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Gastrointestinal System - Coggle Diagram

- - - - Motility Pathologies
        
        Motility
        :star: :star: :star: :star: :star:
        problems with muscularis externa
        Achalasia
        a (no) chalas (movement) ia (condition)
        Etiology
        Idiopathic
        Pathogenesis
        Vagal nerve degeneration or other unkown cause
        leading to
        
        failure of LES to relax
        
        not allowing food to pass into stomach
        
        loss of peristalsis in distal 2/3 of esophagus
        
        vagus nerve only innervates distal 2/3
        
        hard to swallow down food
        
        overtime lead to dilation of distal part of esophagus
        
        Clinical Manifestations
        from most common to least
        
        Dysphagia
        
        Post-prandial Regurgitation
        
        Chest pain
        
        Pyrosis (heartburn)
        
        weight loss and nocturnal cough
        
        symptoms overview
        
        Labratory Investigation and Diagnosis
        from gold standard to least used
        
        :first_place_medal: Esophageal Manometry :first_place_medal:
        
        an instrument used to sense the pressures of muscles in the esophagus
        
        Findings:
        
        increased LES pressure at rest
        
        failure of LES to relax during swallowing
        
        no peristalsic movement at lower esophagus
        
        Barium Oesophagram
        
        involves patient swallowing thick radioactive barium while x-ray is taken
        
        Findings: "bird's beak" appearance of dilated esophagus
        
        not really used anymore bc not ideal to swallow radioactive barium
        
        Endoscopy
        
        not useful to diagnose achalasia but is used to rule out cancer
        
        Reflux Pathologies
        
        How does hypothyroidism affect the anti-reflux mechanism? what does it mean by inadequate clearance of refluxed material?
        
        Neoplastic Pathologies
        
        Neoplastic
        :star: :star: :star: :star: :star:
        Benign: Leiomyoma
        leio smooth myo muscle oma tumor*
        most common type of esophageal tumor
        Cancer
        classified by most likely location on esophagus
        
        Upper 2/3 of Esophagus:
        Squamous Cell Carcinoma
        most common type of esophageal cancer
        
        Risk Factor:
        
        Alcohol :champagne:
        
        Smoking Tobaco :smoking:
        
        male above 50yrs :older_man::skin-tone-4:
        
        (osmosis) food with N-nitrates such as betel nuts :peanuts:
        
        Histology
        
        Lower 1/3 of Esophagus:
        Adenocarcinoma
        
        Risk Factor:
        
        Barret's esophagus
        
        chronic GERD
        
        Histology
        
        Morphology
        
        Both Cancers
        Clinical Manifestations
        
        Slow onset, at first asymptomatic
        
        Progressive dysphagia
        
        first solids then liquids too
        
        Odynophagia
        
        pain when swallowing
        
        Pyrosis (heartburn)
        
        Chest and Back pain
        
        Vomitting
        
        Weight loss
        
        Aggressive Spreading: this is because esophagus has no serosa hence tumor can break capsule easily
        
        Tracheosophageal fistula
        
        if tumor obstructs trachea
        
        Hiccups
        
        if tumor obstructs diaghpram
        
        Diagnosis
        :first_place_medal: Esophagogastroduodendoscopy + biopsy :first_place_medal:
        
        -
        
        Reflux
        :star: :star: :star: :star: :star:
        Problems with epithelial layer
        Physiological :blue_book:
        Reflux of gastric acid into esophagus eg in infants after a meal and it becomes less common as you grow older
        Pathological :red_flag:
        Gastro-esophageal Reflux Disease (GERD) :warning:
        Risk Factors
        
        Etiology:
        
        Inefficiency of anti-reflux mechanism
        anti-reflux mechanism involves the LES ability to contract (close) to prevent acid to come out of stomach aswell as the nerves ability to do so
        
        Smoking :smoking:,alcohol :champagne: toxins, coffee :coffee:circulates through blood and effects nerves and cells
        
        CNS depressants
        
        pregnancy, hypothyroidism?
        
        Sliding hiatal hernia
        
        Delayed gastric emptying
        
        stomach becomes full and might result in reflux material backing up to esophagus
        
        Inadequate clearance of refluxed material?
        
        eg after vomitting the "refluxed" substance could not be properly cleared back into stomach, it just stays in the esophagus due to the inability for LES to relax
        
        Pathophysiology
        
        Repetitive exposure to gastric acids
        
        Squamous cell epithelial of esophagus cannot handle exposure to acids (unlike columnar cells)
        
        epithelial cell and mucosal damage
        
        Inflammation and Ulceration
        
        Obstruction and pain?
        
        Clinical Manifestations
        
        Heartburn (pyrosis) and retrosternal chest pain
        
        epigastric burning sensation
        
        unlike in MI which is a crushing pain
        
        Regurgitation
        
        during eating gastric contents involuntary come back up esophagus into mouth (and then reswallowed)
        
        Dysphagia
        
        nausea and vomitting
        
        Hicough (hiccups: involuntary sounds made from spasm of diagphragm
        
        Others:
        
        Triggers/Exacerbations of Pain:
        
        Postpandrial (after eating)
        
        worse when lying down
        
        worse when leaning forward
        
        when you lean forward your stomach gets pressed
        
        Complications
        
        Bleeding
        
        due to inflammation and ulceration
        
        Stricture
        
        constriction of esophageal lumen
        
        Barret Esophagus
        
        long term complication
        
        metaplasia from squamous to columnar since it can handle acids
        
        can lead to neoplasia (cancer)
        
        other complications not mentioned in slides:
        
        larygnopharyngeal reflux (if acid reaches throat)
        
        acidic taste in mouth
        
        sore throat
        
        hoarseness
        
        chronic cough
        
        tooth pain (if reaches mouth)
        
        pneumonia and asthma (if reach lungs)
        
        Pathological :red_flag:
        Barret's Esophagus
        what?
        Distal (towards the end of esophagus) squamous epithelial cells replaced with non-ciliated columnar epithelial and goblet cells due to prolonged exposure to injury (from acid)
        
        Pathogenesis
        
        Clinical Manifestations
        
        according to Osmosis they're often asymptomatic
        
        but if they do have its same as GERD basically
        
        heartburn
        
        regurgitation
        
        dysphagia
        
        Complications
        
        dysplasia leading to cancer: adenocarcinoma
        
        Histology and Morphology
        Squamous epithelium is pale pearl colored
        Columnar epithelium is a darker brown color
        Normal Esophagus:
        
        Barret's Esophagus:
        
        see how the color changes at the bottom of the esophagus to a brownish color, thats the metaplasia occuring
        
        the columnar epithelial has presence of glands which is why you see glandular structures on the left
      - Structural Pathologies
        :star:
        Atresia
        underdeveloped of GIT
        Tracheosophageal Fistula
        
        congenital defect
        
        abnormal connection between two organs
        
        Diverticulum
        
        more common than fistula
        
        affects muscle, it is an abnormal buldging of muscle layer
        
        different types are classified by location of pouching
        
        can lead to infection and bursting of esophagus
        
        Hiatus Hernia
        hiatus is the small opening in the diagphram where the esophagus goes through
        two types: sliding and rolling, both have same clinical manifestation
        
