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Abdominal AnatomySurface Anatomy • The abdomenisaflexible,dynamiccontainerbetweenthe thorax andthe pelvis • Itiseasilyexaminableandallowsclinicianstomakediagnoseson palpationalone • Itcanbesplitupintoeither4quadrantsor9regions • The 9regionsofthe abdomenare: • The rightandlefthypochondrium • The epigastricregion • The rightandleftflanks(A.K.ALateral regions) • The umbilical region • The leftandrightinguinal region • The pubic/hypogastricregion *The more up-to-date anatomytextbooksdivide the 9regionsbythe subcostal andtranstubercularplanesasthese are more consistentin everyoneAbdominal Surgical Scars • Due tovastnumberofabdominal surgeries,aclinicianmaysee manydifferent scarswheninspectingthe abdomen • These incisionscarsare: Ø Kocher–Allowsaccesstogallbladderandbiliarytree Ø Rooftop–Typicallyusedingastrectomyandlivertransplant Ø Pararectal –Largelyabandoned Ø Paramedian–Allowsaccesstolateral viscera Ø Midline –Allowsaccesstothe majorityofabdominal viscera Ø Transverse- Typicallyusedforlaparoscopicpaediatricsurgery Ø Gridiron–Allowaccesstothe appendix Ø Lanz–Allowaccesstothe appendix Ø Pfannensteel–Allowsaccesstouterusingraviduterus Ø Rutherford-Morrison–Typicallyusedinrenal transplants *MostAbdominal surgeriesare performedlaparoscopically butsome ofthese incisionsmaybe usedforquickaccessAnterolateral Abdominal Wall – Superficial Fascia • Above the umbilicus,the fasciaofthe abdominal wall isconsistentwiththe rest ofthe body • Belowthe umbilicus,the subcutaneoustissue isreinforcedandcansplitinto2 layers: Ø Camper’sFascia Ø Scarpa’sFascia • Camper’sfasciaisconsistentwiththe superficial fastofthe restofthe body • Scarpa’sfasciafadesoutsuperiorlyandlaterallywith the superficial fasciaof the backandthoraxandbecomesColles’fasciainferiorlyAnterolateral Abdominal Wall - MSKAnterolateral Abdominal Wall – MSK Sum. Anterolateral Abdominal Wall - Neurovasculature • The mainvascularsupplytothe abdominal wall comesfromthe superiorandinferiorepigastricarteries • Branchesfromthe intercostal,lumbaranddeepcircumflexiliac Aa.will alsosupplythe wall • The nerve supplytothe anteriorabdominal wall come fromthe lower6thoracicand1 stLumbarnerves • Importantdermatomesofnoteare: Ø T10–whichsuppliesthe umbilicus Ø L1–whichsuppliesthe Inguinal regionandgenitaliaAnterolateral Abdominal Wall – Venous Drainage and Lymphatics • The abdominal wall hasanintricate subcutaneousplexus • Thissuperficial venousplexuswill drainthe abdominal wall into: Ø The axillaryvein Ø The Femoral vein • The superficial lymphaticsystem,ofthe abdominal wall, will draininto: Ø Axillarylymphnodes Ø Parasternal lymphnodes Ø Superficial inguinal lymphnodesPosterior Abdominal Wall • The posteriorabdominal ismade upof3musclesnotfoundinthe anteriorabdominal wall: Ø Psoas Ø QuadratusLumborum Ø Iliacus • The transversusabdominusanddiaphragmwill alsomake upthe musculature ofthe posteriorabdominal wall • The nervesofthe lumbarplexuswill alsobe seenemergingfromthe posteriorabdominal wall.Theyare the: Ø Iliohypogastricnerves Ø Ilioinguinalnerve Ø Lateral cutaneousnervesofthe thigh Ø Genitofemoral nerve Ø Femoral nerve Ø Obturatornerve Ø BranchestoQuadratuslumborumandPsoas Ø Thoracicsplanchnicnervesmayalsobe seenpiercingthe diaphragm astheyjoinplexusestoprovidesymp.supplytoorgansPosterior Abdominal Wall – MSK Sum.Abdominal Aorta • The abdominal aortaisthe continuationofthe thoracicaorta • ItpiercesthediaphragmatT12 • The abdominal