Please enable JavaScript.
Coggle requires JavaScript to display documents.
Gastrointestinal basic science, Anatomy, Physiology, Embryology - Coggle…
Gastrointestinal basic science
Anatomy
inguinal canal(鼠径管)
transversus abdominis muscle; 腹横筋
internal oblique muscle; 内斜筋
transversalis fascia
aponeurosis(腱膜) of external oblique muscle
extraperitoneal tissue; 腹膜外組織
inguinal ligament; 鼠径靱帯
parietal peritoneum; 壁側腹膜
superficial inguinal ring
internal spermatic fascia; 内精筋膜
cremasteric muscle and fascia; 精巣挙筋
external spermatic fascia
apermatic cord; 精索
linea alba
conjoined tendon
pyramidalis muscle; 錐体筋
rectus abdominis muscle; 腹直筋
median umbilical ligament
medial umbilical ligament
abdominal wall
inferior epigastric vessels
deep inguinal ring
liver tissue architecture
apical surface face bile canaliculi (毛細胆管)
basolateral surface face sinusoids (drain to central vein)
portal triad: portal vein, hepatic artery, bile duct
periportal zone=affected by viral hepatitis, ingested toxin; intermediate zone=affected by yellow fever;
pericentral vein zone=affected by ischemia, high concentration of cytochrome P-450, sensitive to metabolic toxin, alcohol hepatitis
unit is made up of hexagonally arranged lobules (central vein, portal triad at edge)
Kupffer cells=macrophages
hepatic stellate store viaminA (in space of Disse) and produce extracellular matrix
hepatic artery, portal vein→central vein; bile duct (to peripheral)
important ligament
gastrocolic ligament
greater curvature and transverse colon
gastroepiploic artery(胃大網動脈)
part of greater omentum(大網)
gastrohepatic ligament
liver to lesser curvature of stomach
gastric vessels
part of lesser omentum(小網)
hepatoduodenal ligament
liver to duodenum
contain portal triad (proper hepatic artery, portal vein, common vile duct)
Pringle maneuver: ligament is compressed to control bleeding
borders the omental foramen(網嚢孔), which connects greater sac and lesser sac
gastrosplenic ligament
greater curvature and spleen
short gastric, left gastroepiplovic artery
part of greater omentum
falciform ligament (肝鎌状間膜)
contain ligamentum teres hepatis(肝円索), patent paraumbilical vein
derivatives of ventral mesentery
liver to anterior abdominal wall
splenorenal ligament
spleen to posterior abdominal wall
splenic artery and vein, tail of pancreas
hernia
protrusion of peritoneum through an opening, incarceration and strangulation
diaphragmatic hernia(横隔膜ヘルニア)
commonly occur on left side
hiatal hernia
stomach herniates upward through the esophageal hiatus(食道裂孔)
sliding hiatal: herniagastroesophageal junction is displaced
paraesophageal hiatal hernia: junction is normal, gastric fundus protrudes into thorax
congenital defect of pleuroperitoneal membrane(胸腹膜ヒダ)
abdominal structure enter thorax
indirect inguinal hernia
through internal and external inguinal ring into scrotum
lateral to inferior epigastric vessels
more common in male
covered by all 3 layers
femoral hernia
more common female
below inguinal ligament through femoral canal below and lateral to pubic tubercle(恥骨結節)
direct inguinal hernia
between inferior epigastric vessels and rectus abdominis
through external ring only
through inguinal triangle
covered by external spermatic fascia
inguinal (Hesselbach) triangle
lateral border of rectus abdominis
inguinal ligament
inferior epigastric vessels
aorta branch
branch
aorta
inferiorphrenic(下横隔)/ superior suprarenal(上副腎)
gonadal
3 more items...