        Complications:
        
        Ulceration
        
        Bleeding
        
        Dysphagia
        
        Treatment:
        
        pull the stomach down
        
        Esophageal Webs and Rings
        abnormal out-pouch of mucosa
        
        Webs: localized out-pouch leading to obstruction
        
        Ring: entire mucosa outpouched leading to stenosis
        
        Different types in detail:
        
        Lacerations
        tear of the mucosa of the esophagus
        can be caused by too much alcohol
        
        Clinical Manifestations:
        
        vomitting
  - - - Gastritis
        
        2 Types: Acute vs Chronic Gastritis
        
        Acute Gastritis
        Etiology
        caused by imbalance of mucosal defenses and acidic environment resulting in tissue damage and inflammation
        
        Excessive Alcohol :champagne:
        
        Long term usage of NSAIDS :pill:
        
        NSAID blocks COX which blocks prostaglandin E2 which normally increases mucous secretion and blocks acid release
        
        Extreme physiological stress
        
        eg: sepsis, shock, trauma
        
        can lead to erosion and further lead to an acute stress ulcer
        
        Dr puru said this not rlly impt to know
        
        two types of Acute Stress Ulcers
        
        once stress is eliminated ulcer will heal within next few weeks
        
        Pathogenesis
        
        acidic environment overtakes mucosal defenses
        
        Erosion of mucosa occurs
        
        if continues erosion damage can spread to submucosa to become an ulcer
        
        if damage hits blood vessel can lead to haemorrhage and GI bleeding
        
        Difference between Erosion and Ulcer
        
        Clinical Manifestations
        
        may be asymptomatic
        
        Epigastric pain
        
        nausea, vomitting
        
        Complications
        
        massive haematemesis
        
        haema blood emesis vomit
        
        malaena
        
        blood in stools
        
        Chronic Gastritis
        if more than 6 weeks its considered chronic gastritis
        chronic gastritis is more concerning than acute because it can develop into cancer
        Etiology
        
        Helicobacter pylori infection (90%) :first_place_medal:
        
        Autoimmune (9%) :second_place_medal:
        
        less than 1%
        
        Pathogenesis
        
        There are two types of chronic gastritis: autoimmune and h.pylori induced... which are talked about below in more detail
        Diagnosis
        :first_place_medal: Serology :first_place_medal:
        diagnostic examination of antibodies in blood plasma serum
        
        Type A (autoimmune):
        
        antibodies to parietal cells (H+/K+ATPase, and intrinsic factor)
        
        Type B (H.pylori):
        
        antibodies to H.pylori antigen
        
        Ways to Differentiate between Type A and Type B
        
        Type B Chronic Gastritis (H. pylori)
        
        Risk Factors
        
        Low socieoeconomic status
        
        poverty
        
        residence in rural areas
        
        Pathogenesis
        effects antrum: Antral type
        but can spread to body: Pangastritis
        
        H.pylori colonizes in pylorus
        
        attacks Delta cells which secretes somatostatin (which functions to decrease acid content)
        
        inhibits somatostatin secretion hence increase level of acid
        
        leads to inflammation
        
        formation of erosions and ulcers
        
        Complications
        
        Peptic Ulcer Disease
        
        Adenocarcinoma
        
        Diagnosis
        
        Non-Invasive
        
        Urease Breath Test :wind_blowing_face:
        
        Helicobacter pylori produces urease
        
        presence of urease changes color of instrument: positive
        
        Invasive
        
        Endoscopy
        
        Serology
        
        Treatment :pill:
        
        Type A Chronic Gastritis (Autoimmune)
        
        Risk Factors
        
        Autoimmune disease
        
        Thyroditis
        
        Grave's Disease
        
        Diabetes mellitus
        
        Pathogenesis
        effects fundus and body
        
        Autoimmune antibodies attack intrinsic factor and ATPase pumps on parietal cells inhibiting release of gastric acid (HCl)
        
        as a result less acid produced and as a compensatory mechanism more gastrin gets secreted by G cells
        
        G cells hyperplasia leads to increase risk of dysplasia and carcinoma
        
        also decreased B12 absorption leads to pernicious/megaloblastic anemia
        
        also decreases the amount of pepsinogen by chief cells
        
        Complication
        
        Pernicious Anemia
        
        Adenocarcinoma
        
        Carcinoid tumor (tumor of neuroendocrine cells)
        
        atrophy of stomach
        
        Diagnosis
        
        wouldn't increase gastrin release lead to more acid secreted why would there be less acid in type A, is it because gastrin works on parietal cells which is the one who secretes the acid in the first place... yea its bc of that lol
      - Chronic Peptic Ulcer Disease
        
        Gastric Cancer
        
        Gastric Cancers
        
        why gastric cancers mostly identified at the later stages?
        
        small tumor might be overlooked
        
        stomach can expand 1/5 liters (can't feel tumor)
        
        Risk Factors
        
        More common in Japan/China :dolls: compared to US/UK
        
        Male :man::skin-tone-2:
        
        low socioeconomic group
        
        Smoked fish :fish: and meat :meat_on_bone:
        
        H.pylori :microscope: :bug:
        
        Smoking :smoking:
        
        Location Probability
        from most common to least
        
        Pylorus and Antrum :first_place_medal:
        
        bc H.pylori colonizes here
        
        Lesser Omentum :second_place_medal:
        
        bc most exposed to food
        
        Cardia
        
        Greater Omentum
        
        Clinical Features
        
        Asymptomatic until late course
        
        3 As :trophy:
        
        Anorexia :person_doing_cartwheel:
        
        Astenia (weight loss) :weight_lifter:
        
        Anemia :sleeping:
        
        vomiting, dysphagia, altered bowel habits, abdominal pain
        
        Classification of Gastric Carcinoma
        based on three different categories
        1. Based on Depth of Invasion
        
        Early Invasion 1/2
        
        only reaches mucosa and submucosa
        
        Early Invasion Morphology
        
        Advanced Invasion 1/2/3
        
        reaches mucosa,submucosa and into muscular wall !
        
        Advanced Invasion Morphology
        
        linitis plastica bc makes stomach looks like a plastic bag
        2. Based on Morphology of Invasion
        look at the two pics above for more detail
        
        ulcerating shows punched out lesion
        diffuse type most likely shows linitis plastica type invasion
        3. Based on Histologic Type of Invasion
        
        Intestinal Type: well differentiated
        better prognosis
        
        Intestinal type Adenocarcinoma
        
        neoplastic intestinal cells and apical mucin/ mucin in lumen???
        
        morphology
        
        consist of columnar, gland-forming cells
        
        darker purple stain (compared to singlet type)
        
        what is desmoplastic stroma??
        
