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All right. Hi, guys. Um Per, would you mind just checking in a sec whether you can see the screen? Yes. Yes, that's fine. Perfect. It's the tech one done. Uh I'll give it to you about three minutes past probably just my washing as well in the background. All right guys. Uh So welcome to the um fifth session in the radiology, anatomy teaching today. We'll be going over the gastrointestinal anatomy and radiology. So, uh in the session, we'd like to cover a revision of the uh abdominal cavity, the underlying viscera, the upper gi tract and the intestines, uh including some basic radiological context to help solidify your, your knowledge. Um Before we begin though, just a disclaimer that this has been made by medical students for medical students. Um So any radiological teaching here will be at a very, very basic level that's accessible and appropriate to first year medical students studying at the University of Sheffield. Um Of course, you're more than welcome to watch if you, if you're not the target audience, but please just bear that in mind that we won't be going into too much complex radiology here. It's primarily a revision session. Ok. So to begin with the abdominal cavity, er, before we sort of like delve deeper, we just, er, need an appreciation of the surface anatomy. So the abdominal cavity can be defined by er, several palpable bony landmarks. If we start at the top here with the border of the thoracic cavity, you see that as you sort of trace the mouse over the costal margin and the xiphoid process of the sternum. Uh, this sort of acts as our, as our border between the thoracic and abdominal cavities. Of course, there's more definite border between the two, which is the, er, the diaphragm and there is communication between the, the two cavities through passageways or hes between the thoracic, er, sorry, within the diaphragm. Uh, can anyone give me the name of any structure that, that cross the diaphragm into the abdomen? Maybe in the chat? Just sort of about one or two? Mhm. I'm not sure if it's, uh, actually coming up um, on my screen. So I'm just gonna join in my phone so I can see the chat. So, Ben. Uh, you want a thoracic aorta? Yeah. So, yeah, so the THS fails, I guess. Yeah, but then when it comes into the, um, into the diaphragm, it comes the uh abdominal aorta. Um, have you got any other, um, aorta, any other structures? Um, I can try and join on my phone here. Ok. Sorry about that. Great. Yes. So, yeah. Thoracic a Yeah. So the, the aorta esophagus and effer vena cava, these are the main ones. Um, definitely the ones to bear in mind. Um, but also bear in mind the, um, azygos system of veins, um, as well as the thoracic duct, uh, the lymphatic duct. But, yeah, those three are the main ones. Um, and if we look, um, sort of more closely down at the, um, sorry, at the, um, inferior boundary of the er abdominal cavity, we see here, the um the pelvis and uh the borders here are the burny landmarks. Um Sorry, this, yeah, so we've got the um iliac crests here which are palpable posteriorly, the anterior superior iliac spines coming down here and towards the pubic tubercles. And these provide our landmarks for the inferior aspects and the ab abdomen is continuous with the pelvic cavity. Um So, you know, there's a lot of um sharing and overlap of different organ systems uh between the two here. But other landmarks to bear in mind would be the umbilicus which sort of sits at the, the midpoint of the abdomen. And it's also used to divide the abdomen into sort of various sort of quadrants um as well as the linear ow, which is this a tendinous white line that goes down the sort of the midline of the, of the abdomen. And that is um formed by the aponeurosis of these two muscles here. But we'll go into that in more detail later. So, yes. Uh As I have sort of hinted that before the abdomen can be divided into uh various sort of quadrants or regions, um There's two major sort of systems for dividing the abdomen up. First, we look at these um four quadrants. Um So as I said before, um this, there is sort of a, is an intersection at the umbilicus. So you've got a vertical line which is just the midline of the body and a horizontal line is a transumbilical plane. So, transumbilical because it crosses horizontally through the umbilicus and this separates our cavity up into sort of four quadrants. Um And these are quite sort of like a broad sort of overview. Um You know, if there's any sort of um sort of localized pain in any of the particular quadrants that can be quite useful for us for a clinical diagnosis. Uh But also more relevant if you're, I guess a phase one student at Sheffield, you have your er, two a of skis where you'd have to perform a uh gi or an abdominal exam. So you'd be talking in terms of uh in terms of abdominal regions or, or, or quadrants, er quadrants. Um But there's also uh another more specific way to divide the abdomen up and that is, so there are nine regions here. Um So I'm just wondering, can anyone tell me what the vertical lines at the nine regions are? So, with the four quarters at the midline. Uh but what are these two, these two lines here and and here and I'm just gonna very quickly join on my laptop test. Um So I can see the trap. So then we have got midclavicular line. So three people said mid midclavicular line. Yeah, I can see the chat now. So that should be, that should be all sorted. Yes, but yeah, no, the mid mid clavicular line here are our vertical lines. So sort of the midpoint of the clavicle and they're also used for the surface anatomy of the thorax. So, so describing the position of uh uh the heart and the lungs, for example. Uh but what about these horizontal lines here? So this uh upper horizontal line here and the one below down here, which uh which, which lines are these. So if we start with the, with this, this upper one here, um If you remember that um model, we were looking at the first slide um of the of the costal margin, this would sort of intersect like the lowest point of the costal margin. This top, this top line, if that gives you any sort of hints. OK. I'm not sure we've got anyone to say anything. So this, this top one here is a subcostal line. Um Yeah, as I say, you know, it's below the costal margin and this bottom one here is our intertubercular line. So it crosses the pubic tubercles. Um And this is, yeah, this is how we divide the abdomen up into our nine regions, which give a more sort of precise way of sort of identifying underlying structures and perhaps localizations of pain. Um And now if we look at the specific names of the regions, so we'll start with these sort of upper regions here. One and three. So what, what are the names given to come to this region? Yes. Um Right and left hypochondrium. Um But that is a very, very easy mistake to make that. Certainly, like I made last year. Um So yeah, the hypochondriac hypo because it's below chondria. So the, the con part refers to the some margin in the cartilage. So you might remember from histology, you got chondrocytes and chondroblasts uh for to do with uh to do with the cartilage. Um But yes, yeah. No. So hypochondriac is someone who's like perhaps overly sensitive to, to uh diseases and think they've got like various diseases when they haven't. Um But yeah, so the, yeah, these are hypochondriac and then what about this? Number two in the middle here? Yes. So, so number two is our epigastric region. Um And you know, so cool because it's the where, you know, most of the stomach sits. Um