You are on page 1of 1

DIGESTIVE SYSTEM LARGE INTESTINE

-

-

Large intestine – starts at the cecum and ends at the anus For absorption of water, liquid intestinal content, chyme. Sigmoid colon- narrowest part in the large intestines Saculation or Costrations – part of the intestine that differentiates large from small intestine when viewed in x-ray. Tinea coli – concentration of longitudinal muscles. Shorter than large intestine up to sigmoid colon.

-

Transverse colon – 90 degree downward to become the Descending colon. Has splenomegaly ligaments. Loses mesentery/ mesocolon – fixed to posterior abdominal wall. Covered by peritoneum Iliac fossa – becomes the sigmoid colon Sigmoid colon – mobile because of mesocolon. Can be lifted up to during incisions. Tinea coli – diminished; lose saculations and mesentery, no mesocolon S3 – ends at the 3rd sigmoidal vertebra Rectum – series of sphincters (voluntary and involuntary) When bolus feces are formed; involuntary relaxes for defecation. Internal Sphincter – controlled by autonomic nervous system.

Seen, measured Ex. Tenderness, mass, fever, jaundice • Abdominal pain Somatic versus visceral Referred pain: visceral in origin poorly localized dull to sever sympathetic nervous system. -Somatic Perception -Stimulus: Distention Diaphragm: pain – left shoulder -Appendix (right iliac fossa): pain – umbilical region (referred pain) -Referred Pain: -Example: -Kidney -Sympathetic fibers enter the somatic cord up to L1 (lower cervical) -Appendix -Sympathetic fibers enter the cord together with somatic fibers from T10 -Acute Appendicitis -Children Early: 0-12 hours Acute: 12-24 hours Perforated: 24-36 hours -Physical Examination -Inspection – visual, flat, globular, distended -Signs: spider angioma/nevus, caput medusa, Grey- tumor sign, distention -AAW abnormalities -Congenital or acquired Congenital -Diastasis recti -Defect of closure 1. Omphalocele 2. Gastrochisis 3. Omphalomesenteric 4. Duct remnants 5. Urachal Anomalies -Omphalomesenteric 1. Duct remnants 2. Umbilical polyp 3. Umbilical sinus 4. Cyst 5. Enteroumbilical fistula Meckel’s diverticulum – out pouching Fistula (communication between 2 spaces) • Urachal Anomalies 1. Vesicoumbilical fistula 2. Urachal sinus 3. Cyst 4. Bladder diverticulum • Umbilical Hernia 1. Spontaneous closure 2. Incarceration rare • Inguinal hernia 1. Indirect patent processus vaginalis 2. High risk of incarceration 3. Unlikely to close “Incarceration” – intestine gets stuck. AAW Abnormalities • Hernias 1. Direct/ indirect inguinal 2. Incisional 3. Umbilical 4. Spigelian 5. Femoral • Infection 1. Necrotizing fasciitis 2. Omphalitis – infection of the umbilicus • Tumors

-

1. 2. 3. 4.

5.
Auscultation • • • • •

Lipoma Fibroma – desmoids Hemangioma Neurofibroma Sarcoma – malignant

Longitudinal Bands: Teaniea Coli 1. Mesocolon to sigmoid colon – tinea coli is attached. 2. Greater Omentum – omental tinea coli 3. Appendices or omental appendices - fat sac like occlusion, hanging on the wall of large intestine Tinea Libera – “free” (no attachment) Regions of the Abdomen: 9 Cecum – located at the iliac region Ascending colon – over lumbar region Right colic flexure – above, right hypochondriac region Sigmoid colon – hypogastric region 1st portion of Large intestine: -Cecum – 3 inches long a. Area were ileum is joined to the large intestine. Imaginary line – below is the cecum, right iliac fossa Behind (posterior) cecum – iliacus Medial – Psoas muscle Appendix – prominent feature of cecum; full of lymphoid tissue. Vermiform appendix – “vermis” – latin; wormlike Appendix – pointing the pelvis; retrosecal (behind). Cecum is mobile; no attachments Ileocecal valve - regulates intestinal contents; no true anatomical sphincter. Protruding (in a way that forms a spinchter); enlarged version of papilla(similar to major duodenal papilla). Closes to prevent backflow of contents. Ascending colon – diameter is narrower; reaches out up 10-12 inches. a. Attached posteriorly to quadratus lumborum. b. Fixed portion of ascending colon. c. Partially covered of the peritoneum. d. Covered by visceral peritoneum. e. Paracolic – peritoneum reflects f. Just below the right lobe of the liver. Right colic flexure/ Hepatic flexure From here, large intestine becomes transverse colon. Can be lifted because it has mesocolon. 20 inches – transverse colon Average size: 45cm Left colic flexure

-

-

BLOOD SUPPLY Superior Mesenteric Artery • Right side – appendix to mid transverse colon; branches: iliocolic artery, appendicular artery. • Middle colic artery – supply the right and left of transverse colon. Left side – inferior mesenteric artery Sigmoids –anastomose with left colic Terminal branch: sigmoid hemorrhoidal. • Collaterals – will not become gangrenous because there is blood supply. Continuous collateral or anastomoses of blood supply. • Marginal artery/ continuous artery • Arc of Ireolan • Marginal Artery of Ramund VENOUS DRAINAGE • Superior mesenteric vein – right side • Inferior Mesenteric Vein – left side • Left side – drains into splenic vein. Splenic vein and superior mesenteric vein joins to form the hepatic portal vein Cancer of large intestine – deposits first in the LIVER because of the anatomical explanation. LYMPHATICS -Aortic chain – lymph trunk (intestinal trunk). -Cancer – travels the thoracic duct and travels to the neck to the subclavian vein and goes to the superior vena cava to the right side of the heart -> to the lungs (perfect repository for cancer cells). INNERVATIONS – plexus of nerves; mesenteric plexus; contain sympathetic and parasympathetic fibers around the main arteries. CLINICAL ABDOMEN Abdominal region – basis A. Chief complaint: B. History • Interview skills • Establish rapport • Present history , past history, personal and social history, family history, obgyne history • Accurate history -> DIAGNOSIS • Symptoms Subjective Nonspecific Ex. Pain, nausea, vomiting, dizziness body weakness, fatigue, anorexia Signs Objectives

Bowel sounds Absent Hypoactive Hyperactive -Ex: Bowel obstruction Hernias -Diaphragm  Bochdalek’s hernia  Morgagni’s hernia Mesentery – internal hernias 1. Foramen of Winslow 2. Paraduodenal hernia 3. Transmesenteric 4. Intersigmoid

1. -

6.

2.

-

Percussion • Dull vs. tympanitic • Fluid wave • Solid/cystic vs air Palpation • Soft/rigid • Masses • Tenderness Diagnostic signs • Rovsing signs - appendicitis • Murphy signs - cholecystitis • Sister mary joseph lymph node – masses in the umbilicus Peritoneal cavity • Site for fluid accumulation 1. Ascites 2. Chyle 3. Blood 4. Urine • Peritonitis 1. Primary vs secondary 2. Septic vs aseptic (chemical) Outcomes of peritonitis • Abscess formation • Adhesions • Secondary bacterial peritonitis Retroperitoneum • Nonspecific symptoms • Inaccessible • Delay in diagnosis -Pancreatitis, retrocecal appendicitis, urinary tract infection Diagnosis of abdominal problem • Careful, methodic, systematic, diagnostic approach • History • Physical Examination • Laboratory Tests • Radiographic and Imaging Studies • Prerequisite knowledge 1. Knowledge of etiology and pathologic processes 2. Anatomy and Physiology

-