Anatomy and Physiology
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Anatomy and Physiology
Notes for Lecture
Practice Exam Questions
Practice Lab Practicals
General Anatomy and Physiology Links
PGCC Anatomy and Physiology Page
Anatomy & Physiology Study and Exam Questions.pdf[/HIDE]
Last edited by trimurtulu; 09-29-2008 at 09:24 AM.
thank you very much
1 Brain 101
• Clinical Examination of the Abdomen
• Anterior Abdominal Wall
• Inguinal Region
• Summary by Gut Derivatives
• Small Intestine
• Large Intestine
• Abdominal Vasculature
• Nervous System
• Posterior Abdominal Wall
• Kidneys and Suprarenal Glands
• Lymphatic System
CLINICAL EXAMINATION OF THE ABDOMEN
Two kinds of pain:
• Visceral Pain: Deep, throbbing, delocalized pain, associated with the visceral organs.
• Somatic Pain: Sharp, piercing, pain localized to the abdominal wall.
Abdominal Medical History: (pqr)2st3
• P -- Provoking: What have you noticed that makes this pain worse?
• P -- Palliating: What relives the pain?
• Q -- Quantity: How much pain are you having?
• Q -- Quality: What does the pain feel like?
• R -- Region: Where is the pain?
• R -- Radiation: Does the pain go (radiate) to any other locale?
• S -- Severity: How does it keep them from doing what they normally would do?
• T -- 3 time related questions
o Did the pain just start (suddenly) or come on gradually?
o Is the pain constant or does it come and go?
o Is the first time you ever had this or have you noticed anything like this before?
OBSERVE: Watch patient walk to table. Look for visible pain and discomfort. Note vital signs, stretch marks, scars, vascular
• Listen for fluid sounds -- mix of fluid and gas mixing by peristalsis.
o If you hear nothing, listen up to five minutes before concluding there are no bowel sounds. It can take a while.
• Listen for blood flow. In some slender people you can hear turbulent flow.
• Listen for Friction Rub, which occurs when inflamed organs rub next to each other.
• Listen for transmission of sounds from chest.
PERCUSSION: Best way to examine liver is by percussion, to feel for borders. Can percuss for spleen to determine if it is
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PALPATE: Feel all major organs for inflammations, abnormalities, position, etc.
• Midsagittal Plane: Vertical line going through the middle of the abdomen.
• Transumbilical Plane: Horizontal line going through the umbilicus.
• Four Quadrants based on those planes:
o Right Upper Quadrant: RUQ
o Right Lower Quadrant: RLQ
o Left Upper Quadrant: LUQ
o Left Lower Quadrant: LLQ
• Vertical lines of division: Left and Right Mid-Clavicular Lines
• Horizontal lines of division:
o Transpyloric Plane: Sometimes used. It is halfway between the jugular notch and the pubic bone.
o Subcostal Plane: Upper plane, passing through the inferior-most margin of the ribs.
o Transtubercular Plane: The line transversing the pubic tubercle.
o Upper: Right Hypochondriac, Epigastric, Left Hypochondriac
o Middle: Right Lumbar, Umbilical, Left Lumbar
o Lower: Right Inguinal, Hypogastric (Suprapubic), Left Inguinal
ANTERIOR ABDOMINAL WALL
Boundaries of the Abdomen:
• Superior Boundary: The diaphragm. It extends to ICS-5 superiorly (at the median line; it is more inferior around the
o Hence the superior limit of the liver is also ICS5 since it push up into the diaphragm.
• Posterior Boundary: Lumbar Vertebrae, and Quadratus Lumborum and Transverse Abdominis muscles.
• Anterolateral Borders: The muscles of abdominal wall: transversus abdominis, and internal and external abdominal
• Inferior Borders: The Pelvic Brim
PELVIC BRIM: Inferior border of the abdomen.
• It consists of the Right and Left Coxal Bones.
o Each coxal bone is made up of an ilium, ischium, and pubic bone.
• Iliac Crest: The superior portion of the iliac bone. The Iliac Tubercles are bony prominences on the iliac crest.
• Anterior Superior Iliac Spine (ASIS): The anterior most feature on the iliac crest.
• Pubic Tubercle: Lateral edge of pubic bone.
• Inguinal Ligament: Found between the ASIS and the pubic tubercle, running in the same direction as the ASIS.
o The femoral vessels and the inguinal canal are both related to the inguinal ligament.
o Formed from aponeurosis part of the external abdominal oblique.
UMBILICUS: Found between L3 and L4 in physically fit persons.
Grandparents Like Pediatric Doctors Preventing Kids Sickness: One Transpyloric Plane -- The Transpyloric plane passes
through L1 and contains the following structures:
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• Pylorus of Stomach
• Duodenal Bulb (Duodenum I)
• Pancreas Body and Tail
Processus Vaginalis: The portion of peritoneum that remains with the testes when they descend into the scrotum.
• Anything that pushes through the anterior abdominal wall will become invested with peritoneum.
• The testes push through the wall, but normally a piece of peritoneum is left behind as the processus vaginalis.
• When the testes descend, the peritoneum goes with it and then scales back. The portion of peritoneum that remains with
the testes is called the processus vaginalis.
7 Layers of the Abdominal Wall:
o Epidermis -- the part we shed
o Dermis -- contains nerves, capillaries, sweat glands, hair follicles.
Has collagen fibers that tend to be horizontal, forming the creasing of the skin. These are called
In surgery, you should cut with Langer's Line, the direction of the collagen, so as to minimize surgical
• Superficial Fascia -- Connective tissue that is not aponeurosis, tendon, or ligament. This is the same thing as the
o Camper's Fascia: Fatty layer, first of the two layers. It is found throughout.
o Scarpa's Fascia: Lower layer, found in the lower 1/3 of the anterior abdominal wall. It has a restrictive location,
defined by the extent of damage occurring with a straddle injury.
The area is restricted to the anterior abdominal wall.
Lateral Limit: Basically the inguinal ligament, where it intersects with fascia lata, so that fluid
does not pass into the thigh.
Inferior Limit = the base of the scrotum.
Posterior Limit = it goes back to the anus, and fills the pelvis in between.
