Abdomen-05

Dr. Santosh Ramkrishna Malwade

All Saints University School of

Medicine
Dominica, Fall 2023
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 Lecture Goals
At the end of this section, students should be able…
• To describe the regions of the small and large intestine, including the anatomy of
the appendix.
• To describe the position and form of the pancreas and its relationships to other
abdominal organs. To discuss the significance of these relationships in relation
to pancreatitis and biliary stone disease.
• To describe the position and form of the liver, the lobes of the liver and their key
anatomical relations. To explain the peritoneal reflections of the liver and its
movement during respiration.
• To summarize the functional anatomy of the portal vein, the portal venous
system and portal-systemic anastomosis and their significance in portal
hypertension.
• To describe the position and form of the gall bladder and biliary tree; their
relations in the abdomen and the significance of these relations in relation to gall
bladder inflammation and biliary stones.
• To describe the position and form of the kidneys and ureters. Demonstrate their
relationships to other abdominal and pelvic structures and discuss the
significance of these relations in relation to urinary stones.
 Lecture Goals
At the end of this section, students should be able…
• To describe the relations of the suprarenal (adrenal) glands and their functional
anatomy.
• To describe the position (in relation to the ribs) and form of the spleen in relation
to its palpation through the abdominal wall and its key anatomical relationships
with other abdominal structures.
• To explain the significance of these relationships in relation to trauma, chronic
infections and disorders of the hematopoetic system.
• To describe the origins, course and major branches of the abdominal aorta,
coeliac axis, superior and inferior mesenteric arteries and their major branches,
the renal and gonadal arteries.
• Demonstrate the origins, course and major tributaries of the inferior vena cava.
• To describe the anatomy of the lymph nodes involved in lymph drainage of
abdominal viscera and its significance in relation to spread of malignancy.
• To interpret standard diagnostic images of the abdomen and recognise common
abnormalities.
 Pancreas
• Gland with both exocrine and endocrine functions
• 6-10 inch in length
• 60-100 gram in weight
• Location: retroperitoneal, 2nd lumbar vertebral level
• Extends in an oblique, transverse position

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 Functions of Pancreas
• The pancreas contains modified simple cuboidal
epithelial cells called acinar cells.
• These cells, which are organized into large clusters
termed acini (sing., acinus), or lobules, secrete the
mucin and digestive enzymes of the pancreatic juice.
• Enzymes travel down the pancreatic duct into the bile
duct in an inactive form
• The simple cuboidal epithelial cells lining the pancreatic
ducts secrete bicarbonate (alkaline fluid) to help
neutralize the acidic chyme arriving in the duodenum
from the stomach.

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 Functions of Pancreas
• The hormones secreted
by the pancreatic
enteroendocrine cells (
located in the islets of
Langerhans) are insulin
and glucagon (which
regulate the level of
glucose in the blood), and
somatostatin (which
prevents the release of
the other two hormones)
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 Head of Pancreas
• Includes uncinate process
• Flattened structure, 2 – 3 cm thick
• Attached to the 2nd and 3rd portions
of duodenum on the right
• Emerges into neck on the left
• Border between head & neck is
determined by gastroduodenal
artery insertion
• The superior pancreaticoduodenal
artery and inferior
pancreaticoduodenal artery
anastamose between the
duodenum and the right lateral
border

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 Neck of Pancreas
• 2.5 cm in length
• Straddles superior
mesenteric and portal vein
• Antero-superior surface
supports the pylorus
• Superior mesenteric vessels
emerge from the inferior
border
• Posteriorly, superior
mesenteric and splenic vein
confluence to form portal vein
• Posteriorly, mostly no
branches to pancreas

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 Body of Pancreas
• Elongated, long structure
• Anterior surface, separated
from stomach by lesser sac
• Posterior surface, related
to aorta, left adrenal gland,
left renal vessels and upper
1/3rd of left kidney
• Splenic vein runs
embedded in the posterior
surface
• Inferior surface is covered
by transverse mesocolon