And if we move down now looking at four and six, yes. Yeah. So these are right in their flanks or our lumbar regions. Um I think you could basically both are exceptional exams, I think. Um and then number five right in the middle. Um There's a bit of a hint of in the photo. Yeah. So, so yeah, this is our, this is our uh umbilical region here. Um Yeah, and the, yeah, the umbilical is like the big sort of giveaway for this. Um And finally 77 and nine, he's still on the, on the one left. I just think about the, the underlying bones as well. Uh It's a bit of a bit of a giveaway. Yes. Yes. So our, our, our right and left. Uh yeah, freac region. Um And then, yeah, this one, this one in the middle on the right guys. Yes. So our, our suprapubic or hypergastric region um again, whatever, whatever you remember better, I prefer supra uh suprapubic uh cos you know, it makes more, more sense to me. Uh missing location. Yeah. So those are our nine regions. And now if we look at the um the abdominal wall, we're going to focus on the interior, lateral abdominal wall. I think the posterior you'll come back to in your sugar anatomy. So if you look at this diagram here, the abdominal wall is proposed of like, you know, various layers of skin fascia, muscle, and peritoneum. Um in terms of these two specific types of fascia campus and scarpers, I don't think it's as relevant to the Sheffield NBC HB Anatomy curriculum, but I did see it. I've seen a few like uh in a few sort of, er, peer teaching, uh, sessions and stuff like that. So I'll just go very briefly. Basically, essentially the cap camp fascias are a layer of, er, subcutaneous adipose tissues are subcutaneous fat and scarps, fascia is much more, er, a me, a me membranous sorry layer of fascia and this scarps fascia allows for the sort of movement of the campus fascia relative to the rectus abdominis and the other muscles of the abdominal wall. Uh, like I said, don't get, don't get too caught up into the specific eponyms. Um I think as long as you sort of, you know, realize that there's a layer of fascia between the skin and the muscle. Um and the purpose of the abdominal walls, the different tissues work together to, uh, you know, primarily protect the abdominal viscera and maintain the position. Um And we'll look a bit later as to what happens when, you know, that it fails in this task. Uh But also to maintain posture. So, you know, we talk a lot about core strength and we've got, um maybe, you know, if you go to the gym or like you, you know, somebody who does Pilates, you know, you got a lot of core exercises designed to help improve your sort of sitting and standing posture. Um Mine is awful at the moment. Uh Sorry, just got a self conscious. Um and finally, as well to increase the intraabdominal pressure. So these contractions of this muscle um increase the intradomal intraabdominal pressure, which is, you know, good for er, coughing. So, quite explosive, coughing, vomiting, childbirth, and uh you know, defecation as well. Um And now focusing in mainly on the, on the muscles of the anterolateral abdominal wall. Can someone tell me which plane is this diagram in which? Yeah. Yeah. Plane. Yes. Yes. So this is our, our transversal axial plane. Um We've got the er skin here sort of like marking the sort of superficial point and then it goes deeper in uh as we get to the bottom of the image. Um And now if we um have a look at these, these muscles here, so can someone tell me uh we'll start with number four, can someone tell me a what muscle this is? And b uh the direction of the fibers uh within the muscle. So you think these, these are the ones uh if you say that line al here is in the midline? Yes. Uh Yeah. So it is, yeah, it is Rectus Abdominis. Um but the um the fibers run vertically, it's um refer to as a, a vertical muscle uh as opposed to these sort of three on the sort of more lateral aspects which are called uh are flat muscles. Um But yeah, so this is, this is Rectus Abdominis and as you said before, the acne neuroses um of these two muscles form the linear alba. Um And now if we um have a look at these ones here on the lateral. So we go with the most superficial one. Number one, can someone tell me a what the muscle is? And b which way the fibers run? So if I told you that these muscles were oh perfect. Yes, external oblique. And yes, the fibers are diagonal. Uh specifically they go inferior immediately uh as opposed to uh number two, which is naming the fibers. So the most superficial one is the external week, the one um information deeper. Yes, internal oblique and the the fibers of this one run er superior media. So um it's important that these fibers run in opposite directions, but it just sort of adds er collective strength to the abdominal wall. Um And I think it is important to know like, you know, specifically uh where the fibers run, I mean, yeah, it's right, same diagonally. Um And finally here, this number three. So the diagram might be a bit of a clue as to the direction of the, of the fibers and which way they're run if you can sort of like um orient yourself. Yes. Yeah. So this is our, yeah, our Transversus abdominis muscle and the fibers in this muscle run horizontally. Um as you sort of, you sort of see it here, I'm not sure like how good the quality is. Um But yes, yeah. No. So these are the uh uh sort of main um muscles of the abdominal wall that you need to know for the curriculum. Um This isn't on the syllabus. Um But it's just important for the next slide. Um But as we have the linear alba here, this sort of tenderness, uh tenderness like band, we also here have this r um linear Semilunaris uh So semilunar line. Um and this can be seen on, on this er image here. Can someone tell me what, what type of imaging is this? Yes. Yeah. So this is a, this is a CT scan. Um And if you see if you sort of like on it yourself, so here there are um oblique muscles here, our rectus abdominis, our linear alba in the middle here and our linear silaris here. So you might have like noticed that like there's different in this um transverse plane, there's different thicknesses of the abdominal wall. So the muscles here are more thicker than these uh tenderness aponeuroses. Um And this can present with uh a problem known as uh herniation. Uh So, because some tell me what AAA hernia is um very broadly, you'd have to get like the uh dictionary definition. Yeah. Yeah. So it's, yeah, it's, it's some structure going where it's not meant to be. Yeah. So, uh specifically in this case, um it's the protrusion of uh sort of tissue uh through an opening in the cavity. So it exploits weaknesses in the um in like um in, in the cavity and like uh in the abdominal wall in this case. So as you see, the weaknesses here will probably be the uh linear alba and semi iris, right? Cos these are quite thin and these are just sort of tenderness as opposed to our thicker muscles. So we see in this image wall, we've got a, a umbilical hernia um and we have some protrusion of um I think it's, I think it's fat through the linear alba dividing the rectus abdominis. And number two, we've got a protrusion of the um of the bowel um through the linear selina. Um So, you know, when intra abdominal pressure increases, um the tissue is going to choose the path of least resistance essentially. And in this case, the least resistance would be our linear alba and semilunaris for them. You also get um this, there's another sort of um cause of sorry, another type of hernia above the umbilicus and you see another sort of protrusion of bowel. Um Yes. And