The outlined region is called the superficial perineal space.
It is called different fascia at different places: Dartos Fascia in scrotum / labia majora, and Colles
Fascia around perineum.
o Fundiform Ligament: The false suspensory ligament of the penis or clitoris. It is an extension of superficial
• Deep Fascia
o A true suspensory ligament occurs in the deep fascia layer, which extends into the penis / clitoris. So, we have
both a true suspensory ligament (deep fascia) and a false one (fundiform ligament / superficial fascia).
o Deep fascia encompasses all muscles of the entire body.
• Muscles -- Three flat muscles plus the longitudinal rectus sheath muscle.
o External Abdominal Oblique -- muscle fiber direction is antero-inferior (like external intercostals -- hands in
Originate at border of Thoracic ribs T5 - T12
Extends to midline and attaches on linea alba. Also attaches to the iliac crest.
Again, the aponeurosis portion of the externals form the inguinal ligaments.
Also forms the superficial inguinal ring, which allows passage of the spermatic cord (male) or round
Superficial Inguinal Ring is made up of two components, lateral crus and medial crus.
Intercrural fibers separate the two.
o Internal Abdominal Oblique
Also has fibers that attach along the inguinal ligament to the pubic crest.
Direction of fibers tends to go outward, from medial to lateral and a little bit inferiorly (inferolaterally).
Borders on ribs 7 - 12.
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The aponeurosis splits and goes both anteriorly (to merge with external aponeurosis) and posteriorly (to
merge with transversus aponeurosis)
o Transversus Abdominis Deep most layer of flat muscles.
Also borders on ribs 7 - 12. Extends down to the pubic crest and medially to the linea alba.
It creates a diagonal pathway for the spermatic cord or round ligament to pass through.
Fibers run transversely! -- horizontally from lateral to medial.
o Rectus Abdominis: Straight muscle.
Passes from Xiphoid Process inferiorly to pubic symphysis (inferior center of pubic bone).
Rectus Sheath holds this rectus muscle in place. It is directly shallow to it, formed by the aponeuroses
of the three flat muscles. It has a posterior and anterior layer, formed from the aponeuroses of the three
Upper 3/4 of Abdominal Wall: All three muscle layers converge on rectus sheath, and pass
both anteriorly (external aponeurosis) and posteriorly (transversus aponeurosis).
This part of the wall is suturable in surgery.
Lower 1/4 of abdominal wall is transversalis fascia. Here, all three muscle layers pass
anteriorly. Here it is called transversalis fascia.
This part of the wall is not suturable in surgery.
Arcuate Line: The line that divides the upper 3/4 of abdomen from lower 1/4, by the differences in the
Transversalis Fascia -- Deep fascia on the interior (deep) surface of the transversus abdominis muscle.
Esp. found in the lower 1/4 of the abdomen.
o It has several names, but it is one continuous plane of fascia, just outside the peritoneum.
o As a continuous plane, it is also an avenue for infection.
• Subserous Fascia
• Peritoneum: A serous membrane that secretes fluid, thus allowing internal organs frictionless movement.
Linea Alba: The best place to make a surgical cut and not hit any nerves is straight down the linea alba.
NERVOUS SUPPLY of Anterior Wall: Ventral Rami of T7 - T12, and L1.
• Dermatomes: How nerves innervate the anterior abdominal wall -- in sections.
• Referred Pain: Example
o T10 goes to umbilical region.
o Appendicitis pain will go to sympathetic nervous system ------> refers back to T10. When rupture occurs, toxins
are released and irritate the peritoneum, resulting in a localized effect.
• Ilioinguinal Nerve: Goes through the inguinal canal, with the spermatic cord (male) or round ligament (female).
o Supplies scrotum (or labia majora) and medial aspect of thigh.
• Iliohypogastric Nerve: Directly superior to ilioinguinal nerve.
o Innervates the suprapubic area.
• Both Ilioinguinal and Iliohypogastric may come off as a single nerve and branch later.
McBurney's Point: The point of surgical incision for an appendectomy.
• Is located on a line along the ASIS. The iliohypogastric nerve is right there, about 1cm superior to the ASIS, so that is the
nerve that ya gotta be weary of when doing an appendectomy.
ARTERIAL SUPPLY of Anterior Wall:
• Superior Epigastric Artery -- Runs directly over rectus abdominis muscle.
• Inferior Epigastric Artery
• Superficial Epigastric Artery
VENOUS SUPPLY of Anterior Wall: The same as the veins above.
• When using a needle to drain peritoneal fluid, do not hit the Superior or Inferior epigastric veins! The result would be
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Inguinal Canal: Formed from the aponeuroses of the three flat muscles.
• It a diagonal passage. Most tubular structures pass through membranes diagonally, as the ureters and fallopian tubes do.
o This provides reinforcement on the wall of the structure being entered.
• Contents of Inguinal Canal
o Spermatic Cord (male) or Round Ligament (female)
o Ilioinguinal Nerve
o Genital Branch of the Genitofemoral Nerve.
Inguinal Triangle (Hesselbach's Triangle): An area of weakness in the aponeurosis, where direct hernias can occur.
o The lateral margin of the rectus muscle (aka semilunaris)
o The Inferior Epigastric Artery
o The Inguinal Ligament
• CONJOINT TENDON: The space of membrane where the transversus abdominis and internal oblique aponeuroses join
into one. It is an area of weakness in the abdominal wall.
HERNIAS: The protrusion of intraperitoneal guts outside of the peritoneum (i.e. through the peritoneal wall).
• DIRECT INGUINAL HERNIA: Gut goes straight through the inguinal triangle, through the conjoint tendon.
o It will be located medial to the inferior epigastric artery
• INDIRECT INGUINAL HERNIA: Hernia that passes through the inguinal canal and originates lateral to the inferior
o Congenital Indirect: The weakness was present at birth.
Agenesis: Absence of growth or closure of some part of the abdominal wall.
Dysgenesis: Incorrect or dysfunctional growth.
o Acquired Indirect:
Ascites -- (fluid buildup in peritoneum)
• Diaphragmatic Hernias:
o HIATAL HERNIA: Distal end of the esophagus can draw itself back into the eosphageal hiatus, pulling part of
the stomach with it.