        Histology
        
        osmosis overview
        
        Diffuse Type: Undifferentiated
        
        genetic correlation more strong than in intestinal
        worse prognosis
        
        Singlet-Ring Cells
        
        Cells
        
        singlet ring cells which does not form glands
        
        Morphology
        
        large cytoplasmic mucin-filled vacoules
        
        peripherally placed crescent shaped nucleus
        
        looks paler compared to intestinal type
        
        Histology
        
        osmosis overview
        
        Clinical Manifestations for both
        
        Spread and Metastasis for both
        
        most common is liver metastasis as it directly spreads there (through lesser ommentum??)
        
        Prognosis
        
        Chronic Peptic Ulcer Disease
        
        Risk Factors
        
        Middle age to older adults
        
        Active disease after weeks/months despite therapy or no therapy
        
        Recurrent H.pylori infections
        
        males
        
        Etiology
        
        :first_place_medal: Helicobacter pylori :microscope: :first_place_medal:
        
        100% cases of duodenal ulcers
        
        pain improves after eating :green_salad:
        
        70% cases of gastric ulcers
        
        pain worsens after eating :-1::skin-tone-3:
        
        :second_place_medal: Chronic use of NSAIDS :pill: :second_place_medal:
        
        :third_place_medal: Cigarette Smoking :smoking: :third_place_medal:
        
        results in imbalance of gastroduodenal mucous defenses and damaging forces (Gastric acid and pepsin)
        Location
        more common in duodenum than in stomach
        however nowadays duodenal ulcers has decreased in number
        
        in stomach ulcers most commonly form in the lesser ommentum
        Pathogenesis
        By H.pylori Infection
        
        H.pylori invades pylorus of stomach
        
        H.pylori attaches onto columnar epithelial cells within mucous protective layer to survive acidic environment
        
        produces enzyme urease to release ammonia (alkaline) which neutralizes acidic environment
        
        Releases CAGA toxin which stimulates inflammatory response
        
        Epithelial cell damage and inflammation
        
        Erosion then ulcer formation
        
        By Long-term usage of NSAIDS
        
        NSAIDS blocks COX enzyme which inhibits prostaglandin E2
        
        No prostaglandin results in decrease mucous secretion and increase gastric acid release by parietal cells
        
        Epithelial damage and inflammation
        
        Erosion then ulcer formation
        
        Symptoms
        
        Complications
        from most common to least
        
        Ulcers formed on the lesser ommentum can erode left gastric artery leading to upper GI bleeding (osmosis). basically when ulcer damage blood vessel it causes bleeding
        
        GI bleeding leads to maelena and haematemesis
        
        Perforation may occur
        which is when ulcer erodes the wall of the organ and infection can spread onto the peritoneum covering the stomach leading to peritinitis :warning: which is an emergency
        
        obstruction of stomach can occur
        
        in the healing process of chronic inflammation fibrosis and scarring occurs causing obstruction
        
        Morphology and Histology
        
        solitary (single in number)
        
        less than 4cm in diameter (its small)
        
        50% is less than 2cm in diameter
        
        if more than 4cm its a benign ulcer
        
        check below for more
        
        Diagnosis
        
        Don't do biopsy of stomach unless you suspect that its a tumor
        
        Features of Benign Ulcer:
        
        -
        
        Treatment
  - - - Chronic Pancreatitis
        
        Chronic Pancreatitis
        
        Chronic pancreatitis is the irreversible inflammation of the pancreas leading to fibrosis of the pancreas' parenchyma
        Etiology
        
        :first_place_medal:Chronic Alchohol Use :champagne::first_place_medal:
        
        Middle age men :man::skin-tone-4:
        
        Long standing duct obstruction
        
        pseudocysts,calculi,trauma,neoplasms, pancreas divisum
        
        Tropical pancreatitis
        
        Africa,Asia tropical – malnutrition
        
        Hereditary pancreatitis
        
        PRSS1,SPINK1 gene
        
        Cystic fibrosis
        
        activates trypsin early
        
        Pathogenesis
        
        Initial Aggressors act on pancreas
        
        Toxic metabolites
        
        the metabolites of alcohol can result in acinar destruction and fibrosis
        
        Oxidative stress
        
        alcohol can induce membrane lipid oxidation,chemokines,fusion of lysosomes and zymogen granules
        
        Ductal obstruction
        
        protein plugs, calculi, calcify
        
        Chronic Inflammation occurs
        
        Parenhymal Fibrosis
        
        TGFB & PDGF induces fibrosis
        
        most prominent thing found in ultrasound
        
        Reduce number and size of acini
        
        Infiltrates of lymphocytes
        
        Signs and Symptoms
        Less severe than acute pancreatitis
        
        Sometimes Asymptomatic
        
        epigastric pain radiating to back
        
        weight loss
        
        Pancreatic insuffiency (endocrine & exocrine)
        
        diabetes mellitus
        
        fat malabsorption: fat in stools
        
        Aggrevating factors of symptoms
        
        alcohol consumption
        
        heavy meals
        
        pancreas works extra hard
        
        Drugs
        
        opiates (morphine, heroine, codenine)
        
        drugs that increase sphincter tone of Oddi
        
        Investigations and Lab Results
        
        Ultrasound and CT scan shows Pancreas having calcium fat depositis
        
        72 hour stool collection (gold standard according to osmosis)
        
        Management
        
        Summary
        
        Pancreatic Neoplasms
        
        Pancreatic Neoplasms
        
        Risk Factors
        
        Modifiable
        
        :first_place_medal: smoking :smoking: :first_place_medal:
        
        alcohol
        
        Non-modifiable
        
        male
        
        age
        
        Arising from Diseases
        
        diabetes
        
        Genetic :star: (pancreatic carcinoma)
        
        activation of K-RAS
        
        deactivation of P16
        
        Classification
        Most common type is neoplasm of Exocrine gland
        there are two types: cystic and solid
        Cystic exocrine gland neoplasm (-cystadenoma)
        there are two types: serous and mucinous
        
        Serous Cystadenoma
        
        arise from cubodial epithelial
        
        location ???
        
        always Benign
        
        Female > Male
        
        Abdominal pain present
        
        morph: small cyst, straw colored fluid
        
        Mucinous Cystadenoma
        
        arise from columnar epithelial
        
        location body and tail
        
        Benign/Borderline/Malignant
        
        Female = Male
        
        Painless
        
        morph: multiple cysts containing mucin w dense stroma
        
        Intraductal Papillary Mucinous Neoplasm (IPMN)
        
        arise from pancreatic duct cells
        
        location head > tail
        
        Benign/Borderline/Malignant
        
        Male > Female
        
        ????pain/painless
        
        Morph: papillary mucinous cysts w/o dense stroma
        
        Solid Exocrine Gland Neoplasm
        Pancreatic Carcinoma
        
        Metastasis (Spread)
        
        Very invasive
        
        Signs and Symptoms
        
        Weight loss
        
        lower abdominal pain
        
        gallstones
        
        Investigations and Laboratory Diagnosis
        
        Medical Imaging and Management
        
        Whipple's Procedure
        
        removing tumor of pancreas with parts of stomach and duodenum due to the common sharing of blood supply
        