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 Tail of Pancreas
• Narrow, short segment
• Lies at the level of the 12th
thoracic vertebra
• Ends within the splenic
hilum
• Lies in the splenophrenic
ligament
• Anteriorly, related to
splenic flexure of colon
• May be injured during
splenectomy (fistula)
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 Pancreatic Duct
• Main duct (Wirsung) runs the entire length of pancreas
• Joins CBD at the ampulla of Vater
• 2 – 4 mm in diameter, 20 secondary branches
• Ductal pressure is 15 – 30 mm Hg (vs. 7 – 17 in
common bile duct) thus preventing damage to panc.
duct
• Lesser duct (Santorini) drains superior portion of head
and empties separately into 2nd portion of duodenum

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 Endoscopic Retrograde
Cholangiopancreatography (ERCP)

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ERCP and Sphincterotomy

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 Arterial Supply of Pancreas
• Anterior collateral arcade between the
anterosuperior and anteroinferior
pancreaticoduodenal artery
• Posterior collateral arcade between the
posterosuperior and posteroinferior
pancreaticoduodenal artery
• Body and tail supplied by splenic artery by about
10 branches
– Three biggest branches are
• Dorsal pancreatic artery
• Pancreatica Magna (midportion of body)
• Caudal pancreatic artery (tail)
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 Arterial Supply of Pancreas
• Variety of major arterial sources (celiac,
SMA and splenic)
– Celiac  Common Hepatic Artery 
Gastroduodenal Artery  Superior
pancreaticoduodenal artery which divides into
anterior and posterior branches
– SMA  Inferior pancreaticoduodenal artery
which divides into anterior and posterior
branches

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Venous Drainage of Pancreas
• Follows arterial supply
• Anterior and posterior arcades drain head and
the body
• Splenic vein drains the body and tail
• Major drainage areas are
– Suprapancreatic portal vein
– Retropancreatic portal vein
– Splenic vein
– Infrapancreatic superior mesenteric vein
• Ultimately, into portal vein

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 Lymphatic Drainage of
Pancreas
• Rich periacinar network that drain into 5
nodal groups
– Superior nodes
– Anterior nodes
– Inferior nodes
– Posterior PD nodes
– Splenic nodes

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 Innervation of Pancreas
• Sympathetic Nerve Path
– Preganglionic sympathetic innervation is from
the greater and lesser thoracic splanchnic
nerves
• Parasympathetic Nerve Path
– Parasympathetic innervation is by way of the
celiac division of the posterior vagal trunk