Referred pain from a hiatal hernia occurs in Epigastric region, around T7-T8.
o Semilunar Hernias: Occur along the rectus sheath and arcuate lines, mostly.
Spleen: It is actually mesodermal in origin, not endodermal like the rest of the abdominal organs.
Retroperitoneal Space: The area behind (posterior to) the peritoneum. Any organs not completely (or almost completely) covered
by peritoneum are considered retroperitoneal organs.
Abdominal Cavity: Everything but the lateral, posterior, and anterior body walls of the abdomen, including both the peritoneal
cavity and the retroperitoneal space.
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Peritoneal Cavity: That part of the abdomen invaginated by peritoneum.
• Peritoneum has visceral and parietal layers, just like the pleural cavity. It is analogous to the organs pushing themselves
into the peritoneum, like a fist into a balloon.
o Visceral Peritoneum: Peritoneum directly on the organs.
o Parietal Peritoneum: Peritoneum surrounding the interior lining of the abdominal wall.
• MALES: The peritoneal cavity is CLOSED.
• FEMALES: The peritoneal cavity is OPEN. It opens out into the cervix and vagina, making it a potential space for
pathogens to enter.
• Peritoneum should be considered a potential space for pathogens and fluids to build up.
Subphrenic Recess: The recess where the peritoneum reflects off the liver (right side) on the inferior surface of the diaphragm.
• It contains the coronary ligament of the liver.
OMENTA: Peritoneum surrounding the stomach
• Lesser Omentum: Peritoneum along the lesser curvature of the stomach, covering the pancreas. It is superior and medial
to the stomach and posterior to parts of the liver, and anterior to pancreas.
o Lesser Omental Bursa / Lesser Peritoneal Sac: The space between the stomach and the liver. The space
anterior to the lesser curvature of the stomach and posterior to the liver.
• EPIPLOIC FORAMEN: A pathway that allows entrance from the lesser peritoneal sac to the greater peritoneal sac.
o The Inferior Vena Cava goes directly posterior to it (retroperitoneal).
o The portal triad is directly anterior to it, in the peritoneum, along the lesser curvature of the stomach.
• Greater Omental Bursa: The space between the stomach and anterior abdominal wall.
o Greater Omentum: The space formed by the peritoneum on the anterior surface of the stomach and the anterior
It attaches to the stomach and to the transverse colon.
Anterior Layer of Greater Omentum: The parietal peritoneum of the abdominal wall.
Posterior Layer of Greater Omentum: The visceral peritoneum along the greater curvature of the
Superior Recess: Where the Lesser Omentum stops at the coronary ligament of the liver and reflects back onto the liver.
Essentially, the space between the stomach and
Inferior Recess: Along the greater curvature of the stomach, where the greater omentum reflects onto the transverse mesocolon.
Essentially, the space between the stomach and transverse colon, inferior to the stomach.
Intra-Peritoneal Organs: Organs completely or almost completely enclosed by peritoneum.
• Gall Bladder
• Transverse Colon: completely
• Cecum (very start of ascending colon)
Retro-Peritoneal Organs: Organs that are located mostly or completely behind the posterior parietal peritoneum.
• Ascending Colon (only 25-50% covered)
• Descending Colon (only 25-50% covered)
• Sigmoid Colon
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• Great Vessels and their primary branches: Abdominal Aorta and Inferior Vena Cava, Celiac Trunk, and Superior and
Inferior Mesenteric arteries and veins.
Mesentery: Two layers of peritoneum opposing each other. Vessels and nerves often lie in the mesentery, where they can easily
reach the organ where the peritoneal layers separate and reflect off the organs.
• THE Mesentery: The one that connects the small intestine to the posterior abdominal wall.
o The root of the mesentery is where the Mesentery connects to the posterior wall.
• Transverse Mesocolon: Specific mesentery connecting the transverse colon to the posterior peritoneum.
• Sigmoid Mesocolon: Specific mesentery connecting the sigmoid colon to the posterior peritoneum.
The Anterior Surface of the Diaphragm:
• Vena Caval Foramen: Hole for the Inferior Vena Cava, where it passes to the liver.
o Around T8
o It is located in the central tendon (superior most part) of the diaphragm.
• Eosphageal Hiatus: Opening that admits the esophagus, guarded by two muscles left crus and right crus.
o Left Gastric Artery and Left Gastric Vein also pass through the eosphageal hiatus.
o Passes through at T10.
• Aortic Hiatus: Is actually posterior to the diaphragm -- not really a hole in the diaphragm.
o Thoracic Duct goes posterior through this opening as well as aorta.
o About Level 12, at lower most part of diaphragm.
• Lumbocostal Arches: Transversalis Fascia on the posterior wall of the diaphragm. Sympathetic Ganglia come through
along these arches.
SUMMARY ACCORDING TO THE GUTS
o 1st two parts of the duodenum: Duodenal Cap and Descending Duodenum.
o Gall Bladder
• ARTERIAL VASCULAR SUPPLY
o Branches of the Celiac Trunk
• LYMPHATIC SUPPLY
o Branches of the Celiac Nodes
• REFERRED PAIN: Occurs in the Epigastric Region.
• VENOUS RETURN: The portal vein.
o Parasympathetic: From Vagus nerve (C10). It is perivascular -- it follows the blood vessels.
o Sympathetic: From the Greater Thoracic Splanchnic Nerves (T6-T10)
o Third and fourth parts of duodenum: Horizontal and Ascending Duodenum.
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o Ascending Colon
o First 2/3 of Transverse Colon
• ARTERIAL VASCULAR SUPPLY
o Branches of the Superior Mesenteric Artery
• LYMPHATIC SUPPLY: Branches of the Superior Mesenteric Nodes.
• REFERRED PAIN: Occurs in the Umbilical Region
• VENOUS RETURN: The Superior Mesenteric Vein.
o Parasympathetic: From Vagus nerve (C10). It is perivascular -- from the blood vessels.
o Sympathetic: From the Lesser Thoracic Splanchnic (T9-T11,L1)
o Distal 1/3 of Transverse Colon
o Descending Colon
o Sigmoid Colon
o Upper portion of anal canal.
