Mediastinum Suhmmary.xls Superior Mediastinum
Oesophagus

   

constrictions: cricopharangeal, aortic arch, thoracic aorta, diaphragm arteries: upper – inf thyroid aa., middle – oesophageal a., lower – oesophageal branches of l gastric a. veins: upper – brachiocephalic vv., middle – azygous v., lower – l. gastric  l. portal lymph: deep cervical nodes, tracheobronchial, preaortic coeliac
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     

nerves: upper – recurrent laryngeal n., sympathetic, inf thyroid n., lower – vagal n., motor – vagal n., afferent – vagal n., sympathetic vestigial fatty structure in adults – starts deteriorating after puberty arteries: thyroid a., internal thoracic a. veins: left thoracic v. two lobes

Thymus

Anterior Inferior Mediastinum Mid Inferior Mediastinum Post Inferior Mediastinum vagus n. lies along oesophagus and travels with it through diaphragm there is some mixing of the nerve fibres splanchnic n. sympathetic chain either side of vertebral column, major enlargements of fibres are called splanchnic nn. azygous v.

           

nn. become slightly rotated so that left becomes anterior and right posterior

T6-T12: greater splanchnic T6-T9, lesser splanchnic T10-T11, least splanchnic T10-T11

drains post. chest wall and some other structures inside (anything too far away from the IVC) enters into SVC just before it enters the heart usually linked to the left renal v. but not the right regular on right but much more variable on left

many textbooks give different courses of left, most common is two hemiazygous vv. (superior and inferior) draining 4 intercostal vv. each coarctation of aorta narrowing of aorta, usually just after the great vessels found in about 1 in 1000 people blockage usually severe, but non-fatal because of collateral circulation

 aorta  subclavian  ITA  AICA  PICA  aorta  causes internal thoracic aa. and intercostals to increase in size (can cause notches in ribs)     
may not be picked up until early infancy when child starts to walk and become more active delay between radial and femoral pulses can be corrected

if constriction more proximal a patent ductus arteriosus may allow the patient to survive by allowing more blood (albeit deoxygenated) into the aorta Thoracic Duct see

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Thoracic Diaphragm
dome shaped musculo-tendinous sheet responsible for 75% of respiratory movement (remaining 25% from sternocloidomastoid + scalenes) expiration = relaxation and ascent (passive) flat diaphragm occurs when too much air in lungs, may occur in acute asthma deep breaths increase abdominal pressure (eg. when defecating, micturating and during parturition) important in blood flow because increasing abdominal pressure and decreasing thoracic pressure sucks blood back into heart muscle fibres named for point of attachment

 

inspiration = contraction and descent (active)

lumbadiaphragmatic – two muscular crura attach to ant-lat surfaces of lumbar vertebrae two areas of weakness with few muscle fibres (between muscles from different points of attachment) vertebrocostal trigone – especially weak on left, hernia of Boch du Lek, can be very serious muscle fibres join to form central tendon in centre

      

costodiaphragmatic – inferior six ribs sternodiaphragmatic – xiphoid sternum

sternocostal triangle – hernia of Morgagni, not usually serious

no bony attachment divided into three leaves (like a clover leaf)

 right lateral (largest)  anterior  left lateral (smallest)
pericardial sac lies in centre and slightly depresses left and right crus attach diaphragm inferiorly to spinal cord right is broader, and longer (L1to L3), muscle fibres wrap around oesophageal hiatus three posterior ligaments around muscles:

     

left is shorter (L1 to L2)

median arcuate ligament – around aortic hiatus (unity of two crura) medial arcuate ligament – around psoas muscle (thickening of ant-lat thoracicolumbar fascia) lateral arcuate ligament – around quadratus lumborum (thickening of ant-lat thoracicolumbar fascia)

Apertures contains three holes through which structures pass: aortic hiatus, oesophageal hiatus, and vena caval foramen
Oesophageal Hiatus (T8)

   

oesophagus – surround tightly by muscle fibres from right crura, prevents reflux vagus nn. (left  ant, right  post) vv. and aa. of oesophagus oesophageal branches of l. gastric a.

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Vena Caval Foramen (T10)

          

located in the posterior junction between the anterior and right leaves of central tendon IVC - tightly attached to diaphragm, acts like pump (inspiration  diameter ) branches of r. phrenic n. (left spreads out over diaphragm) a few lymph nodes doesn‟t actually pass through diaphragm, passes posterior to median arcuate ligament thoracic aorta (not attached) thoracic duct + intercostal lymph trunks azygous vein sometimes splanchnic n.

Aortic Hiatus (T12)

Hiatal Hernia gastro-oesophageal ligaments can become lax, especially with old age part of stomach can herniate above diaphragm

 stomach just slides up oesophagus – sliding hernia  part of stomach comes up beside oesophagus – paraoesophageal hernia  
Supply
Arteries

results in problems with stomach lining and reflux not usually corrected in older people if few problems

    
Veins

musculophrenic (off ITA) pericardiophrenic (off ITA) intercostal inf. phrenic azygous v. pericardiophrenic and musculophrenic (superior) inferior phrenic (inferior) phrenic nn. (off aorta and ITA) (off abdominal aorta) (only blood supply from beneath diaphragm) superior phrenic (thoracic aorta)

   

Nerves

    

each sole motor supply to entire half of diaphragm ½ sensory and ½ motor C3 – C5 (shoulder and neck) 20% have accessory phrenic n. which will help if one is cut

referred pain to shoulder (central, phrenic nn.) and costal margin (peripheral, intercostal nn.)

