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Primitive Gut cloacal membrane Carlson fig 6-20

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Presentation on theme: "Primitive Gut cloacal membrane Carlson fig 6-20"— Presentation transcript:

1 Primitive Gut cloacal membrane Carlson fig 6-20 Folding creates the anterior and posterior intestinal portals (foregut and hindgut, respectively) The cardiac region is brought to the ventral side of the developing gut tube. Juxtaposition of ectoderm and endoderm at: Oropharyngeal (buccopharyngeal) membrane - future mouth Cloacal membrane - future anus Note: there actually isn’t much mesoderm in these membranes, which is important for their breakdown later in development to form the oral and anal orifices.

2 Embryonic Development of the Digestive System

3 Development of Digestive System
Foregut The abdominal esophagus The stomach Proximal half of the duodenum The spleen The liver, gallbladder Pancreas Midgut Second half of the duodenum Jejunum, ileum Cecum, appendix Ascending colon Transverse colon (proximal 2/3) Hindgut Left portion of the tranverse colon Descending colon Sigmoid colon The rectum IMA Celiac trunk SMA

4 Development of Digestive System
Gut tube proper Derivatives of gut tube Foregut: pharynx thyroid esophagus parathyroid glands stomach tympanic cavity proximal duodenum trachea, bronchi, lungs liver, gallbladder pancreas Midgut: proximal duodenum to right half of transverse colon Hindgut: left half of urinary bladder colon to anus (These three regions are defined by their blood supply)

5 Development of Digestive System
4th week 5th week Fig 13.14 Langman’s fig 14-14 Celiac artery supplies the foregut Superior mesenteric artery supplies the midgut Inferior mesenteric artery supplies the hindgut

6 The Abdominal Aorta Overall:
Begins at the aortic hiatus of the diaphragm (T12). Descends in front of the vertebral column. Ends on the body of L4, commonly a little to the left of the middle. It diminishes rapidly in size, in consequence of the many large branches which it gives off.

7 Branches of the Abdominal Aorta
Unpaired branches: Major branches to visceral organs Paired branches: To body wall Kidneys Diaphragm Suprarenal glands Urinary bladder Testis (ovary)

8 Branches of the Abdominal Aorta
Visceral branches: Celiac trunk Liver, Gallbladder Spleen Stomach Esophagus Duodenum Superior and inferior mesenterics Small intestine Large intestine Renal Kidney

9 Branches of the Abdominal Aorta
Visceral branches: Suprarenal Adrenal glands Gonadal Testes Ovaries

10 Branches of the Abdominal Aorta
Parietal branches: Inferior phrenics Inferior diaphragm Lumbars Posterior abdominal wall Median sacral Sacrum Coccyx

11 Branches of Abdominal Aorta

12 Branches of the Abdominal Aorta
Overall: The abdominal viscera and associated organs are supplied by three branches of the abdominal aorta. These are unpaired branches that arise from the anterior part of the aorta. The first of these branches is the celiac trunk (or artery).

13 Celiac Trunk (or Artery)
The celiac trunk: The celiac trunk (T12) is the artery of the organs derived from the primitive foregut. Supplies to the: Abdominal esophagus Stomach Proximal half of the duodenum Spleen Liver, Gallbladder Pancreas

14 Celiac Trunk (or Artery)
1. Left gastric a. 2. Splenic a. 1. Short gastric arteries 2. Splenic brances 3. Left gastroepiploic a. 3. Common hepatic a. 1. Hepatic artery proper 1. Right gastric a. 2. Supraduodenal a. 3. Right hepatic a. 1. Cystic a. 4. Left hepatic a. 2. Gastroduodenal a. 1. Right gastroepiploic a. 2. Anterior superior pancreaticoduodenal a. 3. Posterior superior pancreaticoduodenal a.