• ARTERIAL VASCULAR SUPPLY
o Branches of the Inferior Mesenteric Artery
• LYMPHATIC SUPPLY: Branches of the Inferior Mesenteric Nodes.
o Exception: The upper and lower rectum go to the Right and Left Common Iliac nodes, which then drains straight
to the Lumbar Chain Nodes, and then to Thoracic Duct.
• REFERRED PAIN: Occurs in the Hypogastric (Suprapubic) region.
• VENOUS RETURN: The Inferior Mesenteric Vein.
o Parasympathetic: From Pelvic Splanchnic Nerves (S2-S4).
o Sympathetic: From the Upper Lumbar Splanchnic (L1-L2)
• Stomach begins as a mere dilation of the primitive gut tube.
• It undergoes two basic processes: differentiation and rotation.
• Initially tube attaches to dorsal and ventral walls via dorsal and ventral mesenteries.
o Ventral Mesentery eventually becomes lesser omentum.
o Dorsal Mesentery (Dorsal Mesogastrium) eventually becomes greater omentum.
• Rotation: Then the whole structure rotates 90 to the right, dragging the mesentery along with it.
o The dorsal mesentery becomes the left side of the body, and the posterior of the stomach becomes the left lateral
• Differential Growth: Then differential growth produces the fundus, the greater curvature, and the lesser curvature of the
LOCATION: The pylorus of the stomach at the level of L1, in the transpyloric plane.
• Generally in the right epigastric region, but the location varies depending on position, weight, physiology, etc.
• Cardia: Superior part nearest the esophagus.
• Fundus: That part of the stomach that is actually superior to the abdominal esophagus.
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o Gastric Bubble is located here in radiographs, if person is upright.
o Cardiac Notch is a radiographic feature of being able to see the fundus part of the stomach.
• Body: The main part of the stomach consisting of the greater and leser curvatures.
o Greater Curvature: Inferior border of stomach body.
o Lesser Curvature: Superior border of stomach body.
• Pyloric Region: The most distal part of the stomach, at level of L1, leading into duodenal cup.
• Gastrocolic Ligament: On greater curvature of stomach, attaching to transverse colon. It is part of the greater omentum.
• Gastric Canal: Impression along the lesser curvature of the stomach, on the interior.
o Rugae here are more longitudinal, to guide food to the pylorus.
• Cardiac Opening: The opening at the proximal end, aka the esophogastric junction.
o No true sphincter here.
• Rugae: Mucosal folds of internal wall of stomach. They increase the surface area available for digestion.
• Pyloric Antrum:
• Pyloric Canal: The distal region of the body, in the pyloric zone, leading to pylorus.
• Pyloric Sphincter: At the pylorus, it is a true sphincter controlling flow of chyme into the duodenum.
• The left lobe of the liver overlies the anterior portion of the stomach.
• Spleen is lateral to the stomach, just off the greater curvature.
• The greater omentum is inferior to the stomach (just off greater curvature), and the transverse colon lies directly deep to
• Posterior to Stomach:
o The lesser peritoneal sac.
o The pancreas, with the duodenum surrounding it.
• Bed of the Stomach: Those organs upon which the stomach lies.
o The pancreas, spleen, transverse colon, and a portion of the kidney and suprarenal glands.
• Gastric Bubble can be seen in stomach on X-rays, in the fundus region.
• Stomach Carcinoma is usually in the pyloric region or lower body, close to the pyloric lymph nodes.
• Gastric (Peptic) Ulcers: Acid secretion in stomach.
o Gastroduodenal Artery, posterior to pyloric area, can be affected by an ulcer if the wall is eroded.
VASCULAR / LYMPH SUPPLY:
• Pyloric Lymph Nodes drain to the Celiac Nodes.
• Right and Left Gastric Arteries supply the lesser curvature of the stomach. They come off of the Celiac Trunk, via the
common or proper hepatic arteries.
• Right Gastroepiploic supplies greater curvature, from the gastroduodenal, from the proper hepatic.
• Left Gastroepiploic supplies greater curvature, from the Splenic Artery, from the Celiac Trunk.
DEVELOPMENT: It is mesodermal -- not derived from gut (i.e. nongut)
• It grows within the two layers of peritoneum going to the posterior wall -- within the two folds defining the dorsal
• As the stomach rotates, the spleen is moved to the left of the stomach (lateral to stomach)
• The dorsal mesogastrium in this region becomes the gastrosplenic ligament.
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• Posterior part of mesogastrium adheres to the posterior wall, and the left kidney will then lie directly deep to it. This
portion of the mesentery becomes the splenorenal ligament.
LOCATION: Upper left quadrant, left hypochondriac region, articulated with ribs 9-11 (laterally).
EXTERNAL MORPHOLOGY: It has three grooves (surfaces)
• Renal Surface
• Gastric Surface
• Colic Surface: Anterior / Inferior extremity.
• Hilus: Contains the splenic artery and vein, near the splenorenal ligament.
• Kidney is deep to it, connected by splenorenal ligament.
• Stomach is medial to it, connected by gastrosplenic ligament.
VASCULAR / LYMPH SUPPLY:
• Splenic Artery and Splenic Vein come into the hilus.
DEVELOPMENT: Duodenum is the dividing point between the foregut and midgut.
• It forms in response to the rotation of the stomach.
LOCATION: It is retroperitoneal. (The first portion is actually intraperitoneal, but we won't count that).
• Umbilical Region, and Medial parts of the Left and Right upper quadrants.
EXTERNAL MORPHOLOGY: It is a C-Shaped portion of the gut.
• Duodenal Bulb (I) (foregut) (at about the level of LV1 -- the transpyloric plane)
o Hepatoduodenal Ligament: There is a ligament which is part of lesser omentum.
o This ligament is the sign of peritoneum surrounding the duodenum, hence we will consider the whole duodenum
• Descending Duodenum (II) (foregut) (LV2)
• Horizontal Duodenum (III) (midgut) (LV3)
• Ascending Duodenum (IV) (midgut) (LV2-3)
o Ligament of Treitz: Attaches the fourth part of the duodenum to the right crus of the diaphragm. It goes
posterior to the pancreas. Essentially attaches duodenum to posterior wall.