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Lymphatics

 

network of lymph tubes and lymph nodes on thoracic surface, drain into phrenic lymph nodes cancer can easily spread from one side to the other

Lymphatics
3 major pathways of lymph drainage in the thorax

  

parasternal thoracic duct

(quite superficial)

entire anterior thorax posterior thorax and some lung lung

tracheobronchial region

Nerve System
sympathetic chain and ganglia lie either side of the vertebral column at junction of rib and body sympathetic system (thoracolumbar) fight or flight see diagram in book components of spinal nerve: motor, sensory, sympathetic efferent (mostly post-ganglionic), visceral afferent

 

parasympathetic system

(craniosacral)

relax

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The Abdomen
Overall Organisation
no space in cavity only potential space, fluid accumulation (eg. in liver failure) called ascites peritoneum lines almost all organs in abdomen

    

shiny, thin layer of cells, allows easy sliding in some places during development the two layers become stuck together and organ ends up behind them – retroperitoneal (eg. kidneys, some parts of duodenum, large intestine) two main parts: greater (anterior and posterior) and lesser (superior) peritoneal sacs

 omental bursa = lesser peritoneal sac
two parts joined by epiploic foramen sub phrenic recess formed by double fold of greater peritoneal sac

Arteries three main arteries supply the abdomen
Coeliac Trunk

      

supplies stomach, liver, pancreas, spleen embryological artery of the foregut landmark artery, only visible just inferior to pancreas supplies most of small bowel and part of large intestine embryological artery of the midgut supplies part of large intestine, plus some other structures embryological artery of the hindgut

Superior Mesenteric A

Inferior Mesenteric A

Ligaments and Mesentery ligaments (organ  organ) and mesentery (organ  body wall) hold the contents of the abdomen in place mesentery = double layer of peritoneum that encloses organ and connects it to abdominal wall omentum = double layered sheet or fold of peritoneum



greater omentum (greater curvature of stomach  spleen, diaphragm, transverse colon)

     

formed by gastrophrenic, gastrolenal, and gastrocolic ligaments forms somewhat mobile apron over intestines variety of functions including embryological and scavenging normally fuses in foetal period, obliterating inferior recess of omental bursa four layers of peritoneum

lesser omentum (lesser curvature of stomach and proximal duodenum  liver)

 formed by hepatogastric and hepatoduodenal ligaments
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 lies posterior to left lobe of liver and attaches into the fissure for the ligamentum venosum
and the porta hepatis greater and lesser omentum‟s are connected by the epiploic foramen (of Winslow) other ligaments include lenorenal and phrenicoeliac

Liver
largest gland and largest abdominal organ (weighs about 1.5 kg) surrounded by tough connective tissue capsule pyramidal shape (base at right, apex at left) bare area on posterior surface formed by reflection of peritoneum to form coronary ligaments anatomical appearance relatively unrelated to physiological function (line of functional symmetry lies 1/3 into right lobe) l. hepatic a. and l. portal v. supply the left functional side not the left anatomical side two functional lobes: left (includes caudate and quadrate lobes) and right
Functions



   

processes all food absorbed in blood from intestines etc. stores glycogen secretes bile through bile duct filters blood

Ligaments coronary ligaments attach posterior and superior surface to diaphragm falciform (sickle shaped) ligament arches from diaphragm over liver, attached to diaphragm and anterior abdominal wall ligamentum venosum fissure located superiorly on visceral surface is the remnant of old ductus venosum ligamentum teres hepatis (round ligament) located inferiorly on visceral surface is remnant of old umbilical v. Surfaces
Diaphragmatic

    

mostly separated from diaphragm by subphrenic recess bare area (between coronary ligaments) in direct contact (only thin layer of c.t.) underneath is superior right anterior surface of stomach, superior duodenum, lesser omentum, gall bladder and right colic flexure covered with peritoneum H-shaped group of deep fissures (cross-bar = porta hepatis, vertical lines, sagittal fissures)

Visceral

Porta Hepatis porta hepatis = gateway to liver, deep transverse fissure contains hepatic aa. (30% blood supply, >80% oxygen), portal vv. (70% blood supply, <20% oxygen), and hepatic ducts, hepatic nerve plexus and lymph vessels common hepatic a. (off aorta) branches below liver to form right and left hepatic aa.
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portal v. = superior mesenteric v. + splenic v. Supply arteries: hepatic a. veins: 3 major hepatic veins, drain into IVC nerves: vagus n. (travels with vessels) Clinical can regenerate quite well but can become fibrous with chronic problems liver damage may block portal system leading to portal hypertension the increased volume in the portal system leads to problems in four areas:

   

oesophagus around umbilicus (caput medusae) anal (haemorrhoids) renal

Gall Bladder
pear shaped, lies to right of quadrate lobe of liver stores and concentrates bile (30-60 ml) bile is produced by the liver and collected by the l. and r. hepatic ducts which drain into the common hepatic duct omental foramen immediately to the left of the neck of the gall bladder the common hepatic duct joins with the cystic duct (with spiral fold) to form the common bile duct spiral fold keeps duct open so that bile and flow in and out two sphincters are located in the common bile duct more inferiorly: the sphincter of Oddi if both sphincters are open, bile drains into the ampulla of Vater (hepato-pancreatic ampulla) which passes through the major duodenal papilla into the duodenum if the sphincters are closed the bile travels up the cystic duct Clinical gall bladder pain is felt in the back of the shoulder blades (nerve supply C6-C9) if the bile component are produced out of proportion then gall-stones may form (round if too much cholesterol, pyramidical if too much bilirubin) large gall stones are less of a threat than small ones because they are trapped inside the gall bladder while the small gall stones can pass into the cystic duct causing pain pain caused not by stone, but by distension upstream of it the gall bladder wall can become inflamed and burst can live without gall bladder, but have difficulties digesting fatty foods because not enough bile can be synthesised when removing the gall bladder you must be careful to tie off the cystic a. not the r. hepatic a. or otherwise half the liver will die

  

more superiorly: the choleduct sphincter

 

a typical patient presenting with gall stones is forty, fat, fertile and flatulent

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Pancreas
elongated (12-15cm), soft greyish-pink organ transversely positioned deep in the left hypochondrium major digestive organ (salivary gland of the abdomen) produce many digestive enzymes (exocrine) and glucagon & insulin (endocrine) there is a lot of variation between people in the shape of their pancreas the head sits in the curve of the duodenum and the body and tail stretches to the right

bile ducts lies in a groove in the post-sup surface uncinate process (beneath SM vessels) develops from embryological ventral part of pancreas, the remainder of the pancreas is from the dorsal part
Drainage