15 Celiac Trunk (or Artery)
1. Left gastric a. 2. Splenic a. 1. Short gastric arteries 2. Splenic brances 3. Left gastroepiploic a. 3. Common hepatic a. 1. Hepatic artery proper 1. Right gastric a. 2. Supraduodenal a. 3. Right hepatic a. 1. Cystic a. 4. Left hepatic a. 2. Gastroduodenal a. 1. Right gastroepiploic a. 2. Anterior superior pancreaticoduodenal a. 3. Posterior superior pancreaticoduodenal a.

16 Celiac Trunk (or Artery)
1. Left gastric a. 2. Splenic a. 1. Short gastric arteries 2. Splenic brances 3. Left gastroepiploic a. 3. Common hepatic a. 1. Hepatic artery proper 1. Right gastric a. 2. Supraduodenal a. 3. Right hepatic a. 1. Cystic a. 4. Left hepatic a. 2. Gastroduodenal a. 1. Right gastroepiploic a. 2. Anterior superior pancreaticoduodenal a. 3. Posterior superior pancreaticoduodenal a.

17 Celiac Trunk Left gastric a. Left branch Right branch Short gastric a.
Common hepatic a. Cystic a. Splenic a. Right gastric a. Splenic branches Proper hepatic a. Gastroduodenal a. Left gastroepiploic a. Superior pancreaticoduodenal a. Right gastroepiploic a.

18 Celiac Trunk

19 Celiac Trunk

20 Celiac Trunk Liver (cut) Diaphragm Inferior vena cava Esophagus
Left gastric artery Hepatic artery proper Left gastroepiploic artery Common hepatic artery Splenic artery Right gastric artery Spleen Gallbladder Stomach Gastroduodenal artery Pancreas (major portion lies posterior to stomach) Right gastroepiploic artery Superior mesenteric artery Duodenum Abdominal aorta

21 Superior Mesenteric Artery (SMA)
The SMA: Arises from the anterior surface of the aorta (L1), just inferior to the origin of the celiac trunk. Passes behind the neck of the pancreas. is the artery of the organs derived from the primitive midgut. Supplies to the: intestine from the duodenum and pancreas to the left colic flexure. Second half of the duodenum Jejunum, ileum Cecum, appendix Ascending colon Transverse colon (proximal 2/3)

22 Superior Mesenteric Artery (SMA)
Branches of SMA: 1. Jejunal and ileal arteries 2. Inferior pancreaticoduodenal a. 1. Anterior branch 2. Posterior branch 3. Middle colic a. 4. Right colic a. 5. Ileocolic a. 1. Ileal branch 2. Colic branch 1. Posterior cecal a. 2. Anterior cecal a. 3. Appendicular a.

23 Superior Mesenteric Artery (SMA)
Branches of SMA: 1. Jejunal and ileal arteries 2. Inferior pancreaticoduodenal a. 3. Middle colic a. 4. Right colic a. 5. Ileocolic a. Straight arteries (arteriae rectae) Marginal artery

24 Superior Mesenteric Artery (SMA)
Branches of SMA: 1. Jejunal and ileal arteries 2. Inferior pancreaticoduodenal a. 3. Middle colic a. 4. Right colic a. 5. Ileocolic a. Straight arteries (arteriae rectae) Marginal artery

25 Branches of Superior Mesenteric Artery
Inferior pancreaticoduodenal - not shown on the image. Middle colic - to the transverse colon Right colic - to ascending colon Ileocecal - to last part of ileum, cecum, and appendix Intestinal branches - to jejunum and ileum The middle, right, and ileocecal branches anastomose with each other to form a "marginal" artery along the inner border of the colon. This artery is completed by branches of the left colic which is a branch of the inferior mesenteric

26 Superior Mesenteric Artery
Mesenteric v. Middle colic a. Inf. pancreaticodudenal a. Superior mesenteric a. Right colic a. Jejunal and ileal a. Ileocolic a. Appendicular a.