It is the Suspensory Muscle of the Duodenum -- function to hold duodenum opened / closed for passage
of food into Jejunum.
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• Duodenal Bulb is smooth internally, while the rest of it is rough with mucosal folds.
• Plicae Circulares: The name of the folds on the distal three parts of duodenum.
• Hepatopancreatic Duct: Anastomose of the common bile duct and pancreatic duct onto the duodenum. It joins at the
second part of the duodenum.
• Major Papilla: The opening into the common bile and pancreatic ducts.
o The pancreatic duct usually joins the common bile duct before it reaches the major papilla.
• Minor Papilla: Another duct opening.
• Ampulla (of Vater): Ductule right at the major papilla, which holds bile and pancreatic enzymes.
• The pancreas lies in the internal curvature of the C-Shape.
• Duodenal bulb is in transpyloric plane.
• Superior Mesenteric Artery usually passes over the horizontal duodenum.
• Renal Artery and Vein passes posterior to the ascending (fourth part of) duodenum.
• Aorta: The fourth part of the duodenum lies on the Aorta. Aorta is posterior to duodenum.
• Transverse Mesocolon: Inferior aspect of transverse colon. It covers the pancreas, and crosses the duodenum at the
fourth part (ascending, and most medial part).
• Portal Triad: Common Bile Duct, Portal Vein, Proper Hepatic Artery.
o They are located posterior to the duodenal bulb.
o They are within the free edge of the lesser omentum (hepatoduodenal ligament).
• Pancreas: Within the C-Shape of the duodenum. The head of the pancreas lies posterior to the descending and horizontal
• Duodenal Atresia: Lack of development of duodenum.
• Duodenal Stenosis: Clogging of duodenum.
• Vomiting: Look for bile as a sign of where the obstruction occurred. If there is bile, then it was the lower duodenum
(distal to duodenal papilla), if not, then it was the proximal duodenum (proximal to papilla).
• Duodenal Ulcer: Posterior aspect of the duodenal bulb, if the wall is broken, hemorrhaging can occur as it invades the
o Four times more prevalent than peptic ulcers.
• Paraduodenal Hernia: The Paraduodenal Recess lies just posterior to the fourth part of the duodenum. A portion of
duodenum and ilium can herniate there.
o The inferior mesenteric vein is right there, and can be ruptured as a result.
• Enterogastrone: Is released by duodenum to decrease the peristalsis and acidity of material coming from stomach.
• Cholecystitis: Inflammation of gall-bladder, where bile is stored. Duodenum can form adhesions, etc., from what was
• Referred Pain: Pain referred in duodenum is generally referred to umbilical region, through the greater thoracic
VASCULAR / LYMPH SUPPLY:
• Supplied by both the Celiac Artery (foregut parts) and Superior Mesenteric Artery (Midgut parts).
• Gastroduodenal Arteries: Come from the celiac trunk ultimately.
o Celiac Trunk ------> Common Hepatic ------> Gastroduodenal.
• Hepatic Arteries: Proper Hepatic and Left Hepatic come off of the Common Hepatic Artery.
• Superior Mesenteric Artery and Vein passes over last half (midgut portions) of the duodenum.
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• Starts out with a dorsal and ventral pancreatic bud on either side of the duodenum.
• The ventral bud rotates 180 and joins the dorsal bud.
• The stalk to the ventral bud becomes the major papilla
• The main pancreatic duct is formed from both dorsal and ventral buds.
• Annular Pancreas: The pancreatic lobes migrate around duodenum in the wrong direction and fuse with each other,
strangling the duodenum.
o Can completely block or at best result in stenosis of duodenum.
• Umbilical, Epigastric, and left hypochondriac regions.
• It traverses diagonally from the descending (second) duodenum all the way over to the spleen.
• Head -- snug up against the second and third parts of duodenum.
o Lower portion extending inferiorly from the head is the uncinate process.
• Neck -- directly anterior to superior mesenteric artery and veins, and the portal vein.
• Tail: The tail of the pancreas extends into the splenorenal ligament, associated with the spleen.
• There is a main pancreatic duct running down the center of the organ.
RELATIONSHIPS: Also see external morphology
• The root of the transverse mesocolon runs along the longitudinal axis of the pancreatic, directly anterior to it. (So the
transverse colon lies on top of it).
• Left Adrenal Gland and Left Kidney are just posterior to the body and tail of the pancras.
• Referred epigastric pain could be the pancreas or the gallbladder. If the pain wraps around the the posterior, too, then the
bile duct is probably compressed (stenosis) which could be more serious than just gallbladder.
• Pancreatitis: causes
o Gallstones can block the major papilla in the duodenum. This would cause bile to backflow into the pancreas.
o A stenosis in the pancreaticohepatic duct can cause acid chyme to backflow into the pancreas.
o The stones may block both common bile and pancreatic ducts above, causing both to backflow into pancreas.
VASCULAR / LYMPH SUPPLY:
• Superior Pancreaticoduodenal Arteries (Anterior and Posterior): These come off of the common hepatic, in turn off
of the Celiac Trunk.
o They also anastomose with the Right Gastroepiploic.
o They supply the head, generally.
• Great Pancreatic Artery, and Inferior Pancreatic Artery, come off the Splenic Artery, from the Celiac Trunk.
o Supplies body and tail.
13 Brain 101
DEVELOPMENT: Foregut, closely associated with primitive cystic and pancreatic ducts.
• Starts out as the hepatic diverticulum.
• Hepatic Duct elongates throughout development and joins with cystic duct to form common bile duct in the adult.
• The liver elongates into the septum transversum during development.
o It continues to grow into the diaphragm later, to create the bare area of the liver -- the part that has no
peritoneum covering it.
• The omental foramen is a free border of the lesser omentum. The portal triad travels through this hole.
• The ventral mesentery in the embryo reduces to become the falciform ligament i the adult.