yeah, this, this can cause uh ischemia uh especially, yeah, when the, when the bowel is sort of like pushed out like uh like blood vessels are constricted. Um And this here, number four, I think is quite an unusual one. cos you've got uh I think it's a, a lumbar hernia, it's called um yeah, and it's uh it's the, it's a herniation through the internal oblique aponeurosis in the, in the lumbar region. Um You don't need to know this for um ABC HB for um phase one, certainly just hopefully provide context as a, you know, whether we just down the abdominal wall. Um Another feature of the abdominal wall is the inguinal canal or inguinal canal. Um And this is like a passageway that essentially um connects the abdomen to the genitalia. It contains a lot of structures that are important in the, in the genitals, most of which you will learn in your sugar blocker. But, you know, for example, the sort of spermatic cord and some of the ligaments of the, of the ovaries. Um and this runs parallel to the medial half of the inguinal ligament. Um and it extends from the deep inguinal ring laterally to the superficial inguinal ring media. So as you say, it sort of runs diagonally towards the midline. Um and there are various borders of the inguinal canal and you know, this is probably quite a, a good exam question. I've seen it set in a few mops that I did um last year. So if we start maybe with the er anterior border, er can anyone give me um what the anterior border is is formed up of? I'll give you I'll give you a hint. Um Quite a helpful pneumonic for the borders of the inguinal canal is, is malt. So ma LT, so M stands for muscles, A for aponeuroses, uh L for ligaments and T for er tendons and something else. But I thought that would be going away too much. So, uh each letter here corresponds to uh a specific border and the main um type of tissue that, that, that forms it. OK. So if I give you uh ah external. Yes. Yeah. Yeah. Uh So, yeah, thank you. Um Arterial border is the aponeurosis of the external obliques. Um but also reinforced laterally by the apsis of the internal obliques. That's our a in malt. Um Now, if we go to the posterior border, um I will give you another hint and say that this is our um um actually would be giving it way too much. No, I'll say that this is, this is our, this is our tea in malt and this might be a bit a bit trickier. Um I think it's only briefly mentioned in the uh gi handbook. That's a, that's a good guess for the, for the floor. Um Yeah. No, absolutely. Um And speci specifically, I think the, the floor is the er inguinal ligament. Um And we're gonna see that on the diagram uh for the next slide. Um That's our, that's our l in the, in the acronym. Um So, yeah, a little bit um AAA little bit higher, I think than the um than the pelvic floor. But that is, that is a good guess. Um So you've got uh a and uh ligament we just need which of these are muscles and which muscles are involved and which of these are, are um tendons and something else, I'll say the other, the other tea is er transversalis fascia. So it's a tendon and transversal transvaal fascia that make up one of the borders. Um So fit for you to get as to which one. Yes. Yeah, it's the uh it's the posterior border. Um So uh transverse fas pretty all the standards but our tendon is this um chondro tendon uh which consists of the medial fibers of the internal oblique and transverse abdominis, uh aponeurosis. And so, yeah, together they form a chondroit tendon. And that way the transversalis fascia forms our posterior border. And the roof here is the um is our, is our muscle. So it is our internally can transverse abdominis as well as er transversalis fascia. So, you know, it's sort of perfect pneumonic, but it is um it is quite helpful and it might help to as well to sort of visualize this on this. I took again at the gi anatomy handbook. So here we've got our Deeping green ring and not here and then like our superficial green ring, as you can see, it passes through multiple layers of the abdominal wall, sort of end up more, more me rather than it started. Um So again, similar to the er abdominal wall um there you can get in renal hernias. Um and there's two types of irenal hernia, there are direct and indirect inn hernias. So, uh direct inn hernias are more common and these um protrude medial to the inferior epigastric vessels. Um and they pass through directly through the abdominal wall, um particularly in this area, this re triangle or hes triangle. Um and this can be sort of a point of weakness and a point of protrusion for hernias. So, II don't think you need to know specifically this for the M BC HB. But um give you some context of these images here on the, on the right. So we've got this triangle made up of our registered abdominal media immediately, uh inferior epigastric vessels laterally in the valves and the inguinal ligament. Um and then the second dose, the indirect er inguinal hernias which are protruding laterally to the epigastric vessels uh into the inguinal canal. Um and these are especially less common in females due to the presence of something called the broad ligament which you come to in, in sugar. Um And a little bit of trivia here. Um These are actually my uh medical notes from when I was a baby. So this was just after I was born and I had a a right renal hernia. This could be sort of, you know, quite common in Children and babies, especially premature babies as well because of, you know, weaknesses in uh sort of various tissues and walls. Um And then a few years later when I was, I was a bit older, I had a a left immunal hernia. So, you know, hernias can occur more commonly if you already had one before. I don't remember the exact causes of these. I think the one in 2007 and I'm lifting up like a, a big red boat in my garden. That's quite heavy. Um So I think it was like, you know, my muscles core muscles were contracting and increasing the abdominal pressure and I think maybe that, that was, that was why, but I'm not sure why. I'm just misremembering that. Um um Yes. So uh again, back to the nine regions. So if we look at the um uh viscera beneath each of the nine regions, so, uh in each region, I have omitted one of the organs um that exist within the region. Um So, you know, if you guys just take a look at the other organs there and sort of like try and visualize the um internal anatomy as best as you can from your, your anatomy sessions and tell me which organ is missing in each region. So we'll start with the right hch we've got the liver, the right kidney and the small intestine, but which organ here is missing? Yes. So the gallbladder um yeah, comes in uh basically the power of the liver. Yeah. And then we move over to the er epigastric region. Uh This one hopefully should be sort of fairly er apparent that the liver, pancreas, spleen adrenal glands, er duodenum. And what else is missing. Yeah, the stomach. So, yeah, that's where the bottom of the stomach and then over to our left hypochondriac. So we've got like, obviously because the liver is massive. It sort of spans these regions and the very tip here is in the left uh as well as the, yeah, stomach pancreas, left kidney, uh large and uh sort of uh small intestine. And uh and what? Yes, that's the uh yeah. Oh, sorry. Uh Yeah, the spleen. Um And now we move, um let's move to our, um let's move to the right lumbar region. So we've got our ascending colon, small intestine. Um And um what else? Um I'll give you a clue and say it's not intestinal, the answer I'm looking for. And if you want another