   

head sits on IVC, r. renal vessels, and l. renal v. body intimately related to the splenic v. tail lies between two layers of spenolieno ligament



two pancreatic ducts

 main pancreatic duct drains into the ampulla of Vater (hepatopancreatic ampulla) along
with the bile duct, then empties out the major duodenal papilla

 accessory pancreatic duct empties out the minor duodenal papilla, important if main duct
blocked

 run from tail to head, collecting tributaries in a herringbone pattern 
the main pancreatic duct come largely from the embryological dorsal duct, although the bend in it is ventral part

 sometimes the ventral duct remains giving a large accessory duct 
if obstructed, bile can flow back up into either the gall bladder or the pancreas

 if it flows into the pancreas it can cause pancreatitis as the digestive enzymes begin to
digest the pancreas itself

 

a large tumour or cyst may go unnoticed for many years if it is located in the tail region because there is a lot of room to expand however, if the tumour is located in the head in will soon block off ducts (possibly causing pancreatitis or digestive problems) it is likely to be diagnosed earlier splenic a. (curly, runs along top of pancreas) provides three branches to the pancreas

Supply



 dorsal pancreatic a., great pancreatic a. and caudal pancreatic a. (spaced equally along
length of tail, from right to left)

  

common hepatic a. supplies two branches: the anterior superior pancreaticoduodenal a. (ASPD) and the posterior superior pancreaticoduodenal a. (PSPD) these anastomose with two branches of the SMA: the anterior inferior pancreaticoduodenal a. (AIPD) and the posterior inferior pancreaticoduodenal a. (PIPD) nerve supply is from the coeliac plexus and the splanchnic nn. (especially the greater) (T6-T12)

Spleen
delicate, vascular, lymphoid organ 1” by 3” by 5”, weighs 7 oz, located between ribs 9 and 10 within layers of gastric mesentery
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fully coated with thin and delicate peritoneum gastrosplenic and splenorenal ligaments attached to hilum on medial face
Functions

        

produces white blood cells produces, stores and degrade red blood cells phagocytosis and filtering splenic aa. and vv. enter at hilum of spleen (4-5 branches) short gastric aa. & vv. and epiploic a. and v. travel in the gastrosplenic ligament splenic a. and v. travel in the splenorectal ligament, split to form the inf. and sup. polar aa. splenic aa. are end arteries, therefore blockage causes infarcts in the spleen portal system blockage can cause splenic build, assisted surgically with a spleno-rectal shunt nerve supply from the coeliac plexus, supply smooth muscle around spleen and sinusoids, mostly from greater splanchnic n. (C6-C8/9) most frequently injured organ in the abdomen, usually injured in a motor vehicle accident more easily injured if enlarged, not usually palpable can live with out it (other reticulo-endothelial organ assume functions) rapidly regenerates accessory spleens sometimes found (10% of people, 1 cm diameter)

Supply

Clinical

    

Blood Supply of Gut
supplied by three unpaired visceral branches of the abdominal aorta: coeliac trunk (T10), superior mesenteric artery (L1) and the inferior mesenteric artery (L3) anastomoses occur between the coeliac trunk and SMA at the pancreaticoduodenal aa., and between the SMA and IMA at arterial arcade of the large intestine SMA crosses the renal v., uncinate process of the pancreas and the 3rd part of the duodenum

Stomach
completely covered by peritoneum, unite on either side to form greater and lesser omentum usually J-shaped with entrance (fixed) at T10, exit (free) at L1 can store 2-3 L of food – very distensible composed of three muscular layers: outer, longitudinal; middle, circular; inner, oblique wall is composed of four layers: mucosa, submucosa, muscle and serosa five parts of stomach: cardiac (gastro-oesophageal junction), fundus (above cardiac), body (below cardiac), pyloric antrum (after angular notch), pylorus (valve) fundus in contact with diaphragm cardiac notch located near cardiac orifice angular notch located in centre of lesser curvature, separates pyloric antrum from body exit from stomach controlled by pyloric sphincter (usually in tonic contraction), a thickening of the middle circular layer of muscle the contracted stomach contains longitudinal rugae but these disappear with distension



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Supply

  

nerves: left and right vagus (secretion, muscle contraction), sympathetic arteries: l. & r. gastric and l. & r. gastroepiploic, short gastric aa. veins: same as arteries

Small Intestine
consists of duodenum, jejunum, and ileum jejunum (2/5)and ileum (1/5)are 6-7 metres in length, difficult to distinguish between Duodenum „C‟ shaped, composed of four parts: superior (L1), descending (L3), horizontal (L3), ascending (L4) totals 10” (25cm) in length (2”,3”,4”,1” respectively) widest and least mobile component of the small intestine, retroperitoneal, except for first and last parts closely attached to the head of the pancreas largely located on the right side, except for the horizontal part crossed anteriorly by transverse colon and mesocolon, right side close to pelvis of kidney major and minor duodenal papillae located in descending part supplied by: pancreaticoduodenal aa., supraduodenal a., SMV, portal v. Jejunum begins on LHS at L2 fully covered by peritoneum, thicker and wider than ileum prominent plicae circularis highly vascularised, 2-3 anastomoses of arterial arcade jejuno-ileal junction indistinct because the two are so similar Ileum thinner and narrower than jejunum less vascularised, but more anastomoses (3-5) of arterial arcade

Large Intestine
Caecum blind ending sac, almost completely covered by peritoneum longitudinal muscle contracts into three bands called taenia coli receives ileum and vermiform appendix (below and to the left) lip-like structures (labia) help prevent back-flow into ileum, muscular contractions are also important Colon much wider and thicker than small intestine longitudinal muscle contracts into three bands called taenia coli haustra (or sacculations) are formed because the taenia coli are shorted the colon epiploic appendages, fatty sacs, dangle off haustra composed of four parts: ascending (6”), transverse (18”), descending (12”), sigmoid (18”)