• PRENATAL CIRCULATION: The liver is basically bypassed.
o Ductus Venosus: In the embryo, it connects the umbilical vein with the hepatic vein and inferior vena cava. It
shunts blood going through the liver so that it really doesn't perfuse the liver, but rather bypasses right to the
inferior vena cava.
o Blood going through much of the embryonic portal vein system is shunted through the ductus venosus.
o After birth, the ductus venosus closes and its remnants become the ligamentum venosum, the ligament on the
inferior, posterior aspect of the liver.
o The Round Ligament is what remains of the umbilical vein. It hangs down fro the falciform ligament.
• The liver is not covered in the area of the falciform ligament attachment.
• Highest point is the right lobe. It rises to the 5th intercostal space.
o Coronary Ligament: Reflection of peritoneum off the posterior surface of the liver, with the diaphragm.
A bare area is created by the reflection of the coronary ligaments on the diaphragm. The bare area
touches the diaphragm.
o Right and Left Triangular Ligaments: Part of the Coronary Ligament. Formed by the two layers of
peritoneum extending laterally.
o Falciform Ligament: Liver's reflection of peritoneum with anterior wall. The primitive ventral mesentery.
o Round Ligament (Ligamentum Teres Hepatis) hangs down from the falciform ligament, on the anterior side.
o Ligamentum Venosum: Posterior side of liver, separating the two lobes. It continues superiorly (on the
posterior side) all the way to the superior margin of the liver.
• Lobes: The two lobes are separated by the falciform ligament.
o Left and Right Lobes: The functional lobes of the liver, demarcated by an imaginary line going between the
inferior vena cava (superior part) and the gall bladder (inferior part).
The right lobe is the larger lobe, extending superiorly to the fifth ICS when supine.
The left lobe is the smaller lobe.
o Caudate and Quadrate Lobes: Both on the posterior side, surrounding the porta hepatis (i.e. portal triad).
Caudate Lobe is directly superior to the porta hepatis. Part of the functional left lobe of the liver.
It is closest to the vena cava.
Quadrate lobe is directly inferior to the porta hepatis, also part of the left lobe of the liver.
It is closest to the gall bladder.
• Peritoneal Reflections
o Subphrenic Recess: Recess created by coronary ligament reflecting off the diaphragm.
o Hepatorenal Recess: Recess between the right lobe of the liver and right kidney.
o Diaphragmatic Surface: The surface of the liver facing the diaphragm. Smooth.
o Visceral Surface: The posterior and left surfaces facing the stomach, duodenum, gall bladder, and pancreas.
14 Brain 101
• Porta Hepatis: The hole going through the posterior side of the right lobe, containing the portal triad of vessels:
o Portal Vein
o Common Bile Duct
o Proper Hepatic Artery.
• Difference between functional (surgical) and anatomical lobes: anatomic lobes are divided by the falciform ligament.
Functional lobes (as above) are divided by the imaginary line between the gall bladder and IVC.
o Each functional lobe is supplied by different vessels.
• Inferior Vena Cava: Goes over the reflection of the coronary ligament, through the bare area, on the superior posterior
aspect of the liver.
• Subphrenic Recess: Air can collect in there as a result of surgeries.
• Hepatorenal Recess: This is the lowest area for fluid to collect in the upper abdominal cavity, when the patient is in
ANATOMY—HIGH-YIELD CLINICAL VIGNETTES
These abstracted case vignettes are designed to demonstrate the thought processes necessary to answer multistep clinical reasoning questions.
_ Baby vomits milk when fed and has a gastric air bubble → what kind of ﬁstula is present? →
blind esophagus with lower segment of esophagus attached to trachea.
_ 20-year-old dancer reports decreased plantar ﬂexion and decreased sensation over the back of her thigh, calf, and lateral half of her foot → what spinal nerve is involved? → tibial.
_ Patient presents with decreased pain and temperature sensation over the lateral aspects of both arms → what is the lesion? → syringomyelia.
_ Penlight in patient’s right eye produces bilateral pupillary constriction. When moved to the left eye, there is paradoxical bilateral pupillary dilatation → what is the defect? → atrophy of the left optic nerve.
_ Patient describes decreased prick sensation on the lateral aspect of her leg and foot → a deﬁcit in what muscular action can also be expected? → dorsiﬂexion of foot (common peroneal nerve).
_ Elderly lady presents with arthritis and tingling over lateral digits of her right hand → what is the diagnosis? → carpal tunnel syndrome, median nerve compression.
_ Woman involved in motor vehicle accident cannot turn head to the left and has right shoulder droop → what structure is damaged? → right CN XI (runs through jugular foramen with CN
IX and X), innervating sternocleidomastoid and trapezius muscles.
_ Man presents with one wild, ﬂailing arm → where is the lesion? → contralateral subthalamic nucleus (hemiballismus).
_ Pregnant woman in third trimester has normal blood pressure when standing and sitting. When supine, blood pressure drops to 90/50 → what is the diagnosis? → compression of the inferior vena cava.
_ Soccer player who was kicked in the leg suffered a damaged medial meniscus → what else is likely to have been damaged? → anterior cruciate ligament.
_ Gymnast dislocates her shoulder anteriorly → what nerve is most likely to have been damaged?
→ axillary nerve.
_ Patient with cortical lesion does not know that he has a disease → where is the lesion? → right parietal lobe.
_ Child presents with cleft lip → which embryologic process failed? → fusion of maxillary and medial processes.
_ Patient cannot protrude tongue toward left side and has a right-sided spastic paralysis →where is the lesion? → left medulla, CN XII.
_ Teen falls while rollerblading and hurts his elbow. He can’t feel the median part of his palm →
which nerve and what injury? → ulnar nerve due to broken medial condyle.
_ 24-year-old male develops left testicular cancer → metastatic spread occurs by what route? →
para-aortic lymph nodes (recall descent of testes during development).
_ Field hockey player presents to the ER after falling on her arm during practice. X-ray shows midshaft break of humerus → which nerve and which artery are most likely damaged? → radial nerve and deep brachial artery, which run together.
ANATOMY—HIGH-YIELD GLOSSY MATERIAL
_ Carotid angiography → identify the anterior cerebral artery → occlusion of this artery will pro- duce a deﬁcit where? → contralateral leg.
_ H&E of normal liver → identify the central vein, portal triad, bile canaliculi, etc.