clue, you can just look at the, maybe the, the other side, um the opposite side, try and sort of figure out what, what's missing here. Yeah. So uh my right kidney here and then we move into the er umbilical region, uh duodenum, small intestine. And um oh, I'll give you for this one. It is, it is um intestinal and you might be able to work it out based on like the other sort of surrounding regions which, which part of it is. It's part of a large intestine. Yes. Yeah. Our tran our transverse codon. Um So I've got the ascending colon here. It goes on to the transverse codon and then to our left lumbar region. She got a small intestinal uh left kidney Um But, but what else? Yes. Yeah. Yeah. So our, our, our descending cone on. So up across, down um and then right iliac. So a, a caecum ascending cone, a small intestine. Yes. Appendix. Perfect. And then uh suprapubic or hypergastric region. It's got siga small in testing reproductive organs. And that's quite, yeah, quite a, a big one that's sort of associated with this region. I'd say I'd say the big like significant, yeah, bladder and then finally left iliac um passed the descending colon, small intestine. Um This is uh intestinal, what I'm looking for, I say as well. It's also sorry, this might, yeah, it might be very unhelpful, but it also has been mentioned in uh it's also uh in a previous region. Um Sorry, it's part of an organ. Yeah. S one trade off. Perfect. Um So yeah, it, it's just good to get like a visualization of these sort of my regions. So you have like a understanding of where things are in the, in the abdomen. Um And now we look at some imaging. So again, another CT image. Um so this time we're going to try and identify the er different viscera here. Um So start with um number eight here. One. Quite a big one. Yeah. So this, yeah, this is our, this is our liver on the, on the right side here. And um number one. Oh gallbladder one. Yes. Yeah. No, number one is our, our gallbladder. Yes. Yeah. So um if we move over then yeah, to number number two, think of your nine regions as well. I'll try and like, I guess, translate it uh in your head to a Coronal plane. Yes. Yeah. So this is our, this is our stomach and uh maybe at this sort of level, you can sort of appreciate how this would be like the sort of the epigastric region um moving on to number three, just posterior to the stomach. So, pancreas, yep. And number four, these sort of blobs uh to um natural size here. Not quite the um not, not quite the big hair. Um I think it would be more sort of around, around here. Yeah. So it's actually, it's actually quite hard to like um identify specifically what it is. But yeah, it is uh in intestines. Um I mean, you sort of guess from like the position that would be the um like large intestine, which is sort of framing the um the small ones here. Um And then if we move on to um we want to list number five here. So this is quite like a, a white structure which indicates that, you know, not many x rays are passing through, which might, you know, might mean it's a quite a high density tissue. Yeah, this is, this is rib. Yeah. And um number number six here just in front of this around here. I'm sorry, it's not perfect with the labels. But maybe if it, it helps to sort of think about where it is in relation to some of the other organs that you can identify. Mhm Yeah. Not quite um nerves here. Yeah. Again, I appreciate it's not, it's not very clear on this. Um Maybe, maybe we should just, maybe take a look at this and this, in particular um these two structures here and how close they are. So if we say if we say that these um these here are, are what some, let's le let's move on to number seven, we'll come back to six kidneys. Yeah. And so we know that number six is in quite sort of close proximity to the kidneys s on this uh CT adrenal glands. Yes, thank you. Yeah. So this is uh this is our left adrenal gland here and again, yeah, this was quite difficult cos of this number 10 sort of massive label in the way. Um someone has mentioned um what number 10 is, but it is completely, I think occlu by the label, which isn't very helpful, but this is our AORTA. Um And finally, number nine. Yeah. So this is this number nine is our uh vertebral body here. Um I think uh thoracic because of the, the heart shape of the, of the body here. Um And the fact that your kidneys are sort of like a can be at the level of T 12. Um but II say, er I was just gonna say guys, we're not showing you these CT scans for no reasons. Er, even if you're phase one, they could still test anatomy while giving you an X ray or a CT scan and asking you to identify what it is. Er, because you're taught some basics. So, um, but he just does put it in more practice, I mean, no, no, no, no worries. And I absolutely, II think what I found like, particularly helpful um for like, trying to identify organs on the CT scan. I know some people have like a love hate relationship with ac, but there's a feature where you can sort of, it's called image occlusion where you can sort of basically put the labels that I have these, you know, around the la here. So just sort of them and then you sort of test one at a time and then if you do that sort of like every day or however much a you schedule it, you do begin to get an app over time and it becomes sort of like second nature. Um I mean, that goes to like basically any sort of like er anatomy. And uh yeah, but yeah, that probably says you might get some spotter type questions based on the, on the CT. Um And yeah, if you look at the um this uh that's the peritoneum. So peritoneum, um much like the pleural and the thoracic car um are two continuous layers of connected connective tissue lined by mesothelium. Um And this might be like going up a little bit of the scope. Um But what, what sort of time of epithelium is mesothelium? So, it's more of a histology question. So, you know, I II I'll give you, I'll give you this one. It's, um, it's a simple squamous epithelium and um, our parietal peritoneum lines the internal surface of the abdominal pelvic walls. This is the cavity, much like the parietal pleura and the thoracic cavity. And the protein as it most suggests covers the abdominal organs, abdominal organs. Um and these two layers are separated by a thin layer of fluid, about 50 to 100 mL for, you know, for lubrication. Um and uh interestingly, pain is felt differently in both peritoneal peritoneal layers. So, uh uh pain in the parietal layer uh is different to that in the visceral er layer. So maybe someone can tell me er why this is and what the difference is between the types of pain are. Yeah. So, so um our pa peritoneum is our uh yeah, innervated by the same somatic nerves that innervate the abdominal wall. So this pain tends to be sort of sharp and severe and well localized. Whereas our visceral peritoneum is innervated by er visceral nerves. So the nerves that invade the underlying viscera and tends to be more dull and diffuse. And there's a embryological reasoning in different parts of like the Meder I think that explains it, but I'm not entirely sure you need to go into that much detail. Um And likewise, there are some uh there could be some issues with the uh peritoneum. So, um on the left here, we have um uh a patient with uh ascites. So it's, there's a build up of uh that uh peritoneal fluid in the cavity. Um I think it's clinically significant when it comes greater than 500 mL. Um And the most common cause is uh liver cirrhosis causing portal uh hypertension. So, increase in BP in the portal system. Um And I