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ascending and descending run in paravertebral gutter, transverse is most mobile and has its own mesentery (transverse mesocolon)

Kidneys
bean shaped with indentation on medial side long axis almost parallel with body, but upper pole tilted slight med-post outer part is called the cortex, inner part the medulla, renal columns extend down between pyramids 8-12 foetal lobes form renal pyramids which open in minor calices which in term combine to from major calices and then the renal pelvis surrounded by a tough connective tissue sheath then perirenal fat, renal fascia and pararenal fat renal fascia prevents excessive bleeding veins, artery, ureter and veins enter from anterior to posterior renal pelvis (funnel-shaped) continuous with ureters, located within sinus Ureters pelviuretic junction descends vertically along psoas major (tips of the transverse processes) they leave the abdomen by crossing the pelvic inlet where the common iliac bifurcates 25cm long in total, but only half in the abdomen Clinical three constriction of the ureter



as it enters bladder renal colic (should be called ureteric colic) caused by kidney stones

              

pelviureteric junction leaving abdomen

waves of pain referred from loin to groin flexed hip more comfortable because psoas relaxed

haematuria, frequent urination (every four hours during the day, twice at night) common diseases are: hydronephrosis (distended pelvis) pyelonephritis (inflammation of pelvis) CA of kidney

hypernephrosis congenital abnormalities horseshoe kidney ectopic (pelvic) kidney double ureter polycystic kidney agenesis of kidney

Suprarenal Glands
yellowish-brown, small fatty glands enclosed within fatty capsule of kidney, but separated from kidneys by a little connective tissue
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distinct cortex and medulla (functionally, anatomically, embryologically) right suprarenal gland is pyramidal and in contact with the IVC left suprarenal gland in semilunar and in contact with the stomach bed

Posterior Abdominal Wall
Nerves subcostal n. T12 iliohypogastric n. L1 ilioinguinal n. genitofemoral n. lateral femoral cutaneous n. obturator n. L2-4 femoral n. L2-4 Blood aorta has located below last rib work out by exclusion L1 work out by exclusion, below iliohypogastric L1-2 runs on top of psoas L2-3 lies 1-2 cm below ASIS, attached to fascia of thigh lies medial to psoas lie lateral and underneath psoas

   
IVC has

three anterior visceral branches (coeliac, SMA, IMA) three lateral visceral branches (renal, suprarenal, gonadal) five lateral abdominal wall branches (4 lumbar, inf. phrenic) three terminal branches (common iliac, median sacral) two anterior visceral tributaries (hepatic) three lateral visceral tributaries (renal, suprarenal, r. gonadal) fiver lateral abdominal wall tributaries (lumbar, inf. phrenic)

three tributaries of origin (common iliac, median sacral) the left renal vein receives tributaries from the azygous, gonadal and suprarenal vv., which enter directly into the aorta on the right Muscles psoas major – lateral to vertebrae, inserts on head of femur iliacus – triangular, lateral and inferior to psoas quadratus lumborum – thick muscular sheet, runs from 12th rib to iliac crest Lymphatics lie along aorta, internal iliacs and IVC lumbar lymph nodes drain posterior abdominal wall, kidneys, gonads, uterus, descending colon, pelvis, and lower limbs efferents form right and left lumbar lymph trunks cisterna chyli is a sac-like expansion of the inferior thoracic duct lies to the right side of L1 and L2 thoracic lymph duct is the main lymph duct of the body

   

  

starts at the cisterna chyli drains into venous system between internal jugular and subclavian vv.
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

crosses to the left at T5

Development of the Gut
Gut Tube formation: bilaminar embryo  trilaminar, lateral folding creates tube, yolk sac pinched off to form gut extent: primitive mouth  primitive anus, not open to exterior



membranes rupture at 4 (mouth) and 8 (anus) weeks

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The Pelvis
Pelvic Supply
Arterial internal iliac a. divides into anterior and posterior divisions in the pelvis posterior division forms:

 

iliolumbar a. and lateral sacral a. (small) superior gluteal a. (between lumbosacral trunk and S1)

 continuation of posterior division  leaves between S1 and lumbosacral trunk  enters gluteal region through greater sciatic foramen
anterior division forms:

     

umbilical a. internal pudendal a. obturate a. inferior gluteal a. middle rectal a. inferior vesical a.

(terminal part is a ligament) (between S3 and S4) (between S2 and S3)

Nervous branches of the sacral plexus (S1-4) and anterior rami of L4 &L5 lie on piriformis pelvic splanchnic n. (PNS, S2-4) (fibres run within fascia) pudendal n. (S2-S4) (leave pelvis through greater sciatic foramen, divides into 3 branches in pudendal canal) inferior gluteal n. superior gluteal n. sciatic n.

Pelvic Diaphragm
pelvic diaphragm = coccygeus + levator ani + fascia

forms floor of the true pelvis composed of two muscles

   

very thin muscle (<2 mm) shaped like funnel divides pelvic cavity into two parts: pelvic viscera and ischioanal fossae

coccygeus

 stretched between ischial spine and lower part of the coccyx  degenerated, only a few muscle fibres remain  fused with sacrospinous ligament(beneath sacrotuberous ligament) 
levator ani
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action: increases angle, pulls forward, anorectal junction (additional sphincter action) two layers of fascia cover muscles
Actions

    

three parts: puborectalis, pubococcygeus, iliococcygeus inserts into posterior wall of vagina/prostate forms sling (anococcygeal raphe) around anorectal junction origin: pubic bone, tendinous line (thickening of fascia) and surface of obturator internus

  

supports pelvic viscera (vagina, prostate, anorectal junction) resists inferior thrust of increase intra-abdominal pressure assists the muscle of the anterior abdominal wall in increasing intra-abdominal pressure (to help expel matter from the respiratory tract)

Urogenital Hiatus lies anterior to pelvic diaphragm, near pubic symphysis effluent of pelvis passes through it Urogenital Triangle boundaries:

    

superior: pelvic diaphragm inferior: skin lateral: ischiopubic rami & sacrotuberous ligament (deep) apex: pubic symphysis base: line between two triangles, superficial transverse perineus muscle