aortagivesof: Ø 3unpairedbranches: § CoeliacTrunk § SuperiorMesentericArtery § InferiorMesentericArtery Ø 5pairedbranches: § InferiorPhrenicArteries § Middle Suprarenal Arteries § Renal arteries § Gonadal arteries § Lumbararteries Ø 3terminal branches: § Leftandrightcommoniliacarteries § Mediansacral arteryAbdominal Aortic Aneurysm • AnAAAisaballooningofthe abdominal aortadue toaweaknessin the arterial wall • Itusuallyisasymptomaticunlessitruptures • ArupturedAAAisamedical emergencyandwill presentas: Ø Suddenabdominal painradiatingtothe backorflanks Ø Hypotension Ø Tachycardia Ø Collapse Ø Apulsatile,abdominal mass • Olderpatientswhosmoke are atagreaterrisk • Treatmentstoreduce the riskofthe AAArupturinginclude: Ø MedicationstolowerBPandcholesterol Ø Surgery(Ifthe aneurysmislarge enough) • Patientsathigherrisk: Ø Over65 Ø Smokers Ø HighBPandCholesterolRectus Sheath • The rectussheathenclosesrectusabdominusandpyramidalis • Itisformedbythe3aponeurosesofthelateralabdominalmuscles • The wall variesat3levels: Ø Above the costal margin: § AnteriorWall:Ext.Oblique Apo. § PosteriorWall:ThoracicWall Ø Betweenthe costal marginandarcuate line*: § AnteriorWall:Ext.Oblique Apo.+Anterior½ ofInt.Oblique Apo. § PosteriorWall: Posterior½ofInt.Oblique Apo.+ TransversalisApo. Ø Betweenthe arcuate line*andthe pubis: § AnteriorWall:3Aponeuroses § PosteriorWall:TransversalisFascia *The arcuate line islocated~1/3the distance betweenumbilicus andthepubicsymphysisInguinal Canal • The inguinal canal isanoblique passage betweenthe deepand superficial inguinal rings.Itisparallel andabove the inguinal ligament • The deepinguinal ringisahole inthe Transversalisfasciaandthe superficial inguinal ringisahole inthe Ext.Oblique Apo. • Itcontains: Ø InMales:Thespermaticcordstructures Ø InFemales: Theroundligamentoftheuterus Ø InBoth:Bloodandlymphatics, ilioinguinalnerveandgenital branchofgenitofemoral nerve • The wallsofthe inguinal canal are: Ø Anterior:Int.Oblique (Lat.)+Ext.Oblique Apo. Ø Posterior:TransversalisFascia(Lat.)+ ConjointTendon(Med.) Ø Superior:Int.Oblique +TransversusAbdominusFibres Ø Inferior:Inguinalligament+LacunarLigament(Lat.)Inguinal CanalHesselbach’s Triangle • Hesselbach’sTriangle isaregioninthe anteriorabdominal wall • Itcontainsthelayersoftheabdominalwallandmarksanareaof weaknessforhernias • Itsboundariesare: Ø Medial –lateralborderoftherectusabdominismuscle Ø Lateral –inferiorepigastricvessels Ø Inferior–inguinalligamentInguinal Hernias • Aninguinal herniaisaprotrusionof abdominal contentsintothe inguinal canal • Directinguinal herniasbulge throughthe posteriorwall ofthe inguinal canal.Indirectinguinal herniasbulge throughthe deep inguinal ringandintothe inguinal canal • Directinguinal herniasare foundinhesselbach’striangle whilst indirectinguinal herniasare lateral • Inguinalherniasarethemostcommonabdominalherniawith indirectherniasbeingthe mostcommontype ofinguinal hernias • All herniaspose ariskofstrangulationtothe herniacontentsand mustbe repairedearly • Astrangulatedherniamaypresentwithsuddenpain,nauseaand vomitingandarapidheartratePeritoneum • The peritoneumisthe serousmembrane thatlinesthe internal surface ofthe abdominopelvicwall andorgans • The peritoneal cavitycanbe dividedintothe lesserandgreater sacs.These sacsare incommunicationthroughthe epiploic foramen • The peritoneumcanfoldonitselftoform: Ø The GreaterOmentum–Afoldofperitoneumthathangs likeanapronfromthestomachtotransversecolon. Ø The