think this particular patient had um testicular cancer because I think it can be associated with, with cancer as well. So they had a drain inserted um because the ascites wasn't going away because of the medication, which you can sort of see here. And I think on an X ray, it's like, um you know, you get like this sort of haziness. Um but it's, you know, mainly diagnosed sort of clinically by observation, maybe percussion. Um And you know, the biochemical makings of the acidic fluid can tell us a little bit about the underlying cause. Um And secondly, we look at the CT scan here on the on the right is showing us uh peritonitis. Um So, uh in act this uh is seen as like smooth, thickening of the peritoneal layers as well as localized er collections of fluid here. And you see some sort uh interconnecting collections here. Uh and this can be caused by inflammation of the er organs underneath it. So, for example, appendicitis uh but it also can be due to infection, for example, er spontaneous bacterial peritonitis uh due to a bacterial infection. And there's something I haven't shown here which is um peritoneal adhesions. So, uh adhesions and then I suggest uh uh where the peritoneal layers stick together and this can be due to um damage in one of the layers. So when one of the layers gets damaged, it releases um uh produces fibrins or scar tissue and then this causes the two layers to sort of stick together. Um So yeah, we talked about the uh the person and, but we also have this uh retro personal space where the organs within are normally only covered by peritoneum on, on one sort of one aspect and like a, you know, good. You want to remember um the retroperitoneal organs is sad pucker. So I'm just wondering like it doesn't have to go, don't have to go through it and all day if anyone could just sort of like give me a name of any organ that's retroperitoneal. Yep. So you got super renal guns. Yep. Kidneys. Yeah. Esophagus, I think just because we might be at risk of running over slightly. I'm just going to, yeah. But yeah, basically s are suprarenal adrenal glands. A is ac duodenum, the pancreas and the exception of the tails are p ureter, kidney esophagus is, I guess an Americanized spelling in our rectum. All of these are, are retro peritoneal organs. So just, you know, remember the pneumonic you should be fine. Um And then finally on uh on the protein. So we have um yes, it's very useful at sort of um anchoring organs to certain other aspects in the abdomen. Um But also, you know, it can form these um reflections that facilitate neurovascular supply to various organs. And the two that you know, there are the Mery and the omentum. So can anyone tell me the difference between the Mery and the omentum in terms of the principal organ involved? So this is the organ being anchored. So start with the mus tree which, which organ is being anchored in the, in the mus tree, I guess organs. Yeah. Yeah. Yeah. So it's a part, parts of our large intestine. Um Yeah, are um anchored by the mu tree but also, yeah, the small, small intestine as well. Uh Absolutely. And what about the, the amenta two are going to say, I think one's more uh I guess um obvious than the other. Yeah. Yeah. The stomach and liver are are, yeah, definitely, definitely involved. I guess it depends on what your sort of definition of anchor is. Um But yeah, the duodenum is also also um connected by the omentum. Um And so what are the, what are the connections? So the music tree connects smaller parts of the large intestine to what I'll give you another clue. It's not another organ almost. Yeah. So it's, it is the abdominal wall but it's the um, the posterior um posterior abdominal wall um for the small and large intestines. Um And what about the stomach? So, just give me another like um another sort of few catches someone's already mentioned the liver, which is correct. Um But there's two more that I'm looking for. Oh, yeah. So, yeah. So the omentum connects the stomach duo is the small intestine, transverse colon and the liver and omentum is divided into a greater omentum and lesser omentum. So the greater omentum gets the greater curvature of the stomach to the small intestine. The lesser omentum connects a lesser curvature of the stomach and the duo to the liver. Um But also interestingly, there's a structure, a lesser omentum that's sort of embedded in the lesser omentum. Can anyone tell me what the name of the structure is and what their constituents are? Uh It might help to think about like which organs are involved in terms of connections of the lesser omentum, specifically the stomach and the liver. Yeah, that's not a, not a bad guess, but I was thinking maybe of the um the portal triad. Um So this is our hepatic portal vein, um bile ducts and hepatic artery. Yeah. So the gallbladder. Yeah. Um certainly like um involved in like the um in the bar aspect of it. Um Yeah. So if we look at the uh blood supply generally of the abdominal viscera. So, you have, um, three major unaired arteries, um branching off off the abdominal aorta, uh Celac trunk, uh superior mesenteric artery and our inferior mesenteric arteries. These are quite, you know, sort of just easy to remember. Um, just, yeah, like a, a flash day or two. and what are the, um embryological re er regions that the celiac trunk supplies in the abdomen? So, looking at sort of embryological divisions, what, what is uh the celiac Trump's supply? Yes. For gut and uh superior mesenteric, Medgar and fine are inferior mesenteric. Hi gut. Yes. Um And there's also sort of like a, a parallel splanchnic nerve, uh sort of synthetic splanchnic nerve supply as well that follows the same embryological divisions um are um greater or lesser and least splanchnic nerves for um supply of the foregut, make it high up respectively. Um So we're looking at more the uh upper gi tract. So we're gonna start with the, the distal esophagus. So the esophagus crosses the diagram of the esophageal hiatus, which spinal level is that. Yes, T 10. And this is an area of constrictions. This is where food is, you know, along the, because there's a number of areas of constriction this to one of them and this is where food could be likely to be lodged. Um And the muscle fibers surrounding the hiatus. Um They constitute what's known as the lower esophageal sphincter, which is a functional or physiological sphincter. Uh And functional sphincters, their opening and closing isn't dictated by a specific localized muscle, but rather by the surrounding muscle fibers as well as other um um anatomical er features. So we're going to that a little bit later when we look at the stomach. Uh but what's the um the arterial supply of the um of the distal esophagus? Yeah, vagus, vagus nerve gives us our parasympathetic. Um Yeah, and that's important for peristalsis. So, remember that sympathetic is breast and digest. So you vagus initiates peristalsis which is like the movement or sort of the waves, I guess down the esophagus that propels the bolus from the, from the start to the stomach. Um But yes, the uh arterial supply here is, are, are left gastric artery and similarly uh oh no, actually hang on, sorry, gave that one away. But yeah, venous drainage is through er esophageal veins and the systemic venous system. Uh where do these esophageal esophageal veins drain into as well? Um Afterwards, yes. And they drain into our, yeah, azygous system of veins. And what about um another, another um system of drain venous drainage from the uh from the stomach? See, we've got the systemic one here of the