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 Pancreas Divisum
• Pancreas divisum develops prenatally
• It is caused by the failure of the ducts of the dorsal and
ventral buds to fuse during embryologic development, at
approximately the eighth week of intrauterine life
 Pancreas Divisum
• Pancreas divisum is the most common
congenital anomaly of the pancreas.[1] It occurs
in approximately 7% of autopsy series (range, 1-
14%)
• The frequency of finding this condition varies
greatly in endoscopic retrograde
cholangiopancreatography (ERCP) series (4-
25%), depending on the population studied and
the degree to which complete pancreatography
is pursued
 Annular Pancreas
• Annular pancreas is a rare congenital abnormality
characterized by a ring of pancreatic tissue surrounding
the descending portion of the duodenum
• It is thought to originate from incomplete rotation of the
ventral pancreatic bud.
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 Signs and Symptoms
• Prenatal:
– Polyhydramnios
• Neonates:
– Bilious vomiting (not always)
– Upper abdominal distension
– Decreased frequency of meconium stool
– Feeding intolerance
 Signs and Symptoms
• Adults
– Epigastric pain
– Nausea/vomiting
– Early satiety
– Acute or chronic pancreatitis
– Biliary obstruction
 Pancreatic Cancer
• Pancreatic cancer is the fourth
leading cause of cancer deaths
among men and women, being
responsible for 6% of all cancer-
related deaths
• Approximately 75% of all
pancreatic carcinomas occur
within the head or neck of the
pancreas, 15-20% occur in the
body of the pancreas, and 5-10%
occur in the tail
• Of all pancreatic cancers, 80% are
adenocarcinomas of the ductal
epithelium. Only 2% of tumors of
the exocrine pancreas are benign.
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 Pancreatic Cancer
• Symptoms
– Patients typically report the gradual onset of
nonspecific symptoms such as anorexia, malaise,
nausea, fatigue, and midepigastric or back pain
• Prognosis
– Pancreatic carcinoma is unfortunately usually a fatal
disease. The collective median survival time for all
patients is 4-6 months.
– The relative 1-year survival rate for patients with
pancreatic cancer is only 24%, and
– the overall 5-year survival rate is 5%, having
increased from 3% rate as calculated between 1975
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and 1977
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 Spleen
• The largest single mass of
lymphoid tissue in the body
• The spleen is slightly larger
than a clenched fist and
weighs about 180 to 250
grams
• Oval shaped with a notched
anterior border
• Lies just beneath the left half
of the diaphragm close to the
9th, 10th, and 11th ribs
• The splenic capsule and
trabeculae contain smooth
muscle and are capable of
expelling large quantities
of blood into the circulatory
system.
 Spleen
• Is surrounded by peritoneum (intraperitoneal) which
passes from it at the hilum as the gastrosplenic
ligament to the greater curvature of the stomach
(carrying the short gastric and left gastroepiploic
vessels)
• The peritoneum also passes to the left kidney as the
splenicorenal ligament (carrying the splenic vessels
and the tail of the pancreas)
 Functions of Spleen
• Lymphocyte proliferation (B and T cells)
• Immune surveillance and response
• Blood filtration
• Destruction of old or damaged red blood cells
(RBCs)
• Destruction of damaged platelets
• Recycling iron and globin
• Providing a reservoir for blood
• Providing a source of RBCs in early fetal life
 Arterial Supply of the Spleen
• The splenic artery
supplies blood to the
spleen.
• It is the largest branch of
the celiac trunk
• Reaches the spleen's
hilum by passing through
the splenorenal ligament
• Divides into multiple
branches at the hilum
 Venous Drainage of the Spleen

• The splenic vein leaves

the hilum and runs
behind the tail and the
body of the pancreas
behind the neck of the
pancreas, the splenic
vein joins the superior
mesenteric vein to form
the portal vein
 Lymphatic Drainage of the
Spleen
• The splenic lymphatic vessels leave the lymph nodes
in the splenic hilum and pass along the splenic
vessels to the pancreaticosplenic lymph nodes en
route to the celiac nodes
 Innervation of the Spleen
• The nerves of the spleen, derived from the celiac
plexus, are distributed mainly along branches of
the splenic artery, and are vasomotor in function
 Splenomegaly
• A wide variety of diseases are associated with
splenomegaly
• Spleens weighing 400-500 g indicate splenomegaly
• Spleens that are prominent below the costal margin
typically weigh 750-1000 g
 Etiology
• Immune response work hypertrophy - Such as
in subacute bacterial endocarditis or infectious
mononucleosis
• RBC destruction work hypertrophy - Such as in
hereditary spherocytosis or thalassemia major
• Congestive - Such as in splenic vein thrombosis,
portal hypertension, or Banti disease
• Myeloproliferative - Such as in chronic myeloid
metaplasia
• Infiltrative - Such as in sarcoidosis and some
neoplasms
• Neoplastic - Such as in chronic lymphocytic
leukemia and the lymphomas
Immune Thrombocytopenic Purpura
• A clinical syndrome in which a decreased number of
circulating platelets (thrombocytopenia) manifests as a
bleeding tendency, easy bruising (purpura), or
extravasation of blood from capillaries into skin and
mucous membranes (petechiae)
• Due to antiplatelet IgG produced in spleen, which binds
to platelets; platelets are then removed by macrophages
in spleen and liver
Immune Thrombocytopenic Purpura
• Treatment
– Steroids
– Immunosuppressive therapy (IVIG)
– Splenectomy if unresponsive
 Ruptured Spleen
• Although protected under the
bony ribcage, the spleen remains
the most commonly affected
organ in blunt injury to the
abdomen in all age groups.
• Over the last century salvage of
the spleen rather than
splenectomy has become an
objective.
• CT scanning has made
conservative management more
practical
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 Splenectomy

