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ABDOMEN

By: Dr Tegene Gizaw (MD)

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THE ABDOMINAL WALL

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Abdominal wall
 The abdomen is a roughly cylindrical chamber extending from
the inferior margin of the thorax to the superior margin of the
pelvis and the lower limb

 The chamber enclosed by the abdominal wall contains a single


large peritoneal cavity, which freely communicates with the
pelvic cavity.

 Abdominal viscera are either suspended in the peritoneal cavity


by mesenteries or are positioned between the cavity and the
musculoskeletal wall
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Abdominal viscera include:

 major elements of the gastrointestinal system-the caudal


end of the esophagus, stomach, small and large intestines,
liver, pancreas, and gallbladder; the spleen;

 components of the urinary system-kidneys and ureters;

 the suprarenal glands;

 major neurovascular structures.

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The nine regions of abdominal wall

a. Right and left hypochondrium

b. Epigastric region

c. Right and left lumbar (lateral) regions

d. Umbilical region

e. Right and left inguinal (iliac) regions

f. Hypogastric (suprapubic) region

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• In the clinical practice the abdomen is divided in to four
quadrants by two perpendicular lines bisecting at the
umbilicus.

a. Right upper quadrant (RUQ)

b. Right lower quadrant (RLQ)

c. Left upper quadrant (LUQ)

d. Left lower quadrant (LLQ)

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 At the ends of these lines following four important regions of the
abdominal wall also known.

a. Epigastrium

b. Rt & lt flanks

c. Pubis

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 The abdominal wall consists of different layers of
tissues

 These layers are:


 The skin

 Subcutaneous tissue

 Muscles and fascia

 Extraperitoneal tissue

 Peritoneum

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Superficial Fascia
• superficial layer(Camper's fascia):

 contains fat and varies in thickness

 continuous over the inguinal ligament with the superficial fascia of


the thigh and with a similar layer in the perineum

 In men, continues over the penis and, after losing its fat and fusing
with the deeper layer of superficial fascia, continues into the scrotum
where it forms a specialized fascial layer containing smooth muscle
fibers (the dartos fascia)

 In women, this superficial layer retains some fat and is a component


of the labia majora
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Superficial Fascia…
• The deeper membranous layer of superficial fascia (Scarpa's fascia):

 is thin and membranous, and contains little or no fat Inferiorly, it


continues into the thigh, but just below the inguinal ligament, it fuses
with the deep fascia of the thigh (the fascia lata.

 It continues into the anterior part of the perineum where it is firmly


attached to the ischiopubic rami and to the posterior margin of the
perineal membrane. Here, it is referred to as the superficial perineal
fascia (Colles' fascia)

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Neurovascular structures of of the anterior abdominal wall

Arteries

1. Superficial epigastric and superficial circumflex iliac from


femoral artery.

2. Inferior epigastric and deep circumflex iliac from the


external iliac

3. Superior epigastric from the internal thoracic

4. Lower 6 posterior intercostal arteries from the thoracic aorta

5. Lumbar arteries from the abdominal aorta.

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• Veins - share similar name with the arteries, in addition to
which there are unaccompanied paraumbilical vein and
thoracoepigastric veins.

• Lymphatic drainage

- Vessels above the umbilicus drain into the anterior axillary


lymph nodes and those below the umbilicus drain into the
inguinal lymph nodes

- Lymph from the abdominal wall muscle is drained along the


posterior intercostal, superior epigastric and inferior epigastric
vessels to the posterior mediastinal, parasternal and external iliac
nodes respectively 15
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• Nerves
- the abdominal wall is supplied by the ventral rami of the
lower six thoracic nerves (T7 - T12) called
thoracoabdomina nerve and by the branches of lumbar
plexus (iliohypogastric, ilioinguinal) which are L1.