esophageal vein. So, what's the other one we're looking for? Yes. So uh yeah, plastic portal vein. Um and as I mentioned, the nervous supply gives us our parasympathetic innervation and we have branches, oh sorry, branches of the sympathetic trunk, which gives us our sympathetic innervation um in terms of the radiology. So, um we can assess the um the esophagus using what's called a barium swallow. So, uh patient will drinker solution of barium sulfate. Um and that shows up really well on like a X ray arthroscopy. And that can like uh tell us about the um the condition of the esophagus. So whether you have any sort of diverticular tumors, um or ulcers or something like that, we can use uh sort of tracking the, the progress of the barium down the esophagus to sort of try and assess that. Uh But it's also quite useful for um looking at the swallowing um process. So in patients that have had like, you know, recently had like a stroke or might have other swallowing impairments, you know, you can sort of identify where the problem might be using that. So it's quite, it's quite like a useful technique. Um And yeah, so now I'm moving onto the, onto the stomach. So again, this is quite like, ii think this is quite a good exam question. You might have had an I LA on it or might be having an I LA on it. Um We start with number one here. Um which is our, yeah, I'm just say it's our esophagus. Um And then what part of the stomach. Does the esophagus feed into? Not quite the funest, but I, yeah, I ii appreciate why he said that cos they're very sort of close to each other. Yeah. So it feeds into our, our cardia and this angle created between the esophagus and the cardia. Um also contributes to our lower esophageal sphincter. Um Can anyone give me the a, a name if they know it for the, for the angle between uh between these two, I give you and say the name is also a, you know, a bundle found in the heart. Ok. So it's the um it's the the angle of his uh his um that yeah, is it between the esophagus kind? And as I said, like that plus the muscle um surrounding muscles er contribute to our lower esophageal sphincter. And then we go to number three. which yeah, which is our fundus. Um And you know, like many, many sort of like, I guess sacks in the body have a fundus, uh not just the stomach, the bladder and the um uterus as well. Uh So our, our bolus what comes time when it passes into the stomach and mixes with the uh gastric acids, an enzyme. So it comes into the, into the cardia and the fundus. And then where, where is this for this main bulk here? Number 10. Yes. So this is our, this is our body. Um and this is where the um sort of smooth muscle in the, in the, er, in the stomach, sort of contracts and sort of churns the chyme and mixes it with the gastric secretions. And then finally, sorry. No. And then furthermore, uh where does it pass after it um goes through the body like the, this area here. So number five, I can be clear and say that this region of the, of the stomach is known as the pylorus. Ok. So number five is our pyloric antrum and then this sort of narrowing is our our pyloric canal. Um And then both of these lead into our pyloric sphincter here. So, uh pyloric sphincter allows for a metered delivery of chyme into the duodenum because it's got much less sort of capacity for distension in the stomach. So, the majority of the time is sort of reflected back into the body where it's sort of further mixed. Um And I've also given you that number seven way, which is the duodenum. Um And what about these two sort of um these um this aspects of the um yeah, lesser culture and the greater curvature. Um And so, yeah, the stomach is primarily in the left upper quadrant, but it spans over multiple regions. Um The body is an intraperitoneal organ and you see this chest X ray scan here in this uh bottom left hand side, we've got like this gastric bubble. Um And this sort of identifies the fundus of the stomach and, you know, it can be useful in the position, in the position of the gastric bubble can tell us stuff like whether, you know, there's a esophageal hernia. So the stomach is pushed into the esophagus or not. And yeah, the anterior surface of the stomach, the diaphragm methy over the liver and the abdominal wall. Um those are all like, yeah, points of contact. And posteriorly, we have the uh the pancreas. Uh So if we look at the neurovascular supply of your stomach, we've done this, uh, a few slides ago. What's the major abdominal impaired artery that supplies the stomach? Ok. It's a, it's a celiac trunk. Uh cos it's a, it's a four gut structure and uh anastomose run along both the curvatures of the stomach. So we've got the greater curvature and which, which arteries uh make the er anastomosis of the greater curvature. They will know it's union of 22 arteries. Sorry to interrupt again. Ben. So we've sent out the feedback form if anyone wants to fill it now, but again, I don't feel like you need to do it now. We'll just put it there here if anyone needs to leave urgently. Yeah. Yeah. No, absolutely, no worries. Yeah, I think we've run slightly. So I apologies for that. Uh So one of the greater curvature, we've got the gastro mental arteries, the right and left and a lesser curvature. We've got the right and less gastric arteries, um, and venous drainage of the stomach is uh, yeah, for gastric and gastro mental veins which uh, ultimately drainin into the portal, um, hepatic portal vein, um, and innervation of the stomach. Very similar to the esophagus is through our vagus nerve. Uh, and, uh that's a sort of parasympathetic innervation. That's what seeing us a lot of the peristalsis, um, and sort of churning of the stomach. Um, and yeah, this, er, greater splanchnic nerve is our, oh, sorry, is our sympathetic er innervation again. Remember it's a, it's a, it's a foregut organ. Um So we've done, I think in the interest of time I might just go over this. So, yeah, so we've got another ct this time in the coronal plane and we're focusing here on the, on the intestines here. So, um we can see, er, here we've got this hepatic flexure which um uh a hepatic cos it's near the liver and it marks the er transition of the ascending colon into the transverse colon. And then, uh you can see some mesentary here that sort of anchors the er intestines to the posterior abdominal wall. You see all this here and it's sort of quite richly um uh vascularized. Um, and then, yeah, small bowel and right here in the supra region is our bladder. Um So looking again at the small intestine, um we've got our stomach and our duodenum here and then duodenum is the first part of the swollen intestine. And what does that feed into what's the second part? Yes. Uh Judum, uh, a lot of the fluid and, and, and iron is, er, is, is absorbed and then, er, it's not actually, er, it's not labeled on here. Um, but what's, what comes after the Judum, the final part of the small intestine around here? Yes. The ilium here. Yeah. And then we've got this, this valve between the ilium and the first sort of structure of the, uh, the large intestine. What, what's this valve called? Number four? Er So, oh yes, thank you. Yes. So this is the er ileocecal junction which means that number five must be the uh oh no, sorry. Er number six rather is the er is the caecum. And then, yeah, we go up into the ascending colon and what's this little bit here? Um just at the bottom of the cecum called just the appendix. So, looking at the, at the duodenums, you see it sort of um exits the stomach here, sort of goes around the head of