IMA
inferior suprarenal/ renal
SMA
celiac
middle suprarenal
arteries supplying GI are single and branch anterioly
arteries not supplying GI are paired and branch laterally and posteriorly
SMA syndrome: SMA and aorta compress transverse portion of duodenum
area susceptible to ischemia
splenic flexure(脾彎曲部): SMA and IMA
rectosigmoid junction(直腸S状結腸移行部): IMA and superior rectal artery
postosystemic anastomoses
rectum
superior rectal---middle and inferior rectal
umbilicus
paraumbilical---amall epigastric vein
esophagus
left gastric---azygos
transjugular intrahepatic portosystemic shunt; TIPS(経皮的肝内門脈肝静脈短絡術)
relieves portal hypertension
blood supply and innervation
midgut; SMA; vagus nerve; L1
hindgut; IMA; pelvic nerve; L3
foregut; celiac artery; vagus nerve; T12/L1; pharynx and lower esophagus to proximal duodenum, liver, gallbladder, pancreas, spleen
celiac trunk
truck
celiac trunk
left gastric
common hepatic
proper hepatic(固有肝動脈)
gastroduodenal
anterior superior oancreaticoduodenal
posterior superior pancreaticoduodenal
right gastroepiploic
right gastric
splenic
left gastroepiploic
posterior duodenal ulcers penetrate gastroduodenal artery causing hemorrhage
anterior duodenal ulcers perforate(突き破る) into anterior abdominal cavity, leading to pneumoperitoneum
femoral region(大腿部)
organization
lateral to medial: nerve→artery→vein→lymphatics
femoral triangle(大腿三角): femoral nerve, artery, vein
femoral sheath(大腿鞘): fascial tube 3-4cm below inguinal ligament, contains femoral vein, artery, canal, but not nerve
digestive tract
anatomy
layer
submucosa: submucosal nerve plexus (Meissner), secret fluids
muscularis externa: myenteric nerve plexus (Auerbach), motility
mucosa: epithelium, lamina propria(粘膜固有層), muscularis mucosa(粘膜筋板)
serosa(漿膜), adventitia(外膜)
ulcers can extend into submucosa, inner or outer musclar layer, erosion is in mucosa only
electric rhythm: stomach---3/min, duodenum---12/min,
ileum---8~9/min
histology
duodenum: villi, microvilli, Brunner glands, crypts of Lieberkuhn, enterocyst, goblet cell, Paneth cell
jejunum: plicae circulares (円形ひだ), crypt pf Lieberkuhn
stomach: gastric glands
ileum: Peyer patch, plicae circulares, crypt of Lieberkuhn
esophagus: nonkeratinized stratified squamous epithelium
colon: no villi, abundant goblet cell
pectinate line
above
superior rectal artery (branch of IMA)
superior rectal vein (→IMV→splenic vein→portal vein)
visceral nerve
drain to internal iliac LN
internal hemorrhoids(内痔核) (not painful), adenocarcinoma
below
somatic innervation
inferior rectal artery (branch of internal pudendal artery;内陰部動脈)
inferior rectal vein (→internal pudendal vein→→IVC)
drain to superficial inguinal LN
external hemorrhoids, anal fissures, squamous cell carcinoma (painful)
biliary structure
structure
ampulla of Vater
main pancreatic duct
common bile duct
common hepatic duct
cystic duct
gallbladder
accessory pancreatic duct
gallstones at ampulla of Vater cause both cholangitis(胆管炎) and pancreatitis
retroperitoneal(後腹膜) structure
adrenal gland, aorta and IVC(aortaはIVCの左後), duodenum, pancreas, ureters, colon, kidney, esophagus, rectum
Physiology
gastrointestinal regulatory substances
motilin
produces migrating motor complexes (MMCs)
↑ in fasting state
small intestine
vasoactive intestinal polypeptide (VIP)
↑ intestinal water and electrocyte secretion, relaxation of intestinal smooth muscle and sphincter
↑by distention and vagal stimulation, ↓by adrenergic input
parasympathetic ganglia
VIPoma: pancreatic tumor, wate diarrhea, hypokalemia, achlorhydria(無酸症)
glucose-dependent insulinotropic peptide
↓gastric H secretion (exocrine), ↑insulin release (endocrine)
↑ by fatty acid, amino acid, oral glucose
K cell (duodenum, jejunum)
also known as gastric inhibitory peptidase (GIP)
ghrelin
↑ appetite
↑ in fasting state, ↓ by food
from stomach
secretin
↑ pancreatic HCO₃⁻ secretion (alkalinization), bile secretion, ↓gastric acid secretion
↑ by acid, fatty acid
S cells (duodenum)
nitric acid
less of NO cause ↑ LES tone of achalasia
↑smooth muscle relaxation, including LES
cholecystokinin
↑pancreatic secretion, gallbladder contraction, sphincter of Oddi relaxation, ↓gastric emptying
↑ by fatty acids, amino acids
from I cell (duodenum, jejunum)
somatostatin