LesserOmentum–Afoldofperitoneumthatconnects the lessercurvature ofstomachandproximal duodenumto the liver Ø Mesenteries–Afoldofperitoneumthatconnectspartsof the intestinestothe posteriorabdominal wall eg. Transverse Mesocolon,Mesenteryofthe S.IntestineIntra vs Extraperitoneal organs • Asthe name suggests,Intraperitoneal organsare those envelopedbyvisceral peritoneum. • Extraperitoneal organsare organsthatonlyhave theiranterior surface coveredbyparietal peritoneum • Aneasypneumonictorememberextraperitoneal organsis: Ø S-Suprarenal (Adrenal)Glands Ø A-Aorta/IVC Ø D-Duodenum(Excpet1 part) Ø P-Pancreas(ExceptTail) Ø U-Ureters Ø C-Colon(Asc.andDesc.only) Ø K-Kidneys Ø E-(O)esophagus Ø R-RectumQuestion 1 A 74-yearold man notices a lump in his groin. Hedecides toseetheGP. TheGPreduces thelump, puts pressureon themidpoint of theinguinal ligament and asks thepatient to cough causing thelump to reappear. Thepatient is diagnosed with a direct inguinal hernia. What anatomical structures will thehernia pass through? A) Deep inguinal ring and superficial inguinal ring B) Thefemoral ring C) Transversalis fascia and thesuperficial inguinal ring D) Thedeep inguinal ring and external oblique E) Rectus abdominusQuestion 1 A 74-yearold man notices a lump in his groin. Hedecides toseetheGP. TheGPreduces thelump, puts pressureon themidpoint of theinguinal ligament and asks thepatient to cough causing thelump to reappear. Thepatient is diagnosed with a direct inguinal hernia. What anatomical structures will thehernia pass through? A) Deep inguinal ring and superficial inguinal ring B) Thefemoral ring C) Transversalis fasciaand the superficial inguinal ring D) Thedeep inguinal ring and external oblique E) Rectus abdominusQuestion 2 A 86-yearold malepatient arrives totheED with sudden onset, abdominal pain that radiates totheback. On investigation you find that heis tachycardic and hypotensivewith a pulsatileabdominal mass. Hesuddenly becomes unconscious and is rushed to theatre. What is themost likely diagnosis? A) Myocardial Infarction B) SuperiorMesentericIschaemia C) PerforatedDuodenum D) RupturedAbdominal AorticAneurysm E) PulmonaryEmbolismQuestion 2 A 86-yearold malepatient arrives totheED with sudden onset, abdominal pain that radiates totheback. On investigation you find that heis tachycardic and hypotensivewith a pulsatileabdominal mass. Hesuddenly becomes unconscious and is rushed to theatre. What is themost likely diagnosis? A) Myocardial Infarction B) SuperiorMesentericIschaemia C) PerforatedDuodenum D) RupturedAbdominalAorticAneurysm E) PulmonaryEmbolismQuestion 3 A 56-year-old woman presents to theGP, a few months following a recent transplant operation. On examination of her abdomen, theGPsees a Rutherford-Morrison scar as well as a mass in the left inguinal region. What retroperitoneal organ has been transplanted? A) Kidney B) Rectum C) Adrenal gland D) Pancreas E) LiverQuestion 3 A 56-year-old woman presents to theGP, a few months following a recent transplant operation. On examination of her abdomen, theGPsees a Rutherford-Morrison scar as well as a mass in the left inguinal region. What retroperitoneal organ has been transplanted? A) Kidney B) Rectum C) Adrenal gland D) Pancreas E) LiverForegut, Midgut, Hindgut • Duringembryological development,the GITractisformedbythe endoderm • Duringthistime,the guttube canbe splitinto: Ø Foregut–derivatessuppliedbythe CeliacArtery(ApartfromPharynxandLower Resp.Tract).Itgivesrise to: § Pharynx § The