• Indications
– Benign
Hematologic
Disease
– Malignant
Disease
– Trauma
(uncontrolled)
 The Liver
• Second largest organ in the
human body (1200-1600g)
• Approximately 2.5% of body
weight
• Relationships to other structures:
– Anteriorly: Diaphragm, right and
left costal margins, right and left
pleura and lower margins of both
lungs, xiphoid process, and anterior
abdominal wall in the subcostal
angle
– Posteriorly: Diaphragm, right
kidney, hepatic flexure of the colon,
duodenum, gallbladder, inferior
vena cava, and esophagus and
fundus of the stomach
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 Functions of the Liver
• Storage of energy sources (glycogen,
fat, protein, and vitamins)
• Production of cellular fuels (glucose,
fatty acids, and ketoacids)
• Production of plasma proteins and
clotting factors
• Metabolism of toxins and drugs
• Modification of many hormones
• Production of bile acids
• Excretion of substances (bilirubin)
• Storage of iron and many vitamins
• Phagocytosis of foreign materials
that enter the portal circulation from
the bowel
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 Liver Hematopoiesis
• Begins during week 6 and
the liver becomes a bright red.
• This function is responsible for
the relatively large size of the
liver during month 2.
• The liver weighs about 10%
of the total fetal body weight
by week 9
• Liver hematopoiesis subsides
gradually during the last 2
months of intrauterine life,
and only small hematopoietic
islands remain at birth, at
which time,
• the liver is only about 5% of
the total body weight
Structure of Liver-Lobes of Liver
• Right lobe (largest lobe)
• Left lobe
• Quadrate lobe (lies between the gallbladder and the
round ligament of the liver)
• Caudate lobe (lies between the IVC, ligamentum
venosum, and porta hepatis)

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Segments of the Liver

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 Structure of the Liver
• The substance of the liver is composed of
lobules, held together by an extremely fine
areolar tissue, in which ramify the portal
vein, hepatic ducts, hepatic artery, hepatic
veins, lymphatics, and nerves; the whole
being invested by a serous and a fibrous
coat.

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 Lobules of the Liver
• The chief mass of the hepatic substance
• About the size of a millet-seed, measuring
from 1 to 2.5 mm. in diameter

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 Vasculature
• The vessels connected
with the liver are: the
hepatic artery, the portal
vein, and the hepatic
veins
• The liver has a unique
dual blood supply (about
1500 mL/min) both from
the proper hepatic artery
(20-40%) and from the
portal vein (60-80%)
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Vascular Pathway

20 -40%

60-80%
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 Lymphatic Drainage
• The liver produces about one
third to one half of all body
lymph
• Lymph vessels leave the liver
and enter several lymph nodes in
the porta hepatis
• The efferent vessels pass to the
celiac nodes
• A few vessels pass from the bare
area of the liver through the
diaphragm to the posterior
mediastinal lymph nodes

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 Innervation
• Sympathetic and
parasympathetic
nerves form the celiac
plexus
• The anterior vagal
trunk gives rise to a
large hepatic branch,
which passes directly
to the liver

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 Ligaments of Liver
• Round ligament
– Ligament that contains obliterated umbilical vein
• Falciform ligament
– Peritoneal reflection off anterior abdominal wall with round
ligament in its margin
• Triangular Ligaments
– Continuous with the coronary ligaments
• Ligamentum venosum
– Ligamentous remnant of fetal ductus venosus, allowing fetal
blood from placenta to bypass liver
• Coronary ligaments
– Reflections of peritoneum from liver to diaphragm

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 Ligaments of Liver
• Ligamentum venosum
– Ligamentous remnant of fetal ductus venosus, allowing fetal
blood from placenta to bypass liver
• Coronary ligaments
– Reflections of peritoneum from liver to diaphragm

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