_ X-ray of fractured humerus → what nerve is most likely damaged? → radial nerve.
_ X-ray of hip joint → what part undergoes avascular necrosis with fracture at the neck of the fe- mur? → femoral head.
_ Abdominal CT cross-section → obstruction of what structure results in enlarged kidneys? →
inferior vena cava.
_ Intravenous pyelogram with right ureter dilated → where is the obstruction and what is the likely cause? → ureterovesicular junction; stone.
_ Illustration of fetal head → medial maxillary eminence gives rise to what? → primary palate.
_ Abdominal MRI cross-section → locate the splenic artery, portal vein, etc.
_ EM of cell → lysosomes (digestion of macromolecules), RER (protein synthesis), SER (steroid synthesis).
_ Coronal MRI section of the head at the level of the eye → ﬁnd the medial rectus muscle →
what is its function? → medial gaze.
_ Optic nerve path → defect where would cause diminished pupillary reﬂex in right eye? Defect where would cause right homonymous hemianopsia? → right optic nerve; left optic tract.
_ Aortogram → identify adrenal artery, renal arteries, SMA, etc.
_ Chest x-ray showing pleural effusion with layering → where is the ﬂuid located? → costodi- aphragmatic recess.
_ MRI abdominal cross-section → what structure is derivative of the common cardinal veins? →
inferior vena cava.
_ Sagittal MRI of brain of patient with hyperphagia, increased CSF pressure, and visual problems
→ where is the lesion? → hypothalamus.
1. Development of the heart, lung, liver, kidney (i.e., what are the embryologic structures that give rise to these organs?).
2. Etiology and clinical presentation of important congenital malformations (e.g., neural tube defects, cleft palate, tetralogy of Fallot, tracheoesophageal ﬁstula, horseshoe kidney).
3. Development of the central nervous system (e.g., telencephalon, diencephalon, mesen- cephalon).
4. Derivatives of the foregut, midgut, and hindgut as well as their vascular supply.
5. Derivatives of the somites, and malformations associated with defects in somite migration.
6. Changes in the circulatory/respiratory system on the ﬁrst breath of a newborn.
7. Development of the embryonic plate in weeks two and three.
1. Anatomic landmarks in relation to medical procedures (e.g., direct and indirect hernia repair, lumbar puncture, pericardiocentesis).
2. Anatomic landmarks in relation to major organs (e.g., lungs, heart, kidneys).
3. Common injuries of the knee (including clinical examination), hip, shoulder, and clavicle; paying attention to the clinical deﬁcits caused by these injuries (e.g., shoulder separation, hip fracture).
4. Clinical features and anatomic correlations of speciﬁc brachial plexus lesions (e.g., waiter’s tip, wrist drop, claw hand, scapular winging).
5. Clinical features of common peripheral nerve injuries (e.g., common vs. deep peroneal nerve palsy, radial nerve palsy).
6. Etiology and clinical features of common diseases affecting the hands (e.g., carpal tunnel syn- drome, cubital tunnel syndrome, Dupuytren’s contracture).
7. Anatomic basis for the blood–testis barrier.
8. Major blood vessels and collateral circulatory pathways of the gastrointestinal tract (e.g., col- laterals between the superior and inferior mesenteric arteries).
9. Bone structures (metaphysis, epiphysis, diaphysis), including histologic features; linear (epi- physis) and annular (diaphysis) bone growth.
1. Histology of the respiratory tract (i.e., differentiate between the bronchi, terminal bronchioles, respiratory bronchioles, and alveoli).
2. Structure, function, and electron microscopic (EM) appearance of major cellular organelles and structures (e.g., lysosomes, peroxisomes, glycogen, mitochondria, ER, Golgi apparatus, nucleus, nucleolus).
3. Structure, function, and EM appearance of cell–cell junctional structures (e.g., tight junc- tions, gap junctions, desmosomes).
4. Histology of lymphoid organs (e.g., lymph nodes, spleen).
ANATOMY—HIGH-YIELD TOPICS (continued)
5. Resident phagocytic cells of different organisms (e.g., Langerhans cells, Kupffer cells, alveolar macrophages, microglia).
6. Histology of muscle ﬁbers and changes seen with muscle contraction (sarcomere structure, different bands, rigor mortis).
1. Etiology and clinical features of important brain, cranial nerve, and spinal cord lesions (e.g., brain stem lesions and “crossed signs,” dorsal root lesions, effects of schwannoma, Weber and Parinaud syndromes).
2. Production, circulation, and composition of cerebrospinal ﬂuid.
3. Neuroanatomy of hearing (central and peripheral hearing loss).
4. Extraocular muscles (which muscle abducts, adducts, etc.) and their innervation.
5. Structure and function of a chemical synapse (e.g., neuromuscular junction).
6. Major neurotransmitters, receptors, second messengers, and effects.
7. Blood supply of the brain (anterior, middle, posterior cerebral arterial areas, “watershed” ar- eas) and neurologic deﬁcits corresponding to various vascular occlusions.
8. Functional anatomy of the basal ganglia (e.g., globus pallidus, caudate, putamen).
9. Anatomic landmarks near the pituitary gland.
10. Brain MRI/CT, including morphologic changes in disease states (e.g., Huntington’s chorea, MS, aging).
11. Clinical exam of pupillary light reﬂex: pathway tested, important anatomic lesions, swinging light test.
1. X-rays; plain ﬁlms.
a. Fractures (skull, humerus, etc.) and associated clinical ﬁndings.
b. PA and lateral chest ﬁlms, including important landmarks (costodiaphragmatic recess, ma- jor blood vessels, cardiac chambers, and abnormalities seen with different diseases [consoli- dation, pneumothorax, mitral stenosis, cardiomyopathy]).
c. Abdominal ﬁlms, including vasculature (locate important vessels in contrast ﬁlms) and other important structures.
d. Joint ﬁlms (e.g., shoulder, wrist, knee, hip, spine), including important injuries/diseases
(e.g., osteoarthritis, herniated disc).
2. CT/MRI studies.
a. Brain cross-section (e.g., hematomas, brain lesions, extraocular muscles). b. Chest cross-section (e.g., superior vena cava, aortic arch, heart).
c. Abdominal cross-section (e.g., liver, kidney, pancreas, aorta, inferior vena cava, rectus ab- dominis muscle, splenic artery).