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Anterolateral Abdominal wall muscles
There are five muscles :

 three flat muscles whose fibers begin posterolaterally, pass


anteromedially, and are replaced by an aponeurosis as the
muscle continues towards the midline-the external oblique,
internal oblique, and transversus abdominis muscles;

 two vertical muscles, near the midline, which are enclosed


within a tendinous sheath (rectus sheath)formed by the
aponeuroses of the flat muscles.

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1. External oblique muscle

- its fibres run from a cranial-lateral to a caudal-medial


direction

2. Internal oblique muscle

- its fibres run from a caudal-lateral to cranial-medial


direction.

3. Transverse abdominis muscle

- the fibres are transversely oriented

4. Rectus abdominis muscle

- its fibres run in a vertical direction

5. pyramidalis 20
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Muscle Origin Insertion Innervation Function
External oblique Muscular slips from Lateral lip of iliac Anterior rami of lower Compress abdominal
the outer surfaces of crest; aponeurosis six thoracic spinal contents; both
the lower eight ribs ending in midline nerves (T7 to T12) muscles flex trunk;
(ribs V to XII) raphe (linea alba) each muscle bends
trunk to same side,
turning anterior part of
abdomen to opposite
side
Internal oblique Thoracolumbar fascia; Inferior border of the Anterior rami of lower Compress abdominal
iliac crest between lower three or four six thoracic spinal contents; both
origins of external and ribs; aponeurosis nerves (T7 to T12) muscles flex trunk;
transversus; lateral ending in linea alba; and L1 each muscle bends
two-thirds of inguinal pubic crest and trunk and turns
ligament pectineal line anterior part of
abdomen to same
side
Transversus Thoracolumbar fascia; Aponeurosis ending in Anterior rami of lower Compress abdominal
abdominis medial lip of iliac crest; linea alba; pubic crest six thoracic spinal contents
lateral one-third of and pectineal line nerves (T7 to T12)
inguinal ligament; and L1
costal cartilages lower
six ribs (ribs VII to XII)
Rectus abdominis Pubic crest, pubic Costal cartilages of Anterior rami of lower Compress abdominal
tubercle, and pubic ribs V to VII; xiphoid seven thoracic spinal contents; flex vertebral
symphysis process nerves (T7 to T12) column; tense
abdominal wall
Pyramidalis Front of pubis and Into linea alba Anterior ramus of T12 Tenses the linea alba
pubic symphysis 22
• The fibres of internal oblique and external oblique
muscles take different orientations above the ASIS,
but below that they run parallel to each other.

• The rectus abdominis muscle is divided by Three


tendinous intersections

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• The 1st tendinous intersection lies at the level of the 8th rib,
the 3rd at the level of the umbilicus

• the 2nd half way between the 1st and 3rd

• At the lateral borders of the rectus abdominis muscle there


is a curve line extending from the costal margin to the
pubic region called semilunar line

• The point where the second tendinous intersection meets


the costal margin and the semilunar line is the localisation
of the fundus of the gall bladder. 24
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Rectus sheath
• The rectus sheath is a dense connective tissue envelope that
encloses the rectus abdominis muscle.

• It is formed by the aponeurosis of the three flat abdominal wall


muscles (external oblique, internal oblique and transverse
abdominis muscle).

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Contents of the rectus sheath:

1. Rectus abdominis muscle

2. Pyramidalis muscle

3. lower six intercostal nerves

4. The lower six intercostal vessels

5. Inferior and superior epigastric vessels

6. Lymphatic vessels
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Deep fascia of the abdominal wall
• Superficial, intermediate, and deep layers of investing
fascia cover the external aspects of the three muscle
layers
 The internal aspect of the abdominal wall is lined with
endoabdominal (Transversalis)fascia

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Umbilicus

• The umbilicus is found half way between the xiphoid


process and the symphysis pubis.

• At the umbilicus there is no subcutaneous fat.

• Therefore it appears as a depression called the


umbilical fossa.

• This corresponds to the umbilical ring closed by


connective tissue in adults.
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• During embryonic life the following structures
pass through the umbilical ring.