↓gastric acid and pepsinogen secretion, pancreatic and small intestine fluid secretion, gallbladder contraction, insulin and glucagon release
↑ by acid, ↓ by vagal stimulation
from D cell (pancreatic islet, GI mucosa)
inhibit secretion of various acid
gastrin
↑gastric H⁺ secretion, growth of gastric mucosa, gastric motility
↑ by stomach distention/alkalinization, amino acids, peptides, vagal stimulation
from G cell (antrum;幽門洞 of stomach, duodenum)
↓ by pH<1.5
secretory protein
gastric acid
↓ stomach pH
↑ by histamine, vagal stimulation, gastrin
parietal cell
↓ by somatostatin, GIP, prostaglandin, secretin
pepsin
↑ by vagal stimulation, local acid
pepsinogen is converted to pepsin in the presense of H
protein digestion
chief cell
intrinsic factor
vitamin B12 binding protein (required for uptake)
from parietal cell
bicarbonate
↑ by pancreatic and biliary secretion with secretin
cover the gastric epithelium
neutralize acid
mucosal cell, Brunner gland
acid secretion
via enterochromaffin-like cell (こっちのほうが大きい) ro direct
pancreatic secretion
lipase: fat digestion
protease: protein digestion
α-amylase: starch digestion
trypsinogen: converted to trypsin (active) by enteropeptidase
carbohydrate absorption
GLUT5: fluctose
GLUT2: all
SGLT1(Na⁺ dependent): glucose and galactose
vitamin/mineral absorption
folate
absorbed in small bowel
B12
absorbed in terminal ileum along bile salt
iron
absorbed as Fe²⁺ in duodenum
Payer patches
at germinal center, B cell differentiate into IgA
contain specialized M cell
unencapsulated lymphoid tissue in ileum
bilirubin
pathway
RBCs
heme
unconjugated bilirubin
unconjugated bilirubin-albumin complex
conjugated bilirubin
urobilinogen
excreted in feces as stercobilin (80%)
18% to kidney(enterohepatic circulation)
2%to kidney
1 more item...
direct bilirubin: conjugated with glucuronic acid, water soluble
indirect bilirubin: un conjugated, water insoluble
bile
function
digestion and absorption of lipid and fat-soluble vitamins
cholesterol excretion
antimicrobial activity
composed of bile salts, phospholipids, cholesterol, bilirubin, water, and ion
Embryology
pancrea and spleen
ventral pancreatic buds→uncinate process(鉤状突起) and main pancreatic duct
dorsal pancreatic buds→body, tail, isthmus(峡部), accesory pancreatic duct
from foregut
both→pancreatic head
annular pancreas(輪状膵): abnormal rotation of ventral bad→encircle 2nd part of duodenum, duodenum narrowing and vomiting
pancreas divisum(癒合不全): fail to fuse at 8 weeks, may cause chronic abdominal pain and pancreatitis
spleen arises frommesentery of stomach (mesodermal) but has foregut supply (splenic artery)
normal embryology
midgut: lower duodenum to proximal 2/3 of transverse colon(横行結腸)
hindgut: distal 1/3 of transverse colon to anal canal above pectinate line(恥骨櫛線)
foregut: esophagus to upper duodenum
midgut development:
6 week---physiologic midgut herniates through umbilical ring
10 week---return to abdominal cavity+rotate around SMA (270°)
ventral wall defect
due to failure of rostal fold closure, lateral fold closure, or caudal fold closure
gastroschisis(腹壁破裂)
extrusion of abdominal contents through abdominal folds
typically right of umbilicus
not covered by peritoneum(腹膜) or amnion
omphalocele(臍帯ヘルニア)
failure of lateral wall to migrate at umbilical ring→persistent herniation of abdominal contents into umbilical cord
surrounded by peritoneum
associated with congenital anomalies
congenital umbilical hernia
failure of umbilical ring to close after physiologic herniation of the intestine, small defect usually close
hypertrophic pyloric stenosis
palpable olive-shaped mass in epigastric region, visible peristaltic wave(蠕動波), nonbilious projectile vomiting
macrolides
most common of gastric outlet obstruction (1/600)
treatment is surgical incision(pyloromyotomy)
tracheoesophageal anomalies
pure EA or pure TEF or EA with distal TEF
present as polyhydramnios(羊水過多症)
esophageal atresia; EA(食道閉鎖症) with distal tracheoesophageal fistula; TEE(気管食道瘻) is the most common
intestinal atresia
jejunal and ileal atresia: due to ischemic necrosis
duodenal atresia: failure to recanalize, double bubble sign, associated with down syndrome
present with bilious vomiting and abdominal distension within first 1-2 days of life