the er er pancreas and yeah, then just begins um the geum. So it's 12 finger wits long, hence the name duodenum. Um So what is this, this structure here? Duodenal Lar, what does this sort of represent? So I told you it was the Yes. Yeah. So this is the um uh yeah, it's the opening of the bile duct and also the merger of the common bile duct and the pancreatic duct. Um The, yeah, the slide isn't, isn't great. So probably we should, should. It, um, but it also re, er, represents, er, something else. Er, and, yeah. Yeah, perfect. Yeah. Uh, but it's also the, um, er, end of the foregut and the beginning of the mid gut. So, with that in mind, what is the first half of the duodeni supplied with? So be before the, er, papilla. So, w what artery that? Yeah, poorly, poorly phrased. Uh what artery supplies the first half of the duodenum? So it's like thinking broadly, yeah, like um the great sort of abdominal impaired arteries. Yes. So branch of the sea electrons supply the first half of the Juden and the second half of the duodenum is supplied by what, which other artery thinking superior, er, sorry, I think make up, yes, superior mesenteric. Um and then looking at the er, and er, the alium. So, you know, these are um sort of very large and they're also folded uh for a larger area for absorption. Er, and these, what's this, what's the name of these folded mucosa of the J and alium? No, not quite uh J but I understand Jan said that um it's actually the um the, the PK er circularis um and this a provides a, a great alongside the villa and the Microvilli. So, er P circularis we find both in the J and the uh and the, the alium er, in the Jejunum, they're more prominent, pronounced whereas the alium. They're sort of like, less, yeah, less numerous. Um But we also have um these um sub submucosal patches as well called Payers patches. Um And they're in uh either the Geum or the, so where, where are they, are they in the jun or the alium or the II, don't know how, how everyone pronounce it. Yep. So they're in the, yeah, they're in the, in the ilium. Um So just something to remember again, quite like a fairly standard s pa question, you know. Um And then if we look folks in on the sy enteric art, um so we've um uh cover this again briefly the slide before where, where does the superior mesenteric artery leave the abdominal aorta? Which spinal level? Uh OK. So it's uh it's, it's L1 is the, yeah, the vertebral level that it leaves and then this splits into about 20 anatomizing branches um that um supply the, um the small intestine. Uh does they all know what these, what these branches are called? Also a name for a place that you go to play? Like retro games? Yes. Yeah, these are arcades. Um So you can sort of see here. Uh these sort of loops here are arcades and um yeah, this, yeah, but these arcades project er, straight arteries, er, which is the part of the intestinal walls. They don't know the name of these straight arteries. I will give you clear and say it's on, on the diagram at the bottom, right. Um Yeah, so these, sorry, these are uh vasorex. Um and these are embedded in the music tree of the small intestine, as I said, you know, it's quite important for the neurovascular supply and we saw on the CT as well that it was quite richly vascularized. Um And yeah, these are sort of our relevant branches that s uh supply the small intestine superior mesenteric artery. So we've got the agin uh I II ilio artery. Um, and now looking more at the large intestines. So we've basically, yeah, we've basically done the er, appendix and cecum. Um I'm trying to remember what this, er, flexure was called thinking of where it is in proximity to other organs. Yes, this is uh hepatic collections. It's close to the liver. And on the other side, we have what, which flexor our splenic fles close to the spleen. And then we've got eyes, yeah, descending colon and a this bend. Um What's, what's this called sigmoid? Absolutely. And then that feeds into what the rectum. Perfect. Yes. And then uh we also uh if you look into the er, internal anatomy of the intestines, um, so we'll start uh in the walls um of, of the, of the intestines. So we've got like a number of different structures that differentiate the large intestine from the small intestine. So firstly, look at these like longitudinal sort of uh muscle bands. Um because we know what these are called, they're quite difficult to spell, I'm not sure I spell them. Right. But yes, these are, yeah, tenure Coli. Um, I think so. Yeah. Um, and there's, I think about three of these long bands and they're involved in sort of peristalsis but also the formation of these, er, sort of compartments. Does anyone know what these are just uh along here? So, so these are our um hus or Fust administrations. Um And then finally, we've got these um uh lymph nodes sort of embedded in the wall and these are um uh epiploic appendages or a mental appendices. II, go with epiploic. I think that's what it's written in the anatomy handbook. Um And I think the purpose of which is to try some sort of um immunity, I think protection as well against peritonitis. But again, I think for phase one, you just need to know that they are there in the large intestine as opposed to, as opposed to the small. Um And if you look at it on an X ray, it can be quite hard to see. But if you look here at the level of the splenic flexure, I think Prolia is actually helping me out by tracing over it, you can sort of see these, these house here and as they go down, you've got the, the descending colon, transverse colon here. Um We see, I see both the ascending as well. Um So we know this is our largest intestine because it's sort of more peripheral, the last one intestine located in the, in the center. Um But when we, when we look at the er intestines, we employ something called the 369 rule. Um So if we look at these, these, how are here, um this rule um refers to the, the caliber of the intestines. So the, the diameter. So um I can see um small intestine, um, anything over three centimeters is considered to be uh distended. Uh small intestine, large intestine is uh six centimeters with the exception of the cecum, which is nine. So as you can see here, we've got, yeah, we've got like a, a large intestine of above six C oh sorry meters, I mean centimeters, uh six centimeters which uh indicates uh distension. Um and then if we move on to um uh another form of er, er radiography where I think we're almost at the end. So have, you know, everyone by too much uh ultrasounds. So, uh what were you looking at here? Um Is it, is it small or large intestine? Uh not, not large? Yeah, this is, this is the um er er smaller testing because of the uh PK circularis here. Um And um yeah, and you'll see that you uh that this is um dilated, um it says they have above like 2.5%. So I think around that 2.5 centimeters. So I think it's around 2.5 or three centimeters. Uh, but it is showing a small bowel obstruction. Um, and is this ultrasound? Is it high or low contrast? So, no, and obviously this, this isn't like something that's gonna come up in your face on exam as well. It's just, yeah, just purely. Yeah. So, yeah, there's no, no pressure, uh, to get it right. Yeah, I mean, yeah, I mean, yeah, it's fair enough. This actually um it's a low contrast. So we can't really see much about the vascular supply of the, of the bowel bowel or anything. I think there's um um sort of shape here as well as indicative of like a low contrast um ultrasounds uh just quickly to finish off with the case presentation. Um So uh Mr John