Urogenital Diaphragm (UGD) thin sheet of striated muscle between two sides of pubic arch two membranous sheets with muscle sandwiched between them

  

upper layer: superior fascia of UGD muscle: deep transverse perineal muscle, external urethral sphincter (sphincter urethrae), and perineal body (most posterior part of UGD)

lower layer: inferior fascia of UGD = perineal membrane lies inferior to pelvic diaphragm and urogenital hiatus urethra, (vagina) and anal canal pass through it main sphincter in females is muscle sandwiched between the two layers of fascia, no internal sphincter two perineal spaces: deep and superficial



superficial – between superficial perineal fascia (Colles fascia, fused with fascia lata) and perineal membrane

 male: scrotum, proximal spongy urethra, superficial perineal muscles, related blood vessels
and nerves

 female: root of the clitoris, bulbs of the vestibule, superficial perineal vessels, greater
vestibular glands, related blood vessels and nerves



deep – enclosed by superior and inferior fascia of the UGD

 male: membranous urethra, urinary sphincter, bulbourethral glands, blood vessels, and nn.
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 female: urethra, urinary sphincter, deep transverse perineal muscle, blood vessels, and nn.
Clinical herniation of bladder, rectum or vagina can occur if pelvic diaphragm is weakened (eg. during childbirth)

Rectum
fixed terminal part of the large intestine, continuous with sigmoid colon follows curve of sacrum and coccyx and terminates 3-4 cm ant-inf to coccyx, where it turns 900 to become the anal canal recto-sigmoidal junction located at S3

no epiploic appendages divided into three parts with respect to peritoneal relations

         

no sacculations no mesentery no tenae coli (muscle spreads out to form continuous band)

upper 1/3 anterior and sides covered, lateral reflections (pararectal fossae) allow distension middle 1/3 only covered anteriorly

lower 1/3 devoid of peritoneum mucosa, submucosa and circular muscle form three sharp flexures, transverse rectal folds largest fold located at the bottom rectum divided into upper and lower parts by the middle fold ampulla is very distensible anterior dilation where faeces are held prior to defecation, supported by levator ani muscles

Anal Canal
terminal part of the gastrointestinal tract begins at U-shaped sling formed by levator ani and extends to the anus (exit from the GI tract) descends posteriorly between the perineal body and anococcygeal ligament surrounded by levator ani muscles derived from ectoderm and endoderm

normally membrane perforates at ~8 weeks after fertilisation (membrane between mouth and gut perforates at ~4 weeks) superior half characterised by folds of mucosa called anal columns

       

endoderm above – smooth, columnar EP ectoderm below – two parts: smooth mucous membrane, hairy pigmented skin

contains terminal branches of sup. rectal a. and v. anorectal line, delineated by tops of columns, is where rectum joins anal canal bottom of each fold is joined together by an anal valve, a semilunar fold of EP superior to valves are small anal sinuses, which produce mucus when compressed (aids in defecation) the inferior limit of the anal columns is the pectinate line which separates endoderm from ectoderm
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outer longitudinal muscle is replaced by a fibrous connective tissue membrane below the anorectal junction nerve supply is different depending on the level



above pectinate line: autonomic (SNS + PNS)

 sensitive to stretch but not touch  SNS from inf hypogastric plexus, PNS from the pelvic splanchnic n. (S2-S4) 
below pectinate line: somatic

 sensitive to pain, touch and temperature  inferior rectal n. (branch of the internal pudendal n.)
Sphincters
Internal Anal Sphincter

        

involuntary, thickening of smooth muscle surrounds superior two-thirds of the canal innervated by pelvic splanchnic n. large voluntary sphincter in the perineum surrounds inferior two-thirds of the canal, outside internal anal sphincter large band of either side with subcutaneous, superficial and deep components runs from perineal body to coccyx blends superiorly with puborectalis innervated by inferior rectal n. and perineal n. (S4)

External Anal Sphincter

Ischioanal Fossae
located on each side of anal canal two sides communicate over the anococcygeal ligament large, wedge-shaped (wide inferiorly, apex points superiorly) fat-filled space posterior recess located beneath overhand of gluteus maximus wedge-shaped

       

anteriorly, it continues superior to the UGD, to form the anterior recess

apex: where levator ani meets with obturator internus muscle lateral: ischium and obturator internus medial: anal canal posterior: sacrotuberous ligament, glitters maximus anterior: base of UGD ischioanal fat pad

contents: pudendal canal allows expansion of anal canal during defecation (descent of the faecal mass)

 

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Pudendal Canal

 

located in a splitting of obturator internus fascia in lateral pelvic wall contains the internal pudendal a. and v., and the pudendal n.

 posteriorly gives off inf. rectal vessel and nerves  becomes superficial and supplies external anal sphincter 
pudendal n. supplies most of the perineum

 branches into dorsal n. of the penis/clitoris and perineal n. (which supplies scrotum/labia
and UGD), which run either side of the internal pudendal a. Clinical haemorrhoids

caused by portal hypertension, because of systemic-portal anastomosis hard faeces can tear anal valves leading to an anal fissure

   

can internal (beneath mucosal membrane) or external (beneath skin, often bleed) varicosity of veins causing bleeding and pain distension of the venous plexus of submucosa of anal canal

Urinary System
Ureters female: crossed by uterine a. just lateral to the cervix male: crossed by the ductus deferens Urinary Bladder hollow, muscular organ lined by transition EP wall composed chiefly of the detrusor muscle (smooth)

towards the neck some fibres form the internal urethral sphincter loosely covered by vesical fascia, containing the vesical venous plexus mucous membrane loosely connected to muscle except in trigone area between the three orifices (two ureteric, one urethral) forms trigone no mucosal folding in trigone, because EP tightly attached to underlying muscle separated from the pubis by the rectopubic space and from the uterus by the vesico-uterine space separated from the rectum by the genital septum male: dilated terminal part of vas (ampulla), seminal vesicles urachus (median umbilical fold) runs from the apex to the umbilicus posterior to the internal urethral orifice, a small elevation called the uvuli vesci is created by the middle lobe of the prostate