1. Two umbilical arteries

2. A single umbilical vein

• The closure of the ring starts after birth as the


umbilical cord dries and falls out.

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• Before the time of birth, because the ring is open, some
segments of the intestine protrude through it, this is
called physiological umbilical hernia

• If this herniated parts of the viscera extend into the


umbilical cord with a covering membranous sac of
peritoneum and amnion it is called Omphalocele.

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Internal Surface of Anterolateral
Abdominal Wall
• The infraumbilical part of this surface exhibits five
peritoneal folds
 The median umbilical fold extends from the apex of the
urinary bladder to the umbilicus and covers the median
umbilical ligament, a fibrous remnant of the urachus
 Two medial umbilical folds, lateral to the median
umbilical fold, cover the medial umbilical ligaments,
formed by occluded parts of the umbilical arteries
• Two lateral umbilical folds, lateral to the medial umbilical
folds, cover the inferior epigastric vessels and therefore
bleed if cut 35
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Inguinal canal

• The inguinal canal is a 3 - 5cm long passage through the


fascial and muscular layers of the medial aspect of the lower
abdominal wall

• Lies above and parallel to the medial part of the inguinal


ligament

• The canal begins at the lateral inguinal fossa by its deep


inguinal ring and extends obliquely from a dorso-lateral to a
ventro-medial direction to end at its superficial inguinal
ring above the pubic tubercle 37
• It connects the retroperitoneal space to the scrotum/labia
majora and transmits the spermatic cord in males, the
round ligament of the uterus in females & a branch of
ilioinguinal nerve in both sexes.

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• Contents of the inguinal canal:

1. Spermatic cord in males

2. Round lig. of the uterus in females

3. Ilioinguinal nerve in both sexes

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Spermatic cord

• The spermatic cord is formed by structures passing to and


from the scrotum that suspend the testis in the scrotum.

• It is formed at the deep inguinal ring and ends at the


Superoposterior border of the testis.

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Contents of the spermatic cord
1. Ductus deferens

2. Artery and vein of the ductus deferens

3. Testicular artery

4. Pampiniform plexus of veins (testicular veins)

5. Cremasteric artery & vein (small vessels associated


with the cremasteric fassia)

6. Sympathetic and parasympathetic nerves

7. Genital branch of genitofemoral nerve

8. Lymphatic vessels
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Inguinal hernia

• There are two types of inguinal hernia, direct and indirect


inguinal hernias, the boundary between them being the
lateral umbilical fold containing the inferior epigastric
vessels

• Inguinal hernia is more common in males (90% )

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A. Direct inguinal hernia

- It is less common than the indirect (15 - 25% of the cases)

and is usually acquired.

- It penetrates the abdominal wall medial to the lateral


umbilical fold through the medial inguinal fossa to enter
the inguinal canal.

-Such hernia usually occurs in older age groups when the


abdominal become atrophied

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- Bulging occurs medial to inferior epigastric vessels in the
inguinal triangle bounded by:

 Laterally: Inferior epigastric vessels

 Medially: Rectus abdominus muscle

 Inferiorly: Inguinal ligament

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B. Indirect inguinal hernia

- is more common than the direct constituting 75 - 85% of all the


cases.

- enters the inguinal canal through the deep inguinal ring that lies in
the lateral inguinal fossa and leaves the canal through the
superficial inguinal ring to extend to the scrotum or labia majora

- the indirect inguinal hernia can be congenital or acquired

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Other hernias of the abdominal wall

• Epigastric hernia

- small protrusion of extraperitoneal fat through a defect in the


linea alba above the umbilicus.

• Umbilical hernia

- protrusion of the mid gut through the umbilicus (exomphalos)


and is not common in adults.

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- if it occurs in infants and small children it is the herniation of
the peritoneum and some abdominal contents through the
umbilicus due to the weakness of the umbilical scar.