Erythrocyte Anucleate, biconcave → large surface area: volume Eryth red; cyte cell.
ratio → easy gas exchange (O2 and CO2). Source of Erythrocytosis polycythemia energy glucose (90% anaerobically degraded to increased number of red cells lactate, 10% by HMP shunt). Survival time 120 Anisocytosis varying sizes
days. Membrane contains the chloride-bicarbonate Poikilocytosis varying shapes antiport important in the “physiologic chloride shift,” Reticulocyte baby erythrocyte which allows the RBC to transport CO2 from the
periphery to the lungs for elimination.
Leukocyte Types: granulocytes (basophils, eosinophils, neutrophils) Leuk white; cyte cell. and mononuclear cells (lymphocytes, monocytes).
Responsible for defense against infections. Normally
4,000–10,000 per microliter.
Basophil Mediates allergic reaction. 1% of all leukocytes. Basophilic staining readily Bilobate nucleus. Densely basophilic granules with basic stains. containing heparin (anticoagulant), histamine
(vasodilator) and other vasoactive amines, and SRS-A.
Mast cell Mediates allergic reaction. Degranulation = release of Involved in type I hypersensi- histamine, heparin, and eosinophil chemotactic tivity reactions. Cromolyn factors. Can bind IgE to membrane. Mast cells sodium prevents mast cell resemble basophils structurally and functionally but degranulation.
are not the same cell type.
Eosinophil 1%–6% of all leukocytes. Bilobate nucleus. Packed with Eosin a dye; philic loving. large eosinophilic granules of uniform size. Defends Causes of eosinophilia NAACP: against helminthic and protozoan infections. Highly Neoplastic
phagocytic for antigen–antibody complexes. Asthma
Collagen vascular diseases Parasites
Neutrophil Acute inﬂammatory response cell. 40%–75% WBCs. Hypersegmented polys are
Phagocytic. Multilobed nucleus. Large, spherical, seen in vit. B12/folate
azurophilic 1 granules (called lysosomes) contain deﬁciency. hydrolytic enzymes, lysozyme, myeloperoxidase.
Monocyte 2%–10% of leukocytes. Large. Kidney-shaped nucleus. Mono = one, single; cyte = cell
Extensive “frosted glass” cytoplasm. Differentiates
into macrophages in tissues.
Lymphocyte Small. Round, densely staining nucleus. Small amount of pale cytoplasm. B lymphocytes produce antibodies. T lymphocytes manifest the cellular immune response as well as
regulate B lymphocytes and macrophages.
B lymphocyte Part of humoral immune response. Arises from stem B Bone marrow. cells in bone marrow. Matures in marrow. Migrates to
peripheral lymphoid tissue (follicles of lymph nodes, white pulp of spleen, unencapsulated lymphoid tissue). When antigen is encountered, B cells differentiate into plasma cells and produce antibodies. Has memory. Can function as antigen-presenting cell
Plasma cell Off-center nucleus, clock-face chromatin distribution, Multiple myeloma is a plasma abundant RER and well-developed Golgi apparatus. cell neoplasm.
B cells differentiate into plasma cells, which can produce large amounts of antibody speciﬁc to a particular antigen.
T lymphocyte Mediates cellular immune response. Originates from T is for Thymus. CD is for stem cells in the bone marrow, but matures in the Cluster of Differentiation. thymus. T cells differentiate into cytotoxic T cells MHC CD 8 (e.g., MHC 2
(MHC I, CD8), helper T cells (MHC II, CD4), CD4 8). suppressor T cells, delayed hypersensitivity T cells.
Macrophage Phagocytizes bacteria, cell debris, and senescent red Macro large; phage = eater. cells and scavenges damaged cells and tissues. Long
life in tissues. Macrophages differentiate from circulating blood monocytes. Activated by -IFN. Can function as APC.
ANATOMY—CELL TYPE (continued)
Airway cells Ciliated cells extend to the respiratory bronchioles; All the mucus secreted can be
goblet cells extend only to the terminal bronchioles. swept orally (ciliated cells Type I cells (97% of alveolar surfaces) line the run deeper).
alveoli. A lecithinsphingomyelin ratio
Type II cells (3%) secrete pulmonary surfactant of 1.5 in amniotic ﬂuid is
(dipalmitoylphosphatidylcholine), which lowers the indicative of fetal lung
alveolar surface tension. Also serve as precursors maturity. to type I cells and other type II cells.
Juxtaglomerular JGA JG cells (modiﬁed smooth muscle of afferent JGA defends glomerular
apparatus (JGA) arteriole) and macula densa (Na+ sensor, part of the ﬁltration rate via the renin- distal convoluted tubule). JG cells secrete renin angiotensin system.
(leading to ↑ angiotensin II and aldosterone levels) Juxta close by. in response to ↓ renal blood pressure, ↓ Na+ delivery
to distal tubule, and ↑ sympathetic tone. JG cells also
Microglia CNS phagocytes. Mesodermal origin. Not readily HIV-infected microglia fuse to discernible in Nissl stains. Have small irregular form multinucleated giant nuclei and relatively little cytoplasm. In response cells in the CNS.
to tissue damage, transform into large ameboid
Oligodendroglia Function to myelinate multiple CNS axons. In Nissl These cells are destroyed in
Node of Ranvier stains, they appear as small nuclei with dark multiple sclerosis. chromatin and little cytoplasm. Predominant type of
glial cell in white matter.
Schwann cells Function to myelinate PNS axons. Unlike Acoustic neuroma is an oligodendroglia, a single Schwann cell myelinates example of a schwannoma. only one PNS axon. Schwann cells promote
ucleus axonal regeneration.
Gas exchange barrier
Surfactant epithelial cell
(constitutive secretion) also serves as
Macrophage progenitor for
type I cells
Type II Alveolar
epithelial cell space
Lamellar bodies CO2
Air-blood Tight junction
barrier (continuous endothelium) Capillary lumen
[QUOTE=mathardy;69810]thanks a lot
thanks a lot
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