27 Inferior Mesenteric Artery (SMA)
The IMA: Arises from the anterior surface of the aorta (L3), inferior to the origin of the SMA. Passes behind the horizontal part of the duodenum. is the artery of the organs derived from the primitive hindgut. Supplies to the: the large intestine from the left colic (or splenic) flexure to the upper part of the rectum.

28 Inferior Mesenteric Artery (SMA)
Branches of IMA: 1. Left colic a. Ascending branch Descending branch 2. Sigmoid aa. 3. Superior rectal a. Straight arteries (arteriae rectae) Marginal artery

29 Inferior Mesenteric Artery (SMA)
Branches of IMA: 1. Left colic a. Ascending branch Descending branch 2. Sigmoid a. 3. Superior a. Straight arteries (arteriae rectae) Marginal artery

30 Inferior Mesenteric Artery
Inferior mesenteric v. Inferior mesenteric a. Left colic a. Sigmoid aa. Superior rectal a.

31 The Duodenum Branches of the SMA Branches of the IMA Transverse colon
Celiac trunk Aorta Superior mesenteric artery Inferior mesenteric artery Branches of the SMA Branches of the IMA • Middle colic artery • Intestinal arteries • Right colic artery • Left colic artery • Ileocolic artery • Sigmoidal arteries • Superior rectal artery Ascending colon Right common iliac artery Descending colon Ileum Cecum Sigmoid colon Appendix Rectum (d) Distribution of the superior and inferior mesenteric arteries. The transverse colon has been pulled superiorly.

32 Branches of Superior Mesenteric Artery
Transverse colon Celiac trunk Superior mesenteric artery Middle colic artery Intestinal arteries Left colic artery Right colic artery Inferior mesenteric artery Ileocolic artery Aorta Ascending colon Sigmoidal arteries Descending colon Ileum Left common iliac artery Superior rectal artery Sigmoid colon Cecum Rectum Appendix

33 Variations in Colic Arteries-1

34 Variations in Colic Arteries-2

35 Variations in Colic Arteries-3

36 Variations in Colic Arteries-4

37 Variations in Colic Arteries-5

38 Marginal Artery of Colon
is also known as the marginal artery of Drummond, named after Sir David Drummond ( ). is a blood vessel that anastomoses the IMA with the SMA. It is sometimes absent, as an anatomical variant.

39 Marginal Artery of Colon
Components: Ileocolic artery: colic branch Right colic artery: ascending and descending branches Middle colic artery: right and left branches Left colic artery: ascending and descending branches Sigmoid arteries: unnamed terminal branches

40 Marginal Artery of Drummond
The anastomoses of the terminal branches of the ileocolic, right colic and middle colic arteries of the SMA, and of the left colic and sigmoid branches of the IMA, form a continuous arterial circle or arcade along the inner border of the colon known as the marginal artery of Drummond. 

41 Marginal Artery of Drummond
Components Ileocolic artery : Colic branch Right colic artery: ascending and descending branches Middle colic artery: right and left branches Left colic artery: ascending and descending branches Sigmoid arteries: unnamed terminal branches

42 Marginal Artery of Drummond
From this marginal artery, straight vessels (known as vasa recta) pass to the colon. The marginal artery is an important connection between the SMA and IMA, and provides collateral flow in the event of occlusion or significant stenosis. 

43 Marginal Artery of Drummond
The junction of the SMA and IMA territories is at the splenic flexure.  Anastomoses here are often weak or absent, hence the marginal artery at this point (known as the Griffiths’ point) is often focally small or discontinuous. For this reason, the splenic flexure is a watershed area prone to ischaemia and infarction.

44 The Arc of Riolan (Riolan’a Arcade, Haller’s Anastomosis
Also known as the 'meandering mesenteric artery. is another vascular arcade present in the colonic mesentery. Connects the proximal middle colic artery with a branch of the left colic artery. This artery is found low in the mesentery, near the root. It is a poor anastomosis and is connected with ischemic colitis.