lowerrespiratorysystem § The oesophagus § The stomach § The proximal halfofthe duodenum § The liver § The biliarysystem § The pancreas Ø Midgut-Itsderivatesaresuppliedbythesuperiormesentericartery.Itgivesrise to: § The restofthe small intestine § The large intestine uptothe distal 1/3ofthe T.Colon Ø Hindgut-Itsderivativesaresuppliedbytheinferiormesentericartery.Itgivesrise to: § The restofthe large intestine § The rectum § The upper2/3ofthe anal canalOverview of Foregut Arterial Supply • The arterial supplytothe foregutisfromthe celiactrunk • The celiactrunkquicklydividesinto3branches.Theyare: Ø The LeftGastricA.–suppliesthe stomachanddistal oesophagus. Itanastomoseswiththerightgastricartery Ø The SplenicA.-suppliesthe pancreas,stomachandspleen.Ithas 3branches: § Pancreaticbranches § Leftgastro-omental A.(AnastomoseswithRight) § ShortGastricAa. Ø The CommonHepaticA.–Itsuppliesthepancreas,stomach, duodenum,biliarysystemandliver.Itgivesofmanybranches, butitterminatesbybifurcatinginto: § The hepaticarteryproper–givesofbranchesthatsupply liverandbiliarysystem § The gastroduodenal artery–givesbranchesthatsupply pancreasandproximal duodenum.Oesophagus • The oesophagusisaling,musculartube thatconnectsthe pharynxto the larynx • ItdescendsbehindthetracheabeforepiercingthediaphragmatT10 andjoiningthe stomach • Itissplitinto4layers: Ø The adventitia Ø The muscle layer Ø The submucosa Ø The mucosa • There are 4areas ofitsdescentwhere foodislikelytobecome impacted: Ø ArchofAorta Ø Bronchus(Leftmainstem) Ø Cricoidcartilage Ø DiaphragmaticHiatusStomach • The stomachisa‘J-shaped’organthatliesinthe epigastricand umbilical regions • Ithas2openingsandisshapedbythegreaterandlessercurvature • The lessercurvature issuspendedfromthe liver bythe lesseromentum andthegreatercurvature isanattachmentpointforthe greater omentum • The stomach’sneurovascularsupplyis: Ø Arterial:GastricAa.,shortgastricAa.andgastro-omental Aa. Ø Venous:HepaticPortalVein • The stomachisdividedinto4parts: Ø Cardia Ø Fundus Ø Body Ø Pylorus Duodenum • The duodenumisa‘C-shaped’continuationofthe GItract • Itisthemostproximalpartofthesmallintestine • Itissplitinto4parts: Ø Superior Ø Descending Ø Inferior Ø Ascending • Neurovascularsupplytotheduodenumincludes: Ø Arterial: Superior.+inferiorpancreaticoduodenal A. Ø Venous:HepaticPortalVein Peptic Ulcer Disease • PUDisaconditioninwhichthe mucosaofthe stomachorduodenum breaks • Causesinclude: Ø H.Pylori Infection Ø NSAIDs Ø Zolliner-Ellisonsyndrome (Rare) • Itwillpresentas: Ø Epigastricpainwhichisaffectedbyeating Ø Bloating Ø Nausea • Treatmentisatriple therapy: Ø High-dose PPI+Amoxicillin+Clarithromycin/Metronidazole Ø High-dose PPI+Clarithromycin+Metronidazole • UntreatedPUDcanleadto: Ø Acute upperGIbleed Ø Perforationorbleeding Ø Gastricoutletobstruction Liver • The liverisalarge glandularorganlocatedinthe RUQ.Itisheld inplacebyamultitude ofligaments. • Ithasmanyfunctionsincluding: Ø Synthesisofbile Ø Glycogenstorage Ø Clottingfactorproduction • There are 4lobesofthe liver, 2mainlobesand2accessory lobes.Theyare: Ø The LeftLobe Ø The RightLobe Ø The Caudate Lobe Ø The Quadrate Lobe • The neurovascularsupplyofthe liveris: Ø Arterial:HepaticAa.