        Prognosis
        
        worst one out there
        
        5 year survival rate is very small
        
        Signs and Symptoms
        
        Laboratory Investigations
        
        Medical Imaging and Management
        Prognosis
        
        Congenital Defects
        
        Congenital Defects
        
        Normal
        The pancreas is formed by two buds (dorsal and ventral) originating from the duodenum (a foregut derivative). The ventral bud rotates around the duodenum and fuses with the dorsal bud, both of which together give rise to the pancreas and its ducts.
        The ventral bud forms the uncinate process and the inferior part of the head of the pancreas. The remaining part of the gland (neck, body, tail, and remaining head) is derived from the dorsal bud.
        Annular Pancreas
        
        incomplete rotation of ventral pancreatic bud
        
        Pancreas Divisum
        
        failure of fusion of the ventral and dorsal bud of pancreas
      - Acute Pancreatitis
        
        Acute pancreatitis is the reversible inflammation of the pancreas, but it is more severe than chronic
        Etiology
        I GET SMASHED
        
        Idiopathic
        
        :first_place_medal:Gallstones (Female) :first_place_medal:
        
        gallstones trapped in duct causes pressure build up and damage to acinar cells and leakage of digestive enzymes
        
        :first_place_medal:Ethanol/Alcohol (Male) :first_place_medal:
        
        Trauma (knife wound)
        
        Mumps
        
        Autoimmune Condition
        
        SLE, RA
        
        Hypertriglyceremia and Hypercalcemia
        
        Hypertriglyceridemia
        
        chylomicrons stuck in capillaries make them ischemic
        
        improves with fasting
        
        Hypercalcemia
        
        calcium deposits in pancreas activates trypsin
        
        Genetics (usually Kids)
        
        Activation Cationic trypsinogen (PRSS1) gene
        
        trypsin gets activated early and cause autodigestion of pancreatic tissue
        
        Deactivation of trypsin inhibitor (SPINK) gene
        
        long lasting trypsin
        
        Endocscopic Retrograde CholangeaoPancreatography (ERGP)
        
        technique used to treat biliary and pancreatic diseases
        
        Drugs
        
        azathioprine
        
        Physiology
        
        Pancreatic enzymes gets secreted into duct as zymogen granules
        
        Lipase
        
        Amylase
        
        Protease
        
        Only in duodenum does the digestive enzymes get activated via trypsin
        
        Trypsinogen gets converted to trypsin in duodenum
        
        Trypsin gets deactivated quickly with Trypsin inhibitor (SPINK gene)
        
        trypsin has a short half life
        
        once trypsin gets removed the enzymes deactivates as a method of regulation
        
        Pathogenesis Generalized
        
        Early conversion of Trypsinogen to trypsin before reaching duodenum
        
        Digestive Enzymes activated
        
        Autodigestion of pancreatic tissues
        
        Adipose tissue digestion --> Fat necrosis
        
        Triggering of nerves stimulating pain --> epigastric pain radiating to back
        
        Digestive enzymes leak into blood vessels
        
        Protein digestion --> Blood vessel necrosis --> haemorrhage (bleeding) and ecchymosis of abdomen
        
        Diagram Sums it up very well
        
        Osmosis Review
        
        Pathogenesis of Gallstones
        
        symptoms can include mild jaundice
        
        Pathogenesis of Heriditary Pancreatitis
        
        Activation of cationic trypsinogen, PRSS1 mutation which creates long lasting trypsin
        
        Prevents the deactivation of trypsin
        
        Activation of digestive enzymes --> pancreatitis
        
        Signs and Symptoms
        
        Epigastric pain sometimes radiating to the back :star:
        
        improves as you lean forward (prayer sign)
        
        Cullen Sign / Grey Turner Sign
        
        Ecchymosis in abdominal area
        
        increase serum lipase and amylase
        
        Nausea
        
        Vomitting for several hours
        
        mild jaundice
        
        fatty stools
        
        eg
        
        Severe Cases
        
        decreased bowel sounds
        
        hypovolumic shock
        
        due to leakage of fluid into interstitial space
        
        leads to DIC bc activation of clotting factors
        
        Complications
        
        Pseudocyst
        
        common complication
        
        false cyst (true one is always lined w epithelium)
        
        Hypovolemic shock
        
        leakage of fluid into interstitial space
        
        death due to DIC bc activation of clotting factors
        
        Gram -ve infection (in 40%-60% patients)
        
        Laboratory Findings
        
        Serum Amylase increased in 24 hours
        
        Serum Lipase increased in 72-96 hours
        
        Glycosuria (in 10% of patients)
        
        Hypocalcemia
        
        this occurs when theres fat necrosis
        
        calcium saponification occurs whereby fatty acid binds with calcium to form calcium soaps
        
        Ultrasound
        
        Management
        
        Resting the pancreas
        
        no food taken orally, just parietal nutrtion
        
        .
        
        Summary
  - - - Inflammatory Bowel Disease
        Comparisons Crohn's Disease vs Ulcerative Colitis
        
        Know the difference between complications of the two diseases
        
        Pathogenesis
        they are similar however in chron's disease it effects all three layers (transmular) whereas UC only effects
        
        chron disease occurs in smokers
        
        different genetic predispositions
        
        treatment different
        
        microscopy is different
        
        Symptoms
        
        Complications
        
        can result in anemia bc it effects the terminal ileum where B12 (needed to make RBC) gets absorbed but it is not considered pernicious anemia
        
        Crohns Disease
        
        transmural inflammation
        
        if reaches serosa and cause perforation which may cause strictures, fistula, obstruction.
        
        most likely effect small intestine
        
        but can spread to the large colon
        
        can result in iron deficiency of anemia bc it effects duodenum where iron gets absorbed
        
        Ulcerative Colitis
        
        inflammation of submucosa and mucosa only
        doesn't have strictures, fistula, instestinal obstruction
        
        more likely to progress to colon cancer
        
        cancer in the GIT mostly occur in the colon and rectum
        
        Bloody diarrhea is more common in ulcerative colitis__
      - Crohn's Disease
        
        Ulcerative Colitis
        
        Pseudomembranous Colitis
        
        Infective Colitis
        
        Ischaemic & Radiation Colitis
        
        Ischaemic and Radiation Colitis
        
        :flag-my:Occurs in Malaysia:flag-my:
        Etiology
        
        After radiotherapy (eg. chemotherapy) of abdomen
        
        hence.. patients with ovarian tumour
        
        Presentation
        
        Patient goes for radiotherapy
        
        2-3 days later they present with bloody diarrhea, ulceration, perforation
        
        Management
        
        will have complete recovery once radiation stops
        
        Infective Colitis
        
        Etiology
        
        common in countries with improper hygiene
        
        Contaminated/Unpasturised milk
        
        food poisoning
        
        Classification
        Tuberculosis bovis Infection
        
        T. bovis transmission to person
        
        :first_place_medal: ingested bovine bacili
        
        :second_place_medal: swallowed infected sputum
        
        colinization in terminal ileum and cecum
        
        Inflammation and ulcer occurs
        
        Caseating granuloma
        
        Amaebic Colitis
        
        Transmission of Entamoeba histolytica
        
        Infected mucosa with yellow ulcers
        
        diarrhea
        
        Diagnosed with biopsy
        
        Pseudomembranous Colitis
        
        :flag-my:Occurs in Malaysia :flag-my:
        Etiology
        
        Consumption of antibiotics (Eg clindamycin) > 5 days resulting in Clostridium difficle infection
        