45 Systemic Arterial Circulation
R. external carotid artery R. internal carotid artery L. external carotid artery L. internal carotid artery R. vertebral R. common carotid – right side of head and neck L. common carotid – left side of head and neck L. vertebral R. axillary R. subclavian – neck and R. upper limb Brachiocephalic – head, neck, and R. upper limb L. subclavian – neck and L. upper limb L. axillary Aortic arch Arteries of R. upper limb Arteries of L. upper limb Ascending aorta – L. ventricle to sternal angle L. and R. coronary arteries Thoracic aorta T5 – T12 (diaphragm) L. ventricle of heart Visceral branches Parietal branches Mediastinal – posterior media- stinum Esophageal – esophagus Bronchial – lungs and bronchi Pericardial – pericardium Posterior intercostals – intercostal muscles, spinal cord, vertebrae, pleurae, skin Superior phrenics – posterior and superior diaphragm Diaphragm Abdominal aorta T12 (diaphragm) – L4 Visceral branches Parietal branches Gonadal – testes or ovaries Suprarenal – adrenal glands and Renal – kidneys Superior and inferior mesenterics – small intestine – colon Celiac trunk – liver – gallbladder – spleen – stomach – esophagus – duodenum Inferior phrenics – inferior diaphragm Lumbars – posterior abdominal wall Median sacral – sacrum – coccyx R. common iliac – pelvis and R. lower limb L. common iliac – pelvis and L. lower limb Arteries of R. lower limb (a) Schematic flowchart Arteries of L. lower limb

46 Flow Chart Summarizing Main Systemic Arteries

47 Flow Chart Summarizing Main Systemic Arteries
Diaphragm Abdominal aorta L. gastric artery Inferior phrenic arteries R. gastric artery Common hepatic artery Hepatic artery proper L Celiac trunk Gastro- duodenal artery Splenic artery R R. gastroepiploic artery Middle suprarenal arteries L. gastroepiploic artery Middle colic artery Intestinal arteries Superior mesenteric artery R. colic artery Renal arteries Ileocolic artery Gonadal arteries Sigmoidal arteries Inferior mesenteric artery L. colic artery Superior rectal artery Lumbar arteries Median sacral artery Common iliac arteries

48 Systemic Venous Circulation
Veins of R. upper limb R. external jugular – superficial head and neck R. vertebral – cervical spinal cord and vertebrae Intracranial dural venous sinuses R. internal jugular – dural venous sinuses of the brain R. subclavian – R. head, neck, and upper limb R. axillary Same as R. brachiocephalic R. brachiocephalic – R. side of head and R. upper limb L. brachiocephalic – L. side of head and L. upper limb Superior vena cava – runs from union of brachiocephalic veins behind manubrium to R. atrium Azygos system – drains much of thorax R. atrium of heart Diaphragm Inferior vena cava – runs from junction of common iliac veins at L5 to R. atrium of heart L., R., and middle hepatic veins – liver R. suprarenal (L. suprarenal drains into L. renal vein) – adrenal glands L. and R. renal veins – kidneys R. gonadal (L. gonadal drains into L. renal vein) – testis or ovary Lumbar veins (several pairs) – posterior abdominal wall R. common iliac – pelvis and R. lower limb L. common iliac – pelvis and L. lower limb Veins of R. lower limb Veins of L. lower limb

49 Flowchart Summarizing The Main Veins
Veins of R. upper limb R. External jugular – superficial head and neck R. vertebral – cervical spinal cord and vertebrae Intracranial dural sinuses R. internal jugular – dural sinuses of the brain R. subclavian – R. head, neck, and upper limb R. axillary Same as R. brachiocephalic R. brachiocephalic – R. side of head and R. upper limb L. brachiocephalic – L. side of head and L. upper limb Superior vena cava – runs from union of brachiocephalic veins behind manubrium to R. atrium Azygos system – drains much of thorax R. atrium of heart Diaphragm Inferior vena cava – runs from junction of common iliac veins at L5 to R. atrium of heart L. and R. hepatic veins – liver R. suprarenal (L. suprarenal drains into L. renal vein) – adrenal glands L. and R. renal veins – kidneys R. gonadal (L. gonadal drains into L. renal vein) – testis or ovary Lumbar veins (several pairs) – posterior abdominal wall R. common iliac – pelvis and R. lower limb L. common iliac – pelvis and L. lower limb Veins of R. lower limb Veins of L. lower limb (a)