(25%) +Hepaticportal vein(75%) Ø Venous:HepaticVv. The Biliary Tree • The biliarytree isaseriesofductsthatallownewlysynthesised bile tobe movedfromthe livertothe gallbladder(forstorage)to the duodenum • Bile (producedbythe hepatocytes)ismovedintothe hepatic ductswhichunite toformthe commonhepaticduct • The commonhepaticductisthenunitedwiththe cysticductso bile canmove freelybetweenthe ductsandthe gallbladder • Atthe site ofunion,the commonbile ductisformedwhich eventuallyuniteswiththe pancreaticductandreleasedintothe duodenum • The neurovascularsupplyofthe gallbladderis: Ø Arterial:CysticArtery Ø Venous:HepaticPortalVeinCalot’s Triangle • Calot’sTriangle isasmall anatomical space locatedatthe porta hepatis • The contentsofCalot’sTriangle are: Ø Righthepaticartery Ø Cysticartery Ø Lymphnode ofLund(the firstlymphnode ofthe gallbladder) Ø Lymphatics • Itsboundariesare: Ø Medial –Commonhepaticduct. Ø Inferior–Cysticduct. Ø Superior–Inferiorsurfaceoftheliver. • Calot’sTriangle isusedinaCholecystectomytoallowthe surgeonto safelyligate the cysticarteryandduct Gallstones • Gallstonesare solidcalculi thatformfrombile products • Theymayleave the gallbladderandblockthe biliarytree • People atriskare ‘the 4 Fs’: Ø Fat Ø Forty Ø Female Ø Fertile • Patientsmaypresentinavarietyofways: Ø Biliarycolic Ø Acute cholecystitis Ø Pancreatitis Ø Obstructive jaundice • Treatmentforgallstonesinclude: Ø Dietaryadvice Ø ERCP(Ifincommonbile duct) Ø TemporaryStenting(Ifincommonbile duct) Ø Lap.CholecystectomyThe Hepatic Portal Vein (HPV) • The HPVisalarge veinthatcarriesnutrientrichbloodfromthe intestinestothe Liver • The HPVisformedbythe unionofthe splenicveinandthe superior mesentericvein • The HPVentersthe liveratthe portahepatisandsplitsinto sinusoidswhichdrainintothe hepaticveins • All hepaticvenousbloodistakenupbythe hepaticveinsinahealthy individualPortal Systemic Anastomosis • Inahealthyindividual,allportalvenousbloodistakenupbythe hepaticveinsafterfilteringinthe liver • Inindividualswithportalhypertensionthisisnotthecaseandsome anastomosesmayformwiththe systemicsystem • Several collateral channelswill openinthiscase.The locationsof these channelsare: Ø The Gastro-Oesophageal junction Ø AnteriorAbdominal Wall Ø Ano-rectal junction Ø Betweenretroperitoneal veinsandmesentericveins • These channelsare weakandare likelytorupture andleadtofatal bloodloss • Onexaminationofapatientwithportal hypertension,youmaysee: Ø CaputMedusae Ø Anal VaricesPancreas and Spleen • The pancreasisaglandularorganwithbothexocrine andendocrine functions • Itissplitupinto5distinctpartsandcontainsaductsystemforits exocrine functions • The ductsofthe pancreasuniteswiththe commonbile ducttoform the hepatopancreaticampullaofVater,whichentersthe duodenum atthe majorduodenal papilla • The neurovascularsupplyofthe pancreasis: Ø Arterial:SplenicA.+Pancreaticoduodenal Aa. Ø Venous: HepaticPortalVein • The spleenisa secondarylymphoidorganwhichhasrolesin immuneresponse andremoval ofoldRBCs • The vascularsupplyofthe spleenis: Ø Arterial:SplenicArtery Ø Venous: HepaticPortalVeinQuestion 4 Which of theseis not a typical portal systemicanastomosis? A) Oesophageal B) Paraumbillical C) Rectal D) Retroperitoneal E) HepaticQuestion 4 Which of theseis not a typical portal systemic anastomoses? A) Oesophageal B) Paraumbillical C) Rectal D) Retroperitoneal E) HepaticQuestion 5 Ageneral surgeonisperformingalaparoscopiccholecystectomyona41-year-old,multiparousfemale patient.Ashe isperformingthe surgeryhe correctlyidentifiesthe cysticartery,incalotstriangle,andligatesit.Ashe doesthis,he cutsanotherstructure nearbyandthe patientstartsto bleed.Whatarteryhasthe surgeonmostlikelycut? A) Commonhepaticartery B) Righthepaticartery C) Lefthepaticartery D) Gastroduodenal artery