        Pathophysiology
        
        C. difficle is part of our normal flora, where a bunch of bacteria live together and compete for resources
        
        taking antibiotics like clindamycin for more than 5 days disrupts the normal flora
        
        Clostridium difficle is resistant to antibiotics hence while other bacterias die c. difficle survives and proliferates
        
        Overgrowth of c. difficle results in infection and release of toxins
        
        resulting in inflammation and tissue damage
        
        results in bleeding --> bloody diarrhea
        
        Symptoms
        
        Diarrhea w or w/o blood & mucous
        
        Abdominal pain
        
        Fever
        
        Complications
        
        Toxic megacolon
        
        colon gets very dilated and can rupture/perforation leading to sepsis and even death
        
        Laboratory Investigations and Diagnosis
        
        Sigmoidoscopy or Colonoscopy shows patchy yellow plaques/elevations
        
        which are pseudomembranes filled with pus
        
        scattered yellow, white membranes plaques of fibrin, leucocytes.
        
        Treatments
        
        Vancomycin
        
        antibiotics that are sensitive to C. difficle
        
        taken orally
        
        Ulcerative Colitis
        
        Etiology
        
        Genetic link
        
        Autoimmune mixed with communal gut bacteria
        
        abnormal Th2 cellular response
        
        Pathophysiology
        
        starts at rectum
        
        usually the intestinal lining is tightly packed together however certain factors such as genetics can cause an increase permeability to the intestinal lining allowing bacteria to come thru and attack
        
        Inflammation confined to mucosa (and submucosa?) only is circumfrential and continous and starts from the rectum up to the descending colon and etc etc and there are no "breaks" or uneffected tissues
        
        Symptoms
        -
        
        Chron's Disease
        
        Etiology
        
        Abnormal Th1 cellular response
        
        Pathophysiology
        
        most common at ileum but can happen anywhere in GIT
        Signs and Symptoms
        
        Bile acid wasting
        
        Targets ileum which is where bile acids are reabsorbed
        
        reduced bile pool leads to increase cholesterol concentration and formation of gallstones
    - - Intussusception
        
        Intussusception
        
        Definition
        condition where a part of the intestine slides into an adjacent part of the intestine
        like a teloscope retracting
        
        Etiology
        
        Children
        
        after gastroenteritis
        
        Adult (less common)
        
        polyps
        
        Lipoma
        
        Adhesion
        
        scar like tissue attaching parts of intestine
        
        surgery done on intestininal tract
        
        weight-loss surgery
        
        bypass surgery
        
        Pathophysiology
        not much on slides, this is from osmosis
        
        polyp/adhesion/post-surgery causes leading or pulling of ileum into cecum
        
        poly can grow outwards edging/pulling the ileum
        
        adhesion between intestinal walls can pull ileum into cecum
        
        idk but something else
        
        increase pressure of adjacent intestine leads to blockage of
        
        food and water --> constipation, abdominal distension, pain
        
        blood vessels --> ischemia
        
        ischemia leads to cell injury and necrosis
        
        necrosis of intestinal tissue
        
        blood vessel damage in submucosa --> bleeding --> bloody stools
        
        broken down epithelial cells --> mucous stool
        
        Blood + Mucous --> red jelly-like stools
        
        leakage of gut bacteria into circulation --> sepsis
        
        Signs and Symptoms
        most commonly happens in Children
        
        severe Abdominal pain
        
        bringing knees onto chest
        
        guarding abdomen with hands
        
        Periods of pain alternating with no pain but lethargy
        
        episodes of pain lasts 10-15 mins followed with 20-30 mins no pain
        
        nausea and vomiting
        
        Red jelly-like stools due to rectal bleeding
        
        mucous might be present in stool
        
        Diagnosis and Investigations
        
        Physical Abdominal examination: can be felt but does not indicate diagnosis
        
        sausage-shaped abdominal mass in right upper quadrant
        
        :trophy:Ultrasonography used for diagnosis
        
        Barium enema and air contrast enema
        
        Barium enema is a test that helps to highlight the large bowel so it can be clearly seen on an X-ray
        
        normal:
        
        intussusception:
        
        Treatment
        
        requires immediate treatment (osmosis)
        
        Liquid contrast enema or Air contrast enema
        
        attempt reduction (push intestine back)
        
        radiological procedure, anesthesia not needed
        
        surgery
        
        pull intestine out of other part
        
        Diverticulosis
        most common for old age GI lower tract bleeding
      - Volvulus
        
        Definition
        condition where a part of the intestine twists and loops upon itself and its mesentary supply
        
        Etiology
        
        Middle aged adult
        
        pregnancy
        
        constipation
        
        Congenital
        
        Pathophysiology
        not much from slides, this from osmosis
        
        looping causes an obstruction of intestine
        
        prevents food and water through --> constipation and pain
        
        abdominal distension
        
        blockage of capillaries leads to tissue ischemia
        
        ischemia leads to cell injury and necrosis
        
        necrosis of mucosa results in
        
        damage of blood vessels --> bleeding
        
        epithelial damage -->
        
        leakage of gut bacteria into circulation --> sepsis
        
        Signs and Symptoms
        
        Sudden onset
        
        Abdominal distension
        
        Abdominal Pain
        
        vomitting
        
        constipation
        
        bloody stools
        
        Diagnosis and Investigations
        
        X-Ray shows coffee bean apperance
        
        colonoscopy
        
        Treatment
        
        Endoscopic colonoscopy
        
        Laparotomy (lapar-stomach)
        
        surgery cutting open abdominal cavity
        
        How does Volvulus cause bleeding?
- - - - Submucosa
        
        Submucosa
        
        Submucosal Nerve Plexus
        
        controls GI secretions and local blood flow
        
        Blood Vessels, Lymph
        
        Submucosal Glands
        
        only esophagus and duodenum have glands in submucosa, the rest doesn't
        
        Dense Connective Tissue
        All*
        
        Esophagus
        
        DCT with elastic fibers
        
        Esophageal glands proper
        
        Stomach
        
        All*
        
        Small Intestine
        
        Duodenum
        
        brunner's glands
        
        Jejunum
        
        longest villi
        
        Ileum
        
        Peyer's patches
        
        more goblet cells
        
        ask question for lecture
        
        Muscalaris Externa
        
        Serosa and Adventitia
        
        Serosa and Adventitia
        
        Serosa vs Adventitia
        
        Adventitia
        
        connective tissue surrounding organs
        
        Covers digestive tract organs outside peritoneal cavity
        
        consist of stronger connective tissue for protection
        
        Serosa
        
        serous membrane composed of two simple squamous mesothelial layers held together by connective tissue layer
        
        covers digestive tract organs within peritoneal cavity
        
        secretes lubricant to reduce friction between organs
        
        some organs have serosa while others have adventitia
        Organs that have Adventitia layer:
        