  

three layers run in many directions external and internal longitudinal, middle circular

 

interureteric crest joins mucosal rugae to trigone

 

female: uterus, vagina

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Control of Micturition

  
Urethra
Male

pelvic splanchnic nn. (PNS, S2-S4) are nerves of micturition, parturition and defecation

 supply motor fibres to detrusor muscle and inhibitory muscles to the internal sphincter
SNS (T11-L2) supply controls diameter of blood vessels and may provide some constrictor fibres cerebral inhibition provides voluntary control of bladder

 until 2-3 years no brain interference, bladder fills then contracts to empty

  

long muscular tube (15-20 cm) carries urine from the bladder and semen from the ejaculatory ducts to the outside divided into three parts

 prostatic (~3 cm) widest and most dilatable, bladder  neck of prostate  membranous (1-2 cm) shortest, thinnest, prostate  bulb of penis  spongy (15-16 cm) longest, runs from bulb  glans, expanded at glans & bulb, openings
for urethral and bulbourethral glands
Female

   

short muscular tube (~4 cm) superior half analogous to the prostatic urethra, inferior half to the membranous urethra external urethral orifice located in the vestibule of the vagina inferior end surrounded by the sphincter urethrae muscle

Male Internal Genitalia
Prostate largest accessory gland of the male reproductive system size of walnut, surrounds the prostatic urethra fibromuscular and glandular branching tubular acini secrete acid phosphatase (prostatic CA = overgrowth of glandular) 60% of men over 80 die of prostate cancer prostatic urethra is kidney shaped in cross-section

 

connective tissue stroma and smooth muscle (BPH = enlargement of stroma)

 

posterior lobes bulges forward to form urethral crest prostatic sinuses are located on either side of crest

 most (12-20) prostatic ductules open into the sinus  secrete prostatic fluid (thin, milky, 20% of seminal fluid) 
in middle part of the crest there is a large rounded structure called the seminal colliculus or veramontanum

 slit-like orifice (~5 mm) opens into the prostatic utricle  ejaculatory ducts open to either side
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two fascial sheaths surround the prostate outer, continuous with fascial sheath of the bladder (false capsule) prostatic venous plexus lies between the fascial sheaths

    

inner, thin dense fibrous capsule of prostate (true capsule)

drains into the pelvic veins, which freely anastomose and possess no valves connected with rich venous plexus in vertebral column (internal vertebral venous plexus) check for spinal metastasis in prostatic CA residual urine volume in bladder acid phosphatase for disease activity prostatic specific antigen (PSA) for CA

Tests

  

Seminal Vesicles coiled tubes ~15 cm long between the fundus of the bladder and the rectum secrete alkaline fluid which makes up 60-80% of seminal fluid similar structure to ampulla of vas (thin walled, honey combed appearance) ends in narrow tube which joins vas to form ejaculatory duct



enters posterior wall of prostatic urethra at seminal colliculus

Male External Genitalia
Penis male organ of copulation, common exit for semen and urine skin very thin, dark and loose composed of three cylindrical bodies of erectile tissue

   

each enclosed by a dense white connective tissue, tunica albuginea all together surrounded by deep fascia of penis two of the three erectile bodies are arranged side by side in dorsal part of the penis, these are the corpora cavernosa

third erectile body is located ventrally and contains the spongy urethra, this is the corpus spongiosum the corpora cavernosa are fused along the middle, except posteriorly where they separate to form the two crura of the penis support the corpus spongiosum root of the penis is located in the superior perineal space consists of roots, bulb (corpus spongiosum, located between crura) and crura (corpora cavernosum) body of penis contains no muscle fibres very sensitive (lots of nerve endings) root, body and glans composed of erectile tissue
Hadley Wickham 29 15/11/09

    

attach to the pubic and ischial rami

distal end is called the glans, composed entirely of corpus spongiosum

 

separated by fibrous septa engorged with blood in erect penis

Female Internal Genitalia
Ovaries referred pain to the medial aspect of the thigh closer to the pelvic wall than the uterus sit on the dorsal aspect of the broad ligament, surface not covered by peritoneum two major ligaments support the ovaries

 

suspensory ligament: fold of peritoneum attached to the pelvic wall, carries ovarian vessels ovarian ligament: between body of uterus and inferior end of ovary, true ligament (remnant of female gubernaculum)

Uterine Tube muscular tube than connects the ovaries to the uterus, carries oocytes to uterus 20-30 fimbriae pull the oocyte into the tube aka. salpinx, fallopian tube extends laterally in the free upper margin of the broad ligament



mesentery attached to the uterine tube is called the mesosalpinx

Uterus composed of two major parts cervix (one-third) communicates with vagina through external os gubernaculum (ovarian and round ligament) is degenerated in the female, but long in the male ovarian ligament attached post-inf to attachment of tubes cervix supported by

 

body (two-thirds)

  

pubocervical transcervical (cardinal ligament) (cervix + lateral vagina  lateral pelvic wall) sacrocervical (cervix  mid sacrum (deep to peritoneum, superficial to levator ani)

Vagina female organ of copulation inferior part of female genital tract and birth canal runs from the vestibule (cleft between labia minora) to the cervix of the uterus internal anterior and posterior are usually in contact with one another passes between medial margins of levator ani cervix inserts into superior anterior wall at a 900 angle

 

recess around the cervix called the fornix angle increases as the bladder fills

Clinical ectopic pregnancy (1/250 pregnancies)
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   

most often occurs in the uterine tubes felt in Douglas pouch with vaginal examination, or seen on ultrasound can rupture tubes and cause potentially fatal bleed very litagatable

Broad Ligament covers urinary system, genital system and rectum contains fallopian tube, blood vessels, round ligament and ovarian ligament double-layered fold of peritoneum continuous mesothelium on anterior and posterior surfaces lateral broad ligament prolonged over ovarian vessels to form the suspensory ligament connects to ovaries via a short peritoneal fold called the mesovarian