E) CeliactrunkQuestion 5 Ageneral surgeonisperformingalaparoscopiccholecystectomyona41-year-old,multiparousfemale patient.Ashe isperformingthe surgeryhe correctlyidentifiesthe cysticartery,incalotstriangle,andligatesit.Ashe doesthis,he cutsanotherstructure nearbyandthe patientstartsto bleed.Whatarteryhasthe surgeonmostlikelycut? A) Commonhepaticartery B) Righthepaticartery C) Lefthepaticartery D) Gastroduodenal artery E) CeliactrunkQuestion 6 Apatientgoestothe GPcomplainingofepigastricpain.He tellsthe GPthatitisbetteroneating,andhe tendstofeel bloated.Hehashadbackpain forthe last3monthsandhasbeentakingover-the-countermedicationtorelieve this.Whatisthe diagnosisanditsmostlikelycause? A) Duodenal ulcerdue toH.Pylori infecton B) Gastriculcerdue toZollinger-Ellisonsyndrome C) Duodenal ulcerdue toNSAIDuse D) Gastriculcerdue toNSAIDuse E) Duodenal Ulcerdue toH.Pylori infectionQuestion 6 Apatientgoestothe GPcomplainingofepigastricpain.He tellsthe GPthatitisbetteroneating,andhe tendstofeel bloated.Hehashadbackpain forthe last3monthsandhasbeentakingover-the-countermedicationtorelieve this.Whatisthe diagnosisanditsmostlikelycause? A) Duodenal ulcerdue toH.Pylori infecton B) Gastriculcerdue toZollinger-Ellisonsyndrome C) DuodenalulcerduetoNSAIDuse D) Gastriculcerdue toNSAIDuse E) Duodenal Ulcerdue toH.Pylori infectionOverview of Midgut Arterial Supply • The arterial supplytothe midgutisfromthe superiormesentericartery • The SMAdividesinto4mainbranches.Theyare: Ø Jejunal andIleal Aa.–Supplyjejunumandileum Ø Middle colicA.–Suppliestransverse colon Ø RightcolicA.–SuppliesAsc.Colon Ø IleocolicA.–Terminal branchofSMA,suppliesileum,caecumand Asc.Colon • The SMAandIMAanastomose viathe marginal arteryJejunum and Ileum Jejunum IleumCecum and Appendix • The cecumisthe mostproximal portionofthe large intestine and attachedtoitisthe appendix • Bothorgansare intraperitoneal • The cecumactsasareservoirforchyme (whichitgetsfromthe ileum),andthe ileocecal valve preventsthe backflowofthischyme • The positionofthe appendixvariesbetweenindividualswiththe mostcommonpositionbeingretrocecal • The neurovascularsupplyforthe appendixis: Ø Arterial:AppendicularA.(FromIleocolicA.) Ø Venous:HepaticPortalVein • The neurovascularsupplyforthe cecumis: Ø Arterial:Ant.+Post.CecalAa.(fromileocolicA.) Ø Venous:HepaticPortalVeinAppendicitis • Appendicitisisacute inflammationofthe appendix • Causesofappendicitisisunclear,inmanycasesitisthoughttoeitherbe: Ø Hyperplasiaoflymphoidfolliclesinthe appendix (Paeds) Ø Fecalith • Apatientwithappendicitismaypresentwith: Ø Painthatstartsatthe umbilicusandmigratestoMcBurney’spoint Ø Lossofappetite Ø Constipation • Treatmentforappendicitisisanappendectomy • Untreatedappendicitismayleadto: Ø Anabscess Ø Peritonitis Ø Enterocutaneousfistula Ø SepsisOverview of Hindgut Arterial Supply • The arterial supplytothe hindgutisfromthe inferiormesenteric artery • The IMAdividesinto3mainbranches.Theyare: Ø LeftColicA.–SupplyDesc.colon Ø SigmoidAa.–Suppliessigmoidcolon Ø Superiorrectal A.