50 Arteries of Rectum and Anal Canal
There are three: 1. Superior rectal a. (from IMA) Supplies the rectal mucosa above the pecten. 2. Middle rectal a. (from internal iliac a.) Supplies the rectal mucosa below the pecten. 3. Inferior rectal a. (from internal iliac a.)

51 Veins of Rectum and Anal Canal
Internal hemorrhoids: 1. Superior rectal vein. The radicles of these vessels raise up the anal columns. The submucous venous anastomosis is the internal rectal venous plexus. These are liable to distention. This causes them to bulge into the anal canal forming internal hemorrhoids. Insensitive to touching, pricking, and cutting.

52 Veins of Rectum and Anal Canal
External hemorrhoids: 1. Middle and inferior rectal veins. The radicles of these vessels raise up the anal columns. The submucous venous anastomosis is the external rectal venous plexus. These are liable to distention. This causes them to bulge into the anal canal forming internal hemorrhoids. Very sensitive to touching, pricking, and cutting.

53 Veins of Stomach

54 Veins of Small and Large Intestines

55 Portal Vein

56 Autonomic Nerves and Ganglia of Abdomen
Celiac Superior mesenteric Aorticorenal Inferior mesenteric

57 Lymphatics of Duodenum
Drain into: Celiac Superior mesenteric Lumbar lymph nodes

58 Lymphatics of The Small Intestine
Drains into Mesenteric Superior mesenteric Inferior mesenteric Lymph leaving the digestive tract does not necessarily run through each node along its pathway. Some run through only one node. Others bypass it and go to neighboring or more proximal nodes. Extensive resection is required for removing cancerous growth.

59 Lymphatics of The Large Intestine
Four groups Epicolic (under the serosa of the wall of the intestine) Paracolic (on the marginal artery) Intermediate (along the large arteries [superior and inferior mesenteric arteries]) Principal (at the root of the superior and inferior mesenteric arteries)

60 Lymphatics of The Large Intestine
Note: Left colic flexure and the left third of the transverse colon have dual lymphatic drainage. Drains down to IM nodes through ascending branch of the left colic artery. Drains up to SM nodes via following IM vein.

61 Lymphatics of The Large Intestine
Note: Left colic flexure and the left third of the transverse colon have dual lymphatic drainage. Drains down to IM nodes through ascending branch of the left colic artery. Drains up to SM nodes via following IM vein.

62 Thoracic Duct Intestinal lymph trunk Lumbar lymph trunks
Efferents of the celiac and SM nodes together form it. Lumbar lymph trunks Chief efferents from the upper lymph nodes together form them. Cisterna chyli Two lumbar trunks are joined by the intestinal trunk in the formation of cisterna chyli. Thoracic duct Empty into the confluence of the left subclavian vein and internal jugular vein

63 Thoracic Duct Intestinal lymph trunk Lumbar lymph trunks
Efferents of the celiac and SM nodes together form it. Lumbar lymph trunks Chief efferents from the upper lymph nodes together form them. Cisterna chyli Two lumbar trunks are joined by the intestinal trunk in the formation of cisterna chyli. Thoracic duct Empty into the confluence of the left subclavian vein and internal jugular vein

64 Lymphatics of the Sigmoid Colon, Rectum, and Anus
Above the pectinate line, drainage is to inferior mesenteric nodes. Below the line, drainage is to the inguinal nodes