        Esophagus (except abdominal layer which has serosa)
        
        Parts of Large Intestine
        
        Ascending and Descending colon
        
        Rectum
        
        Appendix
        
        Organs that have Serosa layer:
        
        Abdominal part of Esophagus
        
        Entire small intestine
        
        Parts of Large Intestine
        
        transverse and sigmoid colon
        
        Others
        
        Histology of Different Organs
        
        Stomach
        
        Fundus and Body
        
        Plyorus
        
        Small Intestine
        
        Duodenum
        
        Jejunum
        
        Ileum
        
        Large Intestine
        
        Appendix
        
        Noted Anatomist Overview
        
        1 more item...
        
        Muscularis Externa
        
        Basic Idea:
        
        Inner Circular Muscle (IC)
        
        Outer Longitudinal Muscle (OL)
        
        Inner circular muscle + outer longitudinal muscle = peristalsis
        
        Myenteric Plexus (MP)
        
        myenteric plexus + submucosal plexus = Enteric NS
        
        controls GI movements
        IC OL MP
        
        Different Organs
        
        Esophagus
        
        IC OL MP but muscle type diff
        
        Upper: skeletal
        
        Middle: skeletal + smooth
        
        Lower: smooth
        
        Stomach
        
        Inner Oblique
        
        helps churn food: can contract and expand
        
        Middle Circular
        
        Outer Longitudinal
        
        MP
        
        Small Intestine
        
        IC OL MP
        
        Large Intestine
        
        MP
        
        Taeina Coli
        
        prominent longitudinal bands of muscle
        
        Appendix
        
        IC OL MP
      - Mucosa
        Innermost
        
        Epithelial Layer:
        
        Esophagus: stratified squamous
        
        Stomach: simple columnar
        
        Intestines: simple columnar with ++ goblet cells
        
        Appendix: simple columnar with ++ goblet cells
        
        Lamina Propria
        (Loose Connective Tissue and Glands)
        
        Esophagus:
        
        LCT
        
        esophageal cardiac glands (neutral mucous)
        
        Stomach:
        
        LCT + gastric glands
        
        Small Intestine:
        
        LCT
        
        Microfold Cells (M cells)
        
        Immune cells (lymphocytes, plasma cells)
        
        Large Intestine:
        
        Crypts of Lieberkuhn (simple, straight tubular glands) (?????)
        
        Appendix
        
        Crypts of Lieberkuhn (simple, straight tubular glands)
        
        Muscularis mucosae
        
        thin layer of smooth muscle between submucosa and mucosa
        
        Example:
        
        mucosa of Small intestine
        
        Mucosa of Large intestine
  - - - Small Intestine
        
        Small Intestine
        
        Mucosa
        Circular folds (Pliace circulares)
        characteristic feature of small intestine
        
        found everywhere in small intestine EXCEPT first part of duodenum (duodenal bulb)
        
        purpose is to increase surface area of the intestine for more effective absorption
        
        different lengths in different areas
        
        duodenum and jejunum has same length
        
        ileum has gradually less circular folds
        
        Circular folds consists of villi and microvilli
        
        hence as u go towards ileum there is less microvilli
        
        Between villi has intestinal glands to lubricate intestine
        
        Submucosa
        How to Distinguish The 3?
        look at submucosa
        
        Duodenum
        
        Brunner's Glands
        
        produces alkaline fluid to neutralize the bile aciditiy
        
        Jejunum
        
        has the longest villi out of the 3
        
        Ileum
        
        Peyer's patches
        
        clusters of lymphoid nodules, also called GALT
        
        most goblet cells out of the 3
        
        Muscularis Externa
        
        Inner part: circular muscle
        
        Outer part: longitudinal muscle
        
        circular muscle results in the sphincter function in sphincter of Oddi which is the hepatopancreatic sphincter (opens major papilla duct)
        Serosa & Adventitia
      - Pancreas
        
        Stroma of Pancreas
        Capsule and Septa
        made out of collagen
        
        Intralobular Duct and Adipocyte
        
        differentiated by blood vessel as it has digestive enzymes inside it (red stain inside duct)
        
        Duct is lined by simple columnar cell epithelial
        
        purple-stained connective tissue surrounding duct
        
        Adipocytes increase in number with age due to more atrophy
        
        Parenchyma of Pancreas
        has endocrine and exocrine part
        Exocrine
        
        Consist of pyramid-shaped secretory cells
        
        arranged in acini (grape sac) structure
        
        peripherally located nucleus towards base
        
        purple stained rough endoplasmic recticulum shown at base of cell
        
        eosinophilic stain of zymogen granules shown at apices of cell
        
        centroacinar cells found at center of acini
        
        more lightly stained than secretory cells
        
        forms intercalated duct
        
        simple cuboidal cell lining duct
        
        but then as intralobular duct forms it becomes stratified cuboidal cells and the connective tissue surrounding the duct thickens
        
        Types of Ducts found in Pancreas
        arranged from smallest to largest / pathway of enzyme
        
        Intercalated
        
        Intralobular
        
        Interlobular
        
        Main Pancreas Duct
        
        Common Bile Duct, Acessory Duct
        
        Endocrine
        
        Islet of Langerhans
        
        more lightly stained than exocrine glands
        
        more smaller in size than exocrine glands
        
        between them shows the fenestrated capillaries
        
        Composed of Different types of cells
        
        Beta Cells (70%) - insulin
        
        Alpha Cells - glucagon
        
        Delta Cells - somatostain
        
        PP cells - pancreatic polypeptide
        
        can be differentiated (Beta and Alpha) through
        Gomori's Stain
- - - - Esophagus
        
        Stomach
        
        Pancreas
        
        Small Intestines
        
        Duodenum
        
        General Tips
        
        Circular Folds (Plicae circularis) are found everywhere in small intestines except duodenal bulb
        
        Reference Photos
        Parts
        
        Flexures
        
        Skeletopy
        
        L1-L3
        Holotopy (Abdominal Surface Markings)
        
        How the duodenum is held
        only first part of duodenum is covered w mesentary, the rest is held by a ligament
        
        Anterior Relations
        
        Posterior Relations
        
        Artery Supply
        
        The Mesentary
        
        covers ileum and jejunum and first part of duodenum
        
        Nerve Supply
        
        1ST PART: DUODENAL BULB
        Relations
        
        Anterior Relations
        
        gallbladder
        
        quadate lobe of liver
        
        Posterior Relations
        
        Gastroduodenal artery
        
        hepatoduodenal ligament (lesser omentum)
        
        portal triad: portal vein, hepatic artery, bile duct
        
        Artery Supply
        
        Gastroduodenal artery
        
        Vein Drainage
        
        portal vein (idk specifics)
        