Doe is a 54 year old man who presents with severe abdominal pain and bloating for the past two days. He reports nausea, vomiting and inability to pass stools or gas. His last normal bowel movement was four days ago and he has a history of hypertension and append appendectomy at the age of 24. So, upon physical examination, the patient appears unwell with tachycardia and a mildly elevated temperature. His abdomen is distended with visible peristalsis and tenderness, particularly in the lower quadrants and bowel sounds were initially hyperactive but have diminished. A rectal exam reveals an empty rectal vault with no bloods. So we look at the initial imaging and abdominal x-rays performed showing dilated small bowel loops with air fluid levels and a step another pattern, there is no free air under the diaphragm ruling out perforation. Um So what I think we actually do have the diagnosis. Yeah. So this, this is a indicative of a um, of a, of a bowel obstruction, a small bowel obstruction and uh it's likely due to remember, you said you had a appendectomy here. So, adhesions as a result of that because, you know, we have the intervention that can leave behind scar tissue which then can cause parts of the small bowel to sort of adhere to each other and sort of constrict. That means that you don't get any passage of, there's no patches of food um across the small bowel into the large intestine and into in et cetera. So it's, um, it's distended because of the build up of food and then laser gas as well. And this is why you can sort of see the small bowel centrally. Whereas like on a normal x-ray, you might not be able to. Um, and you can also see these sort of complete rings here, which is PCO circularis. Um I actually think that this might be from another condition, um, or like an episode called, um, paralytic ileus. Um And that's, you know, it, it's, it's similar to, to small bowel obstruction in that the, uh there's no peristalsis, um because of disruption. So vagal nerve disruption, which, you know, leads to similar presentations of as a small bowel obstruction because you've still got no movement of the small bowel. Um And it says there's a step ladder pass and this is just sort of referring to the uh to the layers of small bowel or bowel here. Um Yeah. So the management, uh also I know the, yeah, the CT scan, uh which we have reveals a dilated small bowel, it's approximal to a transition point in the er minium with collapsed bowel distally. So our transitions point is the transition from like a distension and uh the collapsed bowel. Um So normally the location of the obstruction to the bowel uh beyond the obstruction is, is collapsed because there's nothing passing, passing through it, whereas before it's distended because there's a build up. Um and there's no bowel, thicker, thickening, sorry all signs of perforation. Uh So this, you know, supports the diagnosis of a small bowel obstruction without ischemia because if you had ischemia inflammation, um you know that that would cause cause thickening. Uh and the patient, uh the management is with IV fluids, right? Because you've got an obstruction, you're probably less likely to uh to absorb fluids. So you might have like a electrolyte imbalance, so that can be corrected. Um Nasogastric tube decompression. Um I think this is just to sort of reduce the intra abdominal pressure and make sure try to stimulate some passage on the bowel and bowel rest. So that's sort of nil by mouth. So, you know that no, uh, no food. Um, and that's sort of like, yeah, again to, um, reduce the exacerbation of the symptoms. Um, so, yeah, the medical treatments that we extended first and then the surgical consultation can be advised in case of, er, er, ischemia. Um, but yeah, other possible causes of bowel obstruction could be, uh, hernia, uh, as you, as you saw before and the sort of the ct images of like an umbilical hernia, you've got like, um, uh, sort of like bits of bowel can be sort of trapped in that, ah, causing constriction, neoplasm. So, tumors as well can compress it. Bowel diseases. Crohn's disease, foreign bodies, you know, like, if you, uh, uh, I guess you swallow something that you can't really digest. So, like a child or something you just like, you know, pick up any, anything you can find on the carpet, um, uh, VVI list as well, like a twisting of the bowel. And it's reasons I remember we said that the, um, the intestines and like a lot of the abdominal viscera are quite sort of flexible and there's a lot of like a free movement. Um, well, if you know, the bowel is twisted, um, on the music tree that will sort of constrict it and this can be, you know, quite like a big emergency because it could, like, lead to, uh, ischemia later infarction. So, death of the tissue So this is actually quite, uh, quite significant, uh, and also, yeah, infections as well. Um, so I think we've got like a few S PA s here. Um, what I'll do. Uh, yeah, we have like a run by 20 minutes, so I apologies for that. Um I think P is gonna send up, we, we'll go through them now, but if you do need to leave, I think Pia is gonna send out the slides. If you just fill in the feedback form, they all will be sent out. So, er, like, please don't look at it now because we are going through them now, but they are gonna be on their rad. So, er, meal account. So if you look there, you should be able to get them. So, uh one other thing I wanted to mention as well is um we talked a lot about abdominal x-rays but routinely in practice, we don't order them as much because of the fact that it doesn't, it doesn't show much. Um it's not like the chest x rays that uh you do and you'll be able to get a lot from it. So we routinely routinely go for an X ray for abdomen. If we suspect an obstruction. If not, we'll use some other techniques like CT scans. Yeah. Ok. So just moving on to this s pa question. So a patient is advised in the hospital with abdominal pain in the right upper quadrant, which of the uh which of these organs is located there is a, the liver, the caecum, the colon, the island. Yeah, just be a, the liver. Um And you see sort of the locations of the other of the other organs there. Um And secondly, a patient has an aneurysm for one of the impaired arteries that branches from the abdominal aorta at the level of T 12. Um which um which of these impaired arteries is most likely to be affected. Yeah. So this will be, this will be C this will be uh c act trunk at T 12. Uh S MA is at L1, inferior L3 in the R artery as well at L1. So just you know, that's a uh yeah, quite, quite, maybe a common thing that could pop up. Uh A medical student is dissecting the abdominal cavity. Uh which of the following will help them identify the small intestine. Is it a hos BP circularis c blood appendages or D tenia coli? Yeah. So this would be our, our P RP K uh circularis just uh worth bearing in mind that these other three are found in the um well, the, the large intestine. Um ok. So Prolia uh 35 year old male has many organs. Uh which of the following organs are retroperitoneal. Is it a the stomach b the tail of the pancreas c the aorta or d the liver? Yeah. So yeah, the A also just know about pneumonic, er, Sad pucker. Um, and I think that's about it. Uh, if anyone's got any questions or wants me to go over anything, uh, then just let me know, uh, otherwise you can email purer here. Um, yeah, sorry again for over running. Feel free to go now. Um, yeah, for the slides being sent out in France and you can cover them in your own time if you want. Thank you very much, Ben.