–Terminal branchofIMA,suppliesproximal rectum • The SMAandIMAanastomose viathe marginal arteryColon • The colonisthe distal partofthe GItract.Itisinvolvedinabsorptionof electrolytesandwater. • The vascularsupplyfortheAsc.colonis: Ø Arterial:Ileocolic+RightcolicA. Ø Venous:Ileocolic+ RightcolicV. • The vascularsupplyforthe T.colon is: Ø Arterial:Right+Middle +LeftColicAa. Ø Venous:MiddlecolicV. • The vascularsupplyfortheDesc.colonis: Ø Arterial:LeftcolicA. Ø Venous:LeftcolicV. • The vascularsupplyforthe S.colon is: Ø Arterial:Sigmoidal Aa. Ø Venous:SigmoidalVv. • The colonhasomental appendices,haustraandteniae coli whichdifferentiates itfromthesmall intestine,aswell as,itslargerdiameter.Rectum • The rectumisthe mostdistal portionofthe colon.Itisinvolvedinthe temporary storage offaeces • The relationsofthe rectumishugelyimportantasitallowsthe clinicianto examine some internal organs.These relationsare: Ø Anterior(Male):Rectovesicularpouch,sigmoidcolon,ileum,bladder, prostate andseminal vesicles Ø Anterior(Female):Rectouterine pouch,sigmoidcolon,ileum,vaginaand cervix Ø Posterior:Sacrum,coccyx,piriformis,coccygeus,levatorani andthe sacral plexus • The vascularsupplyofthe rectumis: Ø Arterial:Superior+Middle +InferiorRectal Aa. Ø Venous:Superior+Middle+InferiorRectalVv.Anal Canal • The anal canal isthe final partofthe GItractandithasarole inmaintaining faecal continence anddefecation • Itissurroundedby2analsphincterswhichkeepitcollapsetilldefecation • The anal canal isformedbyboththe hindgut(above the pectinate line)andthe ectoderm(belowthe pectinate line) • The vascularsupplytothe anal canal above the pectinate line is: Ø Arterial:Sup.Rectal A.+Middle Rectal A. Ø Venous: Sup.RectalV. • The vascularsupplytothe anal canal belowthe pectinate line is: Ø Arterial:Inf.Rectal A.+Middle Rectal A. Ø Venous: Inf.RectalV.External Haemmorhoids • Haemorrhoidsare varicositiesofthe tributariesofthe rectal veins • Causesofexternal haemorrhoidsare: Ø Strainingsecondarytoconstipation Ø Increaseintra-abdominal pressureeg.pregnancyorabdominal masses • Patientswithhaemorrhoidsmaypresentwith: Ø FreshPRbleeding Ø Severe perianal pain • Managementforhaemorrhoidsinclude: Ø Dietaryadvice Ø Stool Softeners Ø Injectionsclerotherapyandbandligation Ø HaemorrhoidectomyAbdominal X-ray • Detailsofpatientandradiograph • Radiographquality Ø Whole abdomenvisible Ø Lateral wallsincluded • Obviousabnormalities • Bowel Ø Large bowel isperipherally+hashaustra Ø Small bowel iscentral withvalvulaeconniventes Ø 3,6,9Rule • Organs • Bones Ø Ribs Ø Vertebrae Ø SIjoint Ø PelvisQuestion 7 A32-year-oldpatientphoneshislocal GPpractice aboutasensitive issue.He reportshavingpainingwhengoingtothe toiletforabowel movement andnoticesbloodonthe tissue whenwiping.TheGPbringshiminforaPRexaminationandnoticesanabnormal,vascularsweelingexitingtheanal canal.Whatisthe mostlikelydiagnosis? A) Bowel Cancer B) Haemorrhoids C) Diverticulitis D) InflammatoryBowelDisease E) MesentericIschaemiaQuestion 7 A32-year-oldpatientphoneshislocal GPpractice aboutasensitive issue.He reportshavingpainingwhengoingtothe toiletforabowel movement andnoticesbloodonthe tissue whenwiping.TheGPbringshiminforaPRexaminationandnoticesanabnormal,vascularsweelingexitingtheanal canal.Whatisthe mostlikelydiagnosis? A) Bowel Cancer B) Haemorrhoids C) Diverticulitis D) InflammatoryBowelDisease E) MesentericIschaemiaQuestion 8 Youare onplacementandacruel,general surgeryconsultantasksyoutoidentifythe differentfeaturesofthe small bowel. Whichofthese isnota characteristicfeature ofthe ileum? A) ShortVasaRectae B) Abundentmesentericfat C) Multiple arcades D) Plicae circulares E) SmoothMucosaQuestion 8 Youare onplacementandacruel,general surgeryconsultantasksyoutoidentifythe differentfeaturesofthe small bowel. Whichofthese isnota characteristicfeature ofthe ileum? A) ShortVasaRectae B) Abundentmesentericfat C) Multiple arcades D) Plicaecirculares E) SmoothMucosaThank you