        2ND PART: DESCENDING PART
        Relations
        
        Anterior Relations
        
        Transverse colon
        
        Posterior Relations
        
        Hilum of right kidney (lateral)
        
        head of pancreas (medial)
        
        Artery Supply
        
        Start --> pancreactic duct
        
        Superior pancreatoduodenal
        
        Pancreactic duct --> end
        
        Inferior pancreatoduodenal
        
        Vein Drainage
        
        Portal vein
        
        Ducts
        
        Major papilla duct (Duct of Wirsung)
        
        common bile duct + pancreatic duct --> Ampulla of vater --> opens to major papilla duct or duct of Wirsung
        
        Minor papilla duct
        
        accessory duct of pancreas
        
        Sphincter of Oddi
        
        opening of duct via circular muscle
        
        hepatopancreatic sphincter
        
        importance: controls how much bile and enzyme enters the duodenum
        
        3RD PART: HORIZONAL PART
        Relations
        
        Anterior Relation
        
        Superior Mesenteric Artery and Vein
        
        Posterior Relation
        
        Abdominal Aorta
        
        Inferior vena cava
        
        Cells of the Intestine
        
        PEG ME
        
        Paneth Cells
        
        Enterocytes
        
        Goblet Cells
        
        M Cells (Microfold)
        
        Enteroendocrine Cells
        
        1 more item...
        
        Jejunum & Ileum
        
        Topography
        
        called ileum cuz rests in right iliac fossa
        Holotopy
        
        Jejunum and ileum is covered by layer called mesentery, and this mesentery then joins to form the root of mesentery. basically this tells us that its not just floating around, its held into place
        
        Comparisons
        
        Function
        
        Jejunum: absorbs carbs, proteins
        
        Ileum: absorbs vitamins (eg B12, ADEK), bile salts, and remaining nutrients
        
        Wall Thickness
        
        jejunum is thicker than ileum because it needs to absorb more nutrients and hence requires a greater surface area to absorb more efficiently
        
        Vascularization
        
        Jejunum is more vascularized than ileum bc it needs to be able to absorb all the nutrients (carbs,proteins,fats)
        
        which is why jejunum is darker in color than ileum
        
        Table Summarizing Differences
        
        Large Intestine
        
        Large Intestine
        
        General Tips
        
        Distinguishing Features of large intestine
        
        Taenia coli:
        
        aggregated 3 thick bands of longitudinal muscles
        
        makes the colon get segmented giving rise to haustras
        
        Haustration
        
        pouch-like structures which causes colon to form segments to help slow down fecal matter and help mix the contents of the colon - basis is correct but NOT accurate - yasmin
        
        Appendices epiploicae
        
        peritoneal pouches containing fat
        
        The rectum, anal canal, and appendix DOES NOT have these features
        
        water and electrolytes absorption occurs in ascending and transverse colon
        propulsion and peristalsis occurs in transverse and descending
        Holotopy
        cecum & appendix: right iliac fossa
        sigmoid colon and descending colon: left iliac fossa
        rectum and anal canal: hypogastric
        Artery Supply
        
        SMA supplies right ascending and transverse colon
        IMA supplies left descending and sigmoid colon
        pic showing how mesentary carries blood supply
        
        Cecum and Appendix Blood Supply
        
        Vein Drainage
        
        Lymph Supply
        
        Nerve Supply
        
        Cecum & Appendix:
        
        PSNS: Vagus
        
        SNS: Superior mesenteric plexus (from lesser splanchnic T10)
        
        Referred pain --> umbillicus
        
        in appendicitis the pain begins at the umbillicus which comes and goes but then as the condition progresses it becomes more localized at the right iliac fossa
        
        1 more item...
        
        Stomach
        
        Topography
        
        tbh idk how to make of this below pic
        
        Difference between Anatomically and Histological Structure
        
        anatomically has body
        Blood Supply of Stomach
        
        Celiac Trunk: 3 main branches
        
        Left gastric artery
        
        Hepatic artery
        
        Splenic artery
        
        Blood Supply of Lesser Curvature
        
        Left gastric artery
        
        right gastric artery
        
        Blood Supply of Greater Curvature
        
        short gastric
        
        Left gastroepiploic
        
        Right gastroepiploic
        epiploic means floating
        
        Overview of Blood Supply
        
        Venous Drainage of Stomach
        
        Hepatic Portal Vein
        
        formed by joining superior mesenteric with splenic vein
        
        Lymph Supply of Stomach
        
        Fundus and Top left part of body --> Splenic and Pancreatico-splenic nodes
        
        Bottom left part of body --> right gastroepiploic nodes
        
        Pyloric Region --> Pyloric and Hepatic nodes
        
        Right half --> Left Gastric nodes,
        Regional nodes drain to Coeliac Group of Pre-Aortic
        
        because so many nodes is close to the arteries, it is hard to resection (remove tissue/ part of organ). When patient has stomach cancer they would usually need to resection the lower part of the esophagus and first part of the duodenum
        Nerve supply of Stomach
        PSNS: vagal nerve
        SNS: coeliac plexus and Greater Splanchnic nerves T6-T9
        Cardia
        
        Function:
        
        Cardiac glands secrete mucus to protect esophagus
        
        Fundus
        
        Function
        
        Fundic gland secretes digestive enzymes + mucus
        
        Anatomy
        
        Mucosa and Submucosa forms folds that can expand and contract called Rugae
        
        Has shallower pits but longer gastric glands
        
        Pylorus
        
        Function
        
        Pyloric gland secretes mucus
        
        Neuroendocrine gland secretes gastrin
        
        Anatomy
        
        Has deeper pits but shorter gastric glands
        
        Blood Supply of The Stomach
        
        Oesophagus
        
        Structural Anatomy: 3 Parts
        
        Cervical:
        
        C6: starts
        
        Thoracic:
        
        T1
        
        Abdominal:
        
        T10: Pierces diagphram
        
        T11: ends
        
        Blood Supply: Artery
        
        Cervical & Thoracic:
        
        Inferior Thyroid Artery
        
        Abdnominal:
        
        Left Gastric Artery
        
        Blood Supply: Vein
        
        Cervical: Inferior Thyroid vein
        
        Thoracic: Azygos/Hemiazygos vein
        
        Abdominal: Gastric Vein -> Portal vein
        
        Clinical Significance: esophageal varices in portal hypertension
        
        Natural Constrictions of Esophagus
        
        C6, T4, T5, T10
        
        Clinical Significance:
        
        endoscopy
        
        obstruction in structure
        
        esophageal varicies in T10 ** (??)
        