65 Autonomic Innervation of Abdomen
Parasympathetic nerves Vagus nerve (CN X) Innervates GI tract down to two thirds of the way along the transverse colon. S2-S4 Innervates GI tract starting from the distal one-third of the the transverse colon down to pectinate line in the anal canal. Pelvic splanchnic nerves (nervi errigentes) Sympathetic nerves Sympathetic trunk Thoracic and lumbal splanchnic nerves

66 Autonomic Innervation of Abdomen
Parasympathetic nerves Preganglionic fibres Provided by vagus nerve and sacral splanchnic nerves. Synapse with postganglionic fibres in the walls of the relevant organs. Vagus nerve (CN X) Give rise to anterior and posterior vagal trunks in thorax. Trunks enter abdomen at the esophageal hiatus. Anterior trunk (mainly from the left vagus) Enters anterior to the esophagus. Gives branches to the anterior surface of the stomach and to the liver.

67 Autonomic Innervation of Abdomen
Parasympathetic nerves Posterior trunk (mainly from the right vagus) Enters posterior to the esophagus. Gives branches to the posterior surface of the stomach and celiac plexus. Fibers pass inferiorly to root of superior mesenteric artery. Fibers contribute to perivascular plexuses Accompanying celiac and superior mesenteric artery and their branches. Extend as far as the arterial supply (two thirds of the way along the transverse colon).

68 Autonomic Innervation of Abdomen
Parasympathetic nerves Pelvic splanchnic nerves From spinal cord levels S2–S4 Emerge through pelvic sacral foramina. Ascend from pelvis running in sigmoid mesocolon and peritoneum of posterior abdominal wall. Supply distal one third of transverse colon, descending colon, sigmoid colon, and superior rectum. Postganglionic (postsynaptic) Parasympathetic neurons found in enteric ganglia in wall of viscus.

69 Autonomic Innervation of Abdomen
Sympathetic nerves Greater and lesser splanchnic nerves to Celiac plexus Superior mesenteric plexus

70 Autonomic Innervation of Abdomen
Sympathetic nerves Right and left sympathetic trunks Enter behind the medial arcuate ligament of the diaphragm. Descend along psoas major, with right trunk behind inferior vena cava (IVC). Lie on anterolateral sides of lumbar vertebrae.

71 Autonomic Innervation of Abdomen
Sympathetic nerves Give off three to four lumbar splanchnic nerves (presynaptic sympathetic fibers) to: Intermesenteric plexus Inferior mesenteric plexus Superior hypogastric plexus Postsynaptic fibers from these plexuses innerves nearby target organs.

72 Autonomic Innervation of Abdomen
Sympathetic nerves Sympathetic (paravertebral) ganglia Total of four abdominal sympathetic ganglia per trunk Prevertebral sympathetic ganglia Cell bodies of postsynapatic sympathetic neurons Found in plexuses around roots of major branches of aorta.

73 Autonomic Innervation of Abdomen
Aortic plexuses Network of parasympathetic and sympathetic nerves Parasympathetic mainly from posterior vagal trunk. Sympathetic fibers from thoracic and lumbar splanchnic nerves. Contain prevertebral ganglia

74 Autonomic Innervation of Abdomen
Aortic plexuses Include: Celiac plexus Aorticorenal plexus Renal plexus Superior mesenteric plexus Intermesenteric plexus Inferior mesenteric plexus

75 Autonomic Innervation of Abdomen
Aortic plexuses Perivascular plexuses derived from the aortic plexuses Visceral afferent fibers Carry pain information. Travel with sympathetic fibers back to spinal cord.

76 Vagal visceral afferents
Visceral Pain Vagal visceral afferents Believed to mediate the feelings of: Nausea Distention Involve in visceral reflexes (gastrocecal reflex)

77 Visceral afferents in the sympathetic nerves
Visceral Pain Visceral afferents in the sympathetic nerves Chiefly concerned with the mediation of pain. Sectioning the splanchnic nerves or removing the thoracolumbar parts of the sympathetic trunks can alleviate the pain arising in the abdominal viscera. If disease involves parietal peritoneum, innervated through somatic nervesi, the pain will not be eliminated.

