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Abdominal Blood SupplyLearning outcomes Identify the abdominal aorta and the branches of this vessel Describe the course and relations of the abdominal aorta Identify the coeliac trunk and the branches of this vessel Identify the superior mesenteric artery and the branches of this vesselWhere is the abdominal aorta? • Along posterior abdominal wall • enters at T12 through aortic hiatus • in front of vertebrae • Retroperitoneal i.e. peritoneum only covers anterior surface • @ L4 splits into common iliac arteries (become internal and external iliac arteries)Relations of the aorta Sympathetic IVC Aorta trunk Abdominal Organs Anatomical LHS Anatomical RHSBranches of aorta 1. Inferior phrenic 4. Middle suprarenal 7. IMA - Paired parietal - Paired visceral - Unpaired visceral - L1 - L3 - T12 - Adrenal glands - Diaphragm - Hindgut 5. Renal 8. Median sacral 2. Coeliac artery - Paired visceral - Unpaired parietal - Unpaired visceral - Between L1 and L2 - L4 - T12 - Kidneys - Coccyx, lumbar vertebrae, and - Foregut sacrum 6. Gonadal arteries 3. Superior mesenteric artery (SMA) - Paired visceral 9. Lumbar - L2 - 4 pairs parietal - Unpaired visceral - Male – testicular artery, - L1 female – ovarian artery - L1 – L4 - Midgut - Abdominal wall and spinal cordT12 -------------------------------Inferior phrenic (paired) Coeliac (unpaired) L1 -----------------------------------SMA (unpaired) Suprarenal (paired) Lumbar (paired) Renal (paired) L2 --------------------------------Gonadal (paired) Lumbar (paired) L3 -----------------------------------A (unpaired) Lumbar (paired) L4 - bifurcation ----------------------------------- Lumbar (paired) Median sacral Right common Left common iliac iliacCoeliac trunk and branches Branch of coeliac Branches Supplies Anastomosis Left Gastric artery Oesphageal branches • Cardia of stomach Right gastric artery • Lesser curvature of stomach • Oesophagus Splenic artery Spleen (Very wavy) Left gastroepiploic artery Greater curvature of stomach Right gastroepiploic artery Pancreatic Pancreas Short gastric branches Fundus of stomach Hepatic artery Right gastric artery Lesser curvature of stomach Left gastric artery Duodenal branch gives - 1 part of the duodenum Gastroduodenal artery R gastroepiploic branch (greater curvature) Superior pancreaticoduodenal (between 2 part of duodenum and pancreas) Gives cystic artery (neck of gallbladder) R hepatic artery L hepatic artery SMA and branches Branch of SMA Branches Supplies Anastomosis Inferior pancreaticoduodenal • Pancreas head • 3 part of duodenum Middle colic Proximal 2/3 of transverse colon Right colic Ascending colon up to hepatic flexure Ileocecal • Anterior ileocecal branch • Anterior ileocecal branch • Posterior ileocecal branch which Distal ileum, ileocecal valve, cecum, anastomoses with right colic gives anterior and posterior cecal appendix, and proximal ascending colon • Inferior ileocecal branch branch. Appendicular artery arises anastomoses with SMA from posterior cecal branch Ileal Ileum Jejunal Jejunum IMA and branches Branch of IMA Supplies Left colic • Distal 1/3 of transverse colon • Proximal Descending colon • Splenic flexure Sigmoid arteries • Descending and sigmoid colon • Becomes superior rectal artery after IMA crosses common iliac artery - Superior rectal artery supplies rectum, upper ½ of anal canal - Anastomoses with inferior and middle rectal arteries Marginal Artery • Anastomoses of colic arteries around concave margin of the intestine, forms single arterial line – marginal artery. • Begins at ileocecal junction, anastomoses with ileal branches of SMA and ends where it anastomoses with superior rectal artery. • Collateral blood supply in ischaemia Clinical relevance – Watershed area • Definition: area where a dual blood supply arises from the most distal branches of the 2 large arteries • This case - middle colic and left colic arteries anastomose • Splenic flexure • Marginal artery is a weak link between midgut and hindgut/ at 2/3 along the transverse colon • Makes area prone to ischemia Clinical relevance – AAA • Definition: dilation of abdominal aorta, with diameter >3cm • Risk factors: Ø Men (affected at younger age than women) Ø Smoking Ø Increasing age Ø Hypertension Ø FHx Ø Existing CVD Clinical relevance – AAA contd. Screening • All men offered USS @ 65 to detect asymptomatic AAA • NICE guidelines: women aged over 70 with risk factors can be offered routine USS • Aorta diameter >3cm referred to vascular team, urgently if >5.5cm Clinical relevance – AAA contd. Management • Stop modifiable risk factors e.g. smoking, bad diet and start exercise • Manage hypertension, diabetes, hyperlipidaemia Follow up • Yearly – 3 – 4.4cm • 3 mnthly 4.5 – 5.4cm Clinical relevance – AAA contd. Elective repair • When? Symptomatic aneurysm, diameter grows >1cm annually or diameter >5.5cm • How? Graft via open repair (laparotomy) or endovascular aneurysm repair (EVAR) – uses a stent through femoral arteries • Must inform DVLA >6cm • Stop driving >6.5cm • Stricter rules in drivers of heavy vechicles Clinical relevance – AAA contd. Ruptured AAA – Surgical emergency • Symptoms – severe abdominal pain that may radiate to back or groin, hypotension and tachycardia i.e. haemodynamically unstable, pulsatile mass, collapse, LoC • Permissive hypotension • Haemodynamically unstable – straight to theatre, forget imaging to confirm • CT angiogram – can be used to include or exclude in haemodynamically stable patients Question 1 A 75-year-old man developed ischemia of the splenic flexure of the colon. Which of the following arteries is most likely blocked? A. Ileocolic B. Right colic C. Middle Colic D. Left colic E. Left gastroepiploic Question 1 A 75-year-old man developed ischemia of the splenic flexure of the colon. Which of the following arteries is most likely blocked? A. Ileocolic B. Right colic C. Middle Colic D. Left colic E. Left gastroepiploicQuestion 2 A 59 year old man presents to GP concerned about risk of having an AAA. His friend recently passed away unexpectedly after having a ruptured abdominal aortic aneurysm. No other health conditions, non-smoker, drinks 12 units of alcohol per week, exercises regularly and maintains a normal BMI. Based on the screening program in England, when would he receive a routine ultrasound to assess for an abdominal aortic aneurysm? Question 2 A. Once at 65 B. Never – he doesn’t meet the criteria C. Every 3 years from 62 – 74 D. Once at age 60 E. Every 5 years from 65 - 75 Question 2 A. Once at 65 B. Never – he doesn’t meet the criteria C. Every 3 years from 62 – 74 D. Once at age 60 E. Every 5 years from 65 - 75 Question 3 Which of the following vessels arises from the abdominal aorta proximal to the coeliac trunk? A. Superior mesenteric artery B. Renal artery C. Inferior phrenic artery D. Intercostal artery Question 3 Which of the following vessels arises from the abdominal aorta proximal to the coeliac trunk? A. Superior mesenteric artery B. Renal artery C. Inferior phrenic artery D. Intercostal artery