        Stuff IDG
      - Peritoneum
        
        what? mesothelium (serous membrane) that lines the abdominal wall (PARIETAL layer) and then reflected to various abdominal viscera (organs) as VISCERAL Layer
        fist in balloon analogy, where your visera is the fist pushing into the balloon (peritoneum) but it is not actually inside the balloon.
        it functions for protection
        the viseral and parietal layer is continuous
        
        Supply of Peritoneal Layers
        
        Parietal Layer has the same blood, lymph, and nerve supply as the abdominal wall it lines
        
        nerve supply: lower 6 intercostal nerves
        
        hence it is sensitive to pressure and temperature
        
        Viseral layer has the same blood,lymph, and nerve supply as the organs it covers
        
        hence it is sensitive to chemical irritants and stretch
        
        Whats the difference between Mesothelium and Peritoneum
        t-shirt-cotton analogy
        Name is called peritoneum, it is made out of mesothelium
        
        Intraperitoneal vs Retroperitoneal vs Subperitoneal
        
        some organs are secondary retroperitoneal, where they begin as intraperiotneal but as they develop they gets pushed to posterior abdominal wall
        
        Quiz yourself: which organs are intra/retroperiteneal
        Peritoneal Cavity
        
        empty space between visceral organs filled with a thin fluid
        
        functions to allow movement of organs
        
        reduce friction
        
        allow peristalsis
        
        Subdivisions of Peritoneal Cavity
        
        divided into two parts:
        
        Greater Sac
        
        Two parts: divided by transverse mesocolon
        
        Supracolic Part
        
        hepatorenal pouch located here
        Importance: Hepatorenal pouch of Morrison is most dependent part of peritoneal cavity
        
        Infracolic Part
        
        Lesser Sac (Omental Bursa)
        
        lined by transverse mesocolon and lesser omentum
        
        Organs in Supracolic vs Infracolic
        
        Epiploic Foramen of Winslow
        
        connects lesser sac with greater sac
        Ommentum
        a fold of the peritoneum attached to the stomach
        
        Greater Omentum
        
        The omentum consists of a double sheet of the peritoneum, folded on itself so that it has four mesothelial layers
        
        first it attaches to greater curvature of stomach
        
        then descends
        
        then ascends reattaches onto the anterior surface of the transverse colon and its mesentary
        
        the four layers then fuses with eachother to create the gastrocolic ligament
        
        Lesser Omentum
        
        double layer
        
        attaches to stomach, liver, and duodenum
        
        has two parts
        
        Hepatoduodenal (liver-duodenum)
        
        which contains portal triad
        
        hepatogastric ligament (liver-stomach)
        
        has opening called epiploic foramen which allows access to lesser sac
        
        Extra Images
        
        things to ask: Significance of epiploic foramen
        allows communcation between two sacs just incase eg infection occurs. the lesser sac is behind the stomach so if theres an infection it might spread there and it would be difficult to remove
        
        Complete Anatomy
        Retroperitoneal Organs
        
        Lesser Ommentum functions
        
        Entry into the lesser sac is required for pancreatic surgery and drainage of lesser sac collections.
        if standing it is the most gravity dependent part for:
        
        female: recto-uterine pouch or douglas pouch(between rectum and uterus)
        
        male: vesico-uterine (between rectum and bladder)
        if supine: hepatorenal or morrisons pouch
        
        Recesses
        
        Intra vs Retro peritoneal organs
- - - - Stomach
        
        Stomach Overview
        
        Functions of the Stomach
        
        absorption of water, alcohol, vitamin B12, iron
        
        digestion of fat and protein
        
        motility: segmentation and peristalsis
        
        Gastric Secretions
        Classified by: Mechanism
        
        Exocrine: secrete to duct :door:
        
        HCl :lemon:
        
        (+) acidity
        
        parietal cell
        
        Mucous :sneezing_face:
        
        secreted by more cardiac and pylorus than oxytonic/gastric glands
        
        neutralize acidity (protective)
        
        mucous neck cell
        
        Intrinsic Factor (IF) :pill:
        
        B12 absorption
        
        Parietal cell
        
        Pepsin + Lipase :scissors:
        
        digest food
        
        Chief cell
        
        Paracrine: secrete to neighbor :house_buildings:
        
        Histamine
        
        (+) acidity
        
        ECL cell
        
        Somatostatin
        
        (-) acidity (protective)
        
        D cell
        
        Endocrine: secrete to blood :syringe: secreted more by gastric glands than cardiac/pylorus glands
        
        Gastrin
        
        hormone that stimulates more secretion of acid
        
        G cell (neuroendocrine cell)
        
        Ghrelin
        
        hormone
        
        (+) satiety
        
        Cells of Gastric Gland
        
        Mucous Neck Cell
        
        produces mucous to protect stomach epithelium
        
        Parietal Cell :ribbon: :heartpulse: :lemon:
        
        Produces HCl
        
        Produces Intrinsic Factor (IF)
        
        helps absorbs vit B12
        
        stains P for Pink (eosinophillic)
        
        Chief Cell :male-police-officer::skin-tone-3: :scissors:
        
        Produces Pepsinogen
        
        precursor of pepsin
        
        Produces gastric Lipase
        
        Neuroendocrine Cell
        
        Different types which produces hormones
        
        eg: G cell produces Gastrin
        
        Stem Cell
        
        can change into any cell of gastric gland
        
        Protective Defenses of Stomach
        
        Mucous
        
        Bicarbonate and
        
        Stomach Epithelial Regeneration Rate
        
        regenerates every 3 days
        
        Small Intestines
      - Peristalsis
        
        (toothpaste analogy)
        
        Inner Circular: Segmentation (squeeze)
        
        Outer Longitudinal: Push
        
        Oesophageal Phase of Deglutition
        
        relaxation of UES
        
        relaxation of LES via release of NO and vasoactive intestinal peptide (VIP) which is a inhibitory neurotransmitter that causes relaxation
        
        Achalasia: dysphagia due to incomplete relaxation of LES due to defective NO and VIP release
        on the other hand..
        GERD: acid reflux due to incomplete closure of LES caused by decrease neural activity in area
    - - Deglutition
        __
        Buccal, Pharyngeal, Esophageal
        
        once food touches pharynx process becomes involuntary
        nerves involved:
        
        afferent: glossopharyngeal nerves
        
        efferent: 5th, 9th, 10th, 12th cranial nerves
        
        theres so many nerves bc there are so many protective reflexes involved
        Buccal Phase
        saliva needed to allow lubrication of food
        Pharyngeal Phase
        Protective Reflexes of Deglutition:
        
        pic for reference
        
        Elevation of soft palate
        
        prevent food from going into nasal cavity
        
        closing of epiglottis and vocal cords
        
        prevents food from entering trachea
        
        inhibition of breathing
        
        prevent food from entering trachea
        
        Oesophageal Phase
        
        relaxation of UES
        
        relaxation of LES via release of NO and vasoactive intestinal peptide (VIP) which is a inhibitory neurotransmitter that causes relaxation
- - - - Metronidazole
- - - - Cholera
        
        C.A: vibrio cholera
        Pathogenesis