78 Three Different Types of Abdominal Pain
Visceral pain Quality: pain is generally vague, not well localized, dull, crampy, sickening, hard to accurately describe. Stimuli: three major pain stimuli: (a) Mechanical – receptors respond to perforation and stretching (distention) due to obstruction (b) Chemical receptors – receptors respond to inflammation (bradykinin) due to infection, bile problems, etc. (c) Ischemia – vasoactive agents such as K+, lactate, H+ Cutting/crushing of gut does not produce pain Transmission: sympathetic autonomic nerves (visceral afferent) – NOT parasympathetic (vagotomy has no effect) Location: Foregut seems epigastric (T5-9), Midgut seems periumbilical (T8-11), Hindgut seems hypogastric (T12-L3)

79 Three Different Types of Abdominal Pain
Parietal pain Quality: well localized, sudden onset, sharp Stimuli: anything causing irritation of the parietal paritoneum (perforation, compression, etc.) Transmission: somatic neurons – to dorsal root ganglion on one side (unilateral) Location: localized to dermatome segment closest to pathological process

80 Three Different Types of Abdominal Pain
Referred pain Pain arising from intraabdominal problems that is experienced somewhere else. Convergence projection hypothesis – visceral afferents and somatic neurons comingle at dorsal root ganglion Example: shoulder pain if diaphragm is irritated

81 Referred Pain

82 Referred Pain

83 Referred Pain

84 Referred Pain

85 Referred Pain Foregut: Esophagus to proximal duodenum: Celiac artery, greater splanchnic nerve (enter T5-9) Midgut: Distal duodenum to transverse colon – superior mesenteric artery, lesser splancnic nerve (enter T8-11) Hindgut: Descending colon to anus - inferior mesenteric artery, least splancnic nerve (enter T12-L3) DERMATOME

86 Referred Pain Foregut – esophagus , proximal duodenum – celiac artery, greater splanchnic nerve (enter T5-9) Midgut – distal duodenum to transverse colon – superior mesenteric artery, lesser splancnic nerve (enter T8-11) Hindgut – descending colon to anus - inferior mesenteric artery, least splancnic nerve (enter T12-L3)

87 Referred Pain Structures of the foregut are: T5-9
Esophagus Stomach Duodenum (1st and 2nd parts) Liver Gallbladder Inferior portion of Pancreas Spleen (Note that it is located in the foregut region, but is not a gut organ) Superior portion of pancreas Pain in the foregut is typically referred to the epigastric region. Arterial supply from the celiac trunk, Venous drainage by the portal venous system. Lymph drained to the prevertebral celiac nodes T5-9

88 Referred Pain Structures in the adult midgut T8-11
Duodenum (distal half of 2nd part, 3rd and 4th parts) Jejunum Ileum Cecum Appendix Ascending colon Hepatic flexure of colon. Transverse colon (proximal two-thirds) Arterial supply from the SMA Venous drainage is to the portal venous system. Lymph from the midgut drains to prevertebral superior mesenteric nodes Pain in the midgut is referred to the umbilical region (around the umbilicus (belly button)). T8-11

89 Referred Pain Structures in the adult midgut T12-L3
The distal third of the transverse colon The splenic flexure The descending colon Sigmoid colon Rectum Arterial supply by the IMA Venous drainage is to the portal venous system. Lymphatic drainage is to the chyle cistern. Sympathetic innervation is from the Lumbar splanchnic nerves (L1-L2) Parasympathetic innervation is from S2-S4. Pain in the hindgut is referred to the hypogastric region (T12-L3) T12-L3

90 Referred Pain from the Abdominal Viscera


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