Female External Genitalia
Mons Pubis rounded fatty elevation locate anterior to pubic symphysis specialised part of the fatty layer of subcutaneous connective tissue amount of fat increases during puberty and decreases after menopause mons pubic also becomes covered with coarse pubic hairs during puberty and decrease after menopause Labia Majora two symmetrically folds of skin which provide protection for the urethra and vaginal orifice that opens into the vestibule of the vagina largely filled with subcutaneous fat passes posteriorly from mons pubis to about 2.5cm from the anus situated on either side of the pudendal cleft (slit between labia major into which vagina opens) meet anteriorly at the anterior labial commissure do not join posteriorly, but a fold of skin, called the posterior labial commissure, passes between them homologous to male scrotum Labia Minora thin, delicate folds of fat-free hairless skin located between labia major contain a core of spongy tissue with many small blood vessels and nerve endings enclose the vestibule of the vagina and lie on each side of the vaginal and urethral orifices meet just superior to the clitoris to form a fold of skin called the prepuce (clitoral hood) in young women, labia minora are usually united posteriorly by a small of skin, the frenulum of the labia minora, also known as the fourchette united anteriorly by the frenulum of the clitoris Clitoris 2-3 cm long, homologous to penis (erectile organ) not transversed by the urethra, so it has no corpus spongiosum consists of a root and body (composed of two crura) and a glans (same as the penis)
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highly sensitive to touch, pain and temperature

Perineum
urethra scrotum/labia penis/clitoris superficial perineal muscles Superficial Perineal Muscles
Superficial Transverse Perineal

     

slender, narrow strips of muscle run from ischial tuberosity to perineal body runs in median plane of perineum wraps around the base of the penis/clitoris function: compresses the base of the penis (assist erection, aid in evacuation of urine) surrounds crura of root of penis/clitoris function: forces blood into corpus cavernosa, compresses deep dorsal v.

Bulbospongiosus

Ischiocavernosus

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Clinical Anatomy
Myotonic Dystrophy
Symptoms progressive muscle weakness/wasting, no twitching/extra movements bilateral, affects distal muscles more than proximal difficulty speaking, swallowing, walking, climbing stairs, lifting objects could be caused by a problem with the UMN, LMN, NMJ or muscle reflexes weak, but may be due to muscle weakness (if normal probably excludes an UMN disease) muscle tone normal (spasticity, increased resistance expected in UMN) delayed relaxation after forced contraction – involuntary ongoing contraction - myotonia grip and percussion myotonia present weakness, wasting and myotonia all indicate a problem with the muscle Tests measure creatine kinase (leaks out from damaged muscle) and other enzymes EMG

 

muscle fibres randomly destroyed in primary muscle disease, motor units contain less fibres so signal is smaller and polyphasic in LMN diseases signals are big, broad and polyphasic because a single motor unit will take over fibres abandoned by dead nerves

Diagnosis most probably myotonic dystrophy most common form of muscular dystrophy (1/8000) caused by CAG in gene on chromosome 19 associated with other defects (eg. cataracts, testicular atrophy) myotonia without dystrophy can result in muscle hypertrophy‟

COPD
affects airways of lungs irreversible, progressive, includes airway hypoactivity usually caused by smoking The Patient when young, smoking was very popular and viewed as healthful 10 years ago spent a holiday in Surfer‟s in a medical centre with breathing problems after returning, visited specialist and GP and was put on medication immediately after holiday, didn‟t have much of a problem, but it progressively got worse at the moment, gets very breathless with only small amounts of exertion 50‟s forward exercises worked well for 18 months, but then she collapsed and ended up in Auckland Hospital
Hadley Wickham 33 15/11/09

now does about one hour of housework everyday as exercise got a nebuliser which is very helpful and provides a lot of emotional support doing very well this year up to about 2 months ago very careful about get bronchitis (flu vaccinations, warm clothing, staying away from sick people) children live overseas and when they visit there‟s a lot of excitement and gets very breathless used to travel a lot, but now feels unconfident because she is familiar with medicines at home and she can‟t stay with people who smoke (as many of her friends do) gets very tired at around 7:30 – 8:00 every night Lung Function can lose a lot of lung function before disability occurs FEV1 decreases steadily after the age of 25, and smoking accelerates this decline stopping smoking slows the decline lowered FEV1 required for diagnosis of COPD Breathlessness respiratory drive (O2,CO2, pH, K+) hyperventilating chest wall function (hyperinflated lungs, muscles get tired) physical factors (slight breeze, cold, dry air) psychological factors (anxiety, panic attacks, depression, isolation, effects of having an incurable disease) infection Respiratory Work increased by:

    

increased respiratory drive airway obstruction stiff airways hyperinflation muscle weakness/fatigue

Management smoking cessation eduction exercise avoid infection (flu vaccination, treat exacerbations) medicines oxygen (reserved for chronic hypoxia) (patients with <90% saturation eligible for long-term oxygen) COPD Medication bronchodilators (-agonists, anticholinergics, inhaled steroids) theophylline (mild bronchodilator, stimulates respiratory muscles) oral steroids (acute exacerbations only, major side effects) antibiotics (only used in infection)
Hadley Wickham 34 15/11/09

Polycystic Kidney Disease
Symptoms Timeline
Year 1977 Creatinine 0.07 CLCR 1.6 BP
120

Notes referred from GP tender mass on side of abdomen, very anaemic IVU showed many small and large bilateral kidney cysts diagnosed as adult polycystic kidney disease hereditary, but no family history (commonest genetic cause of kidney failure) no specific treatment

/80

1981 1982 1983 1986 1987 1989 1991 1994 1996 1998 0.285 .5 0.1 0.12 0.13 0.1

1.4
128

painful haematuria (probably caused by rupture of a cyst) /75 pain in loin region
140

/80

significantly raised bp compared with 10 years prior significant reduction in kidney function, but still feeling well

