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Folding creates the anterior and posterior intestinal portals (foregut and hindgut, respectively) The cardiac region is brought to the ventral side of.

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Presentation on theme: "Folding creates the anterior and posterior intestinal portals (foregut and hindgut, respectively) The cardiac region is brought to the ventral side of."— Presentation transcript:

1 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. cloacal membrane Carlson fig 6-20 Primitive Gut

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 Celiac trunk SMA IMA

4 Foregut: pharynxthyroid esophagusparathyroid glands stomachtympanic cavity proximal duodenumtrachea, bronchi, lungs liver, gallbladder pancreas Midgut:proximal duodenum to right half of transverse colon Hindgut:left half of urinary bladder transverse colon to anus Gut tube properDerivatives of gut tube (These three regions are defined by their blood supply) Development of Digestive System

5 4 th week5 th week Celiac artery supplies the foregut Superior mesenteric artery supplies the midgut Inferior mesenteric artery supplies the hindgut Langman’s fig Development of Digestive System

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  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). Branches of the Abdominal Aorta

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)  Celiac trunk:  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)  Celiac trunk:  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)  Celiac trunk:  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 Left gastric a. Common hepatic a. Splenic a. Gastroduodenal a. Proper hepatic a. Right gastric a. Left branch Right branch Cystic a. Short gastric a. Left gastroepiploic a. Right gastroepiploic a. Superior pancreaticoduodenal a. Splenic branches Celiac Trunk

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

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

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 a. Left colic a. Sigmoid aa. Superior rectal a. Inferior mesenteric v.

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

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

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  Marginal artery:  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 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  The arc of Riolan:  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 R. external carotid artery R. internal carotid artery R. common carotid – right side of head and neck L. external carotid artery L. internal carotid artery L. common carotid – left side of head and neck R. vertebralL. vertebral R. axillary Arteries of R. upper limb Mediastinal – posterior media- stinum Esophageal – esophagus Pericardial – pericardium Bronchial – lungs and bronchi Gonadal – testes or ovaries Suprarenal – adrenal glands and Renal – kidneys Celiac trunk – liver – gallbladder – spleen – stomach – esophagus – duodenum Superior and inferior mesenterics – small intestine – colon Brachiocephalic – head, neck, and R. upper limb Posterior intercostals – intercostal muscles, spinal cord, vertebrae, pleurae, skin Inferior phrenics – inferior diaphragm Lumbars – posterior abdominal wall Median sacral – sacrum – coccyx Superior phrenics – posterior and superior diaphragm R. subclavian – neck and R. upper limb L. and R. coronary arteries L. subclavian – neck and L. upper limb L. ventricle of heart Thoracic aorta T 5 – T 12 (diaphragm) Abdominal aorta T 12 (diaphragm) – L 4 Ascending aorta – L. ventricle to sternal angle L. axillary R. common iliac – pelvis and R. lower limb Arteries of R. lower limb (a) Schematic flowchart L. common iliac – pelvis and L. lower limb Arteries of L. lower limb Arteries of L. upper limb Diaphragm Visceral branches Parietal branches Visceral branches Parietal branches Aortic arch Systemic Arterial Circulation

46 Flow Chart Summarizing Main Systemic Arteries

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

48 Systemic Venous Circulation R. external jugular – superficial head and neck R. vertebral – cervical spinal cord and vertebrae R. brachiocephalic – R. side of head and R. upper limb Superior vena cava – runs from union of brachiocephalic veins behind manubrium to R. atrium Inferior vena cava – runs from junction of common iliac veins at L 5 to R. atrium of heart R. atrium of heart L. brachiocephalic – L. side of head and L. upper limb Intracranial dural venous sinuses R. internal jugular – dural venous sinuses of the brain R. subclavian – R. head, neck, and upper limb Same as R. brachiocephalic R. axillary Azygos system – drains much of thorax L., R., and middle hepatic veins – liver Veins of L. lower limb L. and R. renal veins – kidneys Lumbar veins (several pairs) – posterior abdominal wall R. suprarenal (L. suprarenal drains into L. renal vein) – adrenal glands R. gonadal (L. gonadal drains into L. renal vein) – testis or ovary Veins of R. lower limb Veins of R. upper limb R. common iliac – pelvis and R. lower limb L. common iliac – pelvis and L. lower limb Diaphragm

49 Flowchart Summarizing The Main Veins R. External jugular – superficial head and neck R. vertebral – cervical spinal cord and vertebrae R. brachiocephalic – R. side of head and R. upper limb Superior vena cava – runs from union of brachiocephalic veins behind manubrium to R. atrium Inferior vena cava – runs from junction of common iliac veins at L 5 to R. atrium of heart R. atrium of heart Diaphragm L. brachiocephalic – L. side of head and L. upper limb Intracranial dural sinuses R. internal jugular – dural sinuses of the brain R. subclavian – R. head, neck, and upper limb Same as R. brachiocephalic R. axillary Azygos system – drains much of thorax L. and R. hepatic veins – liver Veins of L. lower limb L. and R. renal veins – kidneys Lumbar veins (several pairs) – posterior abdominal wall R. suprarenal (L. suprarenal drains into L. renal vein) – adrenal glands R. gonadal (L. gonadal drains into L. renal vein) – testis or ovary Veins of R. lower limb Veins of R. upper limb R. common iliac – pelvis and R. lower limb L. common iliac – pelvis and 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.)  Supplies the rectal mucosa below the pecten.

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  Ganglia  Celiac  Superior mesenteric  Aorticorenal  Inferior mesenteric

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

58 Lymphatics of The Small Intestine  Drains into 1. Mesenteric 2. Superior mesenteric 3. Inferior mesenteric 1. Lymph leaving the digestive tract does not necessarily run through each node along its pathway. 2. Some run through only one node. 3. Others bypass it and go to neighboring or more proximal nodes. 4. Extensive resection is required for removing cancerous growth.

59 Lymphatics of The Large Intestine  Four groups 1. Epicolic (under the serosa of the wall of the intestine) 2. Paracolic (on the marginal artery) 3. Intermediate (along the large arteries [superior and inferior mesenteric arteries]) 4. Principal (at the root of the superior and inferior mesenteric arteries)

60 Lymphatics of The Large Intestine  Note: 1. 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: 1. 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  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  Intestinal lymph trunk  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 Thoracic Duct

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  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 Autonomic Innervation of Abdomen

66  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. Autonomic Innervation of Abdomen

67  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). Autonomic Innervation of Abdomen

68  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. Autonomic Innervation of Abdomen

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

70  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. Autonomic Innervation of Abdomen

71  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. Autonomic Innervation of Abdomen

72  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. Autonomic Innervation of Abdomen

73  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 Autonomic Innervation of Abdomen

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

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

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

77  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. Visceral Pain

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

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85 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: 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 T8-11 Structures in the adult midgut 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)).

89 Referred Pain Structures in the adult midgut 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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