1
150

/95

treatment started for high blood pressure marked reduction in kidney function

0.2

Now



severe urinary tract infection earlier in the year

     

poor antibiotic penetration because of size of cysts and of kidney fever, pain, haematuria, low blood pressure, headache infection in kidney not bladder (no pain or increased need to pass urine) known complication of PKD

reasonably well, but often nauseous in morning (urea >30) restricted diet – low protein, low potassium and phosphate

 protein – keeps urea (toxic) levels down, small quantities of high quality protein  potassium – kidneys can‟t excrete very well, high levels bad for heart and muscle, take
potassium binders (Al(OH)3 or CaCO3),

 phosphate – excretion impaired, [Ca2+]  [PO43-] = k, so high PO43- lowers Ca2+ which is  

leached from the bones, parathyroid can become very active resulting in further Ca2+ loss, may have to be surgically removed

low energy and need lots of sleep breathlessness

 caused by anaemia (low Hb)  kidneys normally produce erythropoieten, which stimulates the bone marrow to produce
RBCs



muscle cramps, especially with hard physical work

 better since taking potassium binders  very very painful, often in feet and along the shins 
neurological problems (especially numbness of the feet) and itch (caused by waste production accumulating under the skin and causing irritation) also seen in other patients

Treatment dialysis/kidney transplant will be required at a later stage
Hadley Wickham 35 15/11/09

CAPD (Continuous Ambulatory Peritoneal Dialysis)

   

highly vascular potential space between visceral and parietal peritoneum good site for exchange of small molecules 2-3L of fluid poured in by a soft catheter, left in for four hours and drained has to be repeated 4 times a day (~10 minutes each time)
Side Effects

 diverticula in gut can leak bacteria  catheter site can become infected  peritonitis
Advantages

 very simple
Haemodialysis

         

blood flows (200-300 ml/min) into a dialysis machine flows along artificial membrane with dialysis fluid passing in opposite direction arterialised vein (eg. radial v. joined to radial a.) makes puncture easier temporary solutions through skin (eg. into neck) often cause complications best situation is limited help for the patient at a satellite centre 3 times a week (for about 6 hours) best solution immunosuppression techniques getting better high success rate (85-90%) kidneys from matched, immediate family members work best

Kidney Transplant

Molecular Genetics 1 in 3000 carry gene 3 genes linked to PKD
Chromosome PKD1 16 85% Frequency expressed in cell membrane may cause incorrect cell orientation PKD2 PKD3 4 ? 2nd most common common in Europe Notes produces the protein polycystine (unknown function)

Congenital Heart Defects
most common patients seen are those with ventricular septal defects there are four parts where the defect can occur

outlet septum (infundibulum) defects can result from

    

membranous septum inlet septum trabecular septum

deficiency of growth
36 15/11/09

Hadley Wickham

failure of alignment or fusion common defects are

   

perimembranous muscular (inlet or trabeculated) infundibular

Clinical Manifestations have to consider clinical manifestations in three patient groups: infant, child and adult
Infant

     
Child

fail to thrive – don‟t feed well, restless, weight loss/gain, recurrent infections small, active precordium (bouncy chest), loud pansystolic murmur tests: ECG (large RV), chest x-ray (RV hypertrophy, heart dilated, big juicy vessels in congested lungs), echocardiogram assess how big the hole is (with echocardiography or cardiac catheterisation)

 small shunts may spontaneously seal
provide supportive care (digoxin, diuretics) and wait until baby is as old as possible (18-24 months) pulmonary banding, placing a tight band around the pulmonary artery which increases pulmonary resistance and decreases flow, is a surgical treatment that can be used as stop gap fatigue, small stature active precordium, loud pansystolic murmur, 3rd heart sound, possible aortic regurgitation because unsupported valve starts to slip tests: ECG, chest x-ray, echocardiogram, cardiac catheterisation

  

 worst case: raised pulmonary vascular resistance, small pulmonary arterioles (have become
muscular because of increased pressure), raised RVP may have reversed shunt, surgical repair not practical because high RVP would prevent blood flow

 surgery: patch closure, or medical treatment if shunt is small
Adult
Maladie de Roger

 small VSD, left to right shunt, haemodynamincally unimportant  no symptoms, only sign is a heart murmur  only problems may be a roughening of the IVS, leading to possible colonisation by
bacteria causing infective pericarditis

 prophylactic antibiotic treatment before surgery etc., to prevent this from happening
Eisenmengers Complex

   

large VSD, high PVR, right to left shunt RV hypertrophy no treatment options except for combined heart-lung transplant death from cardiac arrhythmia or heart failure

Hadley Wickham

37

15/11/09

Heart Failure
inability of heart to meet metabolic demands of the body leading cause of death and hospital admissions in New Zealand (commonest cause MI) ischaemic heart disease and hypertension are the major causes of HF rheumatic can also cause failure (because of damage to muscle, valve, pericardium, rhythm) pneumonia, and other infections, can exacerbate the condition because of the greater demands on the heart very common for person to become depressed after major surgery or life threatening disease treatment given if there is endogenous depression on top of normal expected depression after stressful event can exercise within limits of physiological constrains Treatments angioplasty (repair lesions of coronary arteries using balloons) ACE inhibitors and frusemide – controls heart failure provastatin when HF is under adequate control with drugs (ACE inhibitors, frusemide, soluble aspirin)

  

sleepy in afternoon sometimes feel very exhausted – overexhaustion no angina after MI because infarct destroys area giving pain (indicates extensive MI)

Symptoms fatigue breathlessness (fluid in lungs) oedema (fluid leaks out of high venous pressure) anorexia, loss of appetite ascites, congested liver gut oedema, thick walled, boggy – can‟t assume medicines will be absorbed impotence (vascular disease, medication, psychological factors) Clinical Findings HR 120 (resting tachycardia) blood pressure 90/60 (very low) JVP +12cm (volume overload, oedema in feet) apex beat laterally displaced (anterior axillary line, 6th ICS), diffuse lungs wet, with crackles and pleural effusions wide heart (cardiothoracic ratio greater than 50%) LV dilated, overall LV function severally depressed weight gain because of fluid overload



Hadley Wickham

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