• Femoral hernia

- protrusion through the femoral ring found behind the medial


part of the inguinal ligament. this is more common in
females b/c of the wide pelvis that females have.

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• Paraumbilical hernia

- umbilical hernia does not occur in adults through the umbilical


scar but through the linea alba just above the umbilicus and this
is known as paraumbilical hernia.

• Interstitial hernia

- found between the layers of the abdominal wall.

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• Spigelian hernia

- occurs through the semilunar line along the lateral border of


the rectus sheath.

- it usually occurs at the level of the arcuate line.

• Incisional hernia

- is a hernia that protrudes through an operative incision.

- it is common after wound infection when the scar is weak.

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ABDOMINAL CAVITY

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The Abdominal cavity

• The abdominal cavity contains:


1. Most of the organs of the digestive system (stomach,
intestine, liver, pancreas)

2. Parts of the urogenital system (kidneys, ureters)

3. Lymphatic organs and tissues (spleen, lymph nodes)

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4. Endocrine glands (suprarenal, ovaries)

5. Autonomic plexuses

6. A serous membrane, the peritoneum

• The abdominal cavity is divided into:

1. Peritoneal cavity

2. Retroperitoneal space

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Peritoneum
• The peritoneum is a smooth glistening, serous membrane
that lines the abdominal wall and covers the outer
surfaces of some abdominal organs.

• It is the largest serous membrane of the body.

• it consists an outer layer of connective tissue (gives


strength) & an inner layer of simple squamous
epithelium (mesothelium) (which secretes serous fluid
that lubricates the surface)
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• It has two parts:

I. Parietal peritoneum - lines the inner surface of the


abdominal & pelvic walls & the lower surface of the
diaphragm.

II. Visceral peritoneum - forms the periotoneal covering


(serosa) of some organs

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1. Some organs are called intraperitoneal organs e.g. liver,
stomach, spleen, superior part of the duodenum, jejunum,
ileum transverse colon and sigmoid colon

- The intraperitoneal organs are fixed to the body wall by


folds of peritoneum that increase the mobility of the organ
and also form pathways for the passage of vessels, nerves
& lymphatics. E.g. Mesentry, mesocolon, mesoappendix,
omenta…..

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2. Some organs like the kidneys, ureters, abdominal aorta,

inferior vena cava, thoracic duct, sympathetic trunk


etc… develop out side the peritoneum and lie on the
posterior abdominal wall being covered by peritoneum
only on their anterior aspect; such organs are said to be
primary retroperitoneal (extra peritoneal) organs.

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3. Other organs originally develop with in the peritoneum

and with passage of the foetal time they are pressed to


the abdominal wall and partially lose their peritoneal
cover and will have a free contact to the posterior
abdominal wall (to > 50% of their circumference they
are under peritoneal cover).
- Such organs are called secondary retroperitoneal (partial intra
peritoneal) organs, e.g. descending, horizontal and ascending
parts of the duodenum, pancreas, ascending and descending
colon, part of the rectum
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Peritoneal cavity
• It is the potential space between the two peritoneal layers
• contains a very thin film of fluid that keeps the surface
moist.
• it includes the intraperitoneal organs.
• Divided broadly into two parts:
 greater sac - between the the anterior abdominal wall
and the abdominal organs
 lesser sac (omental bursa) - lies mostly behind the
stomach & lesser omentum
• These two sacs communicate through the epiploic
foramen (Omental foramen or foramen of winslow).
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• The peritoneal cavity is a completely closed sac in males
but in females the uterine tubes open in to it.

• On the other end the uterine tubes open in to the uterine


cavity which communicates with the exterior through the
vagina.

• Radiographic examination of the tubal patency can be


done by injecting contrast (hysterosalpingography)

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Clinical significance of the peritoneum

• The peritoneum produces fluid (exudation) and cells in


response to injury or infection and tends to wall of or localize
infection.

• During infection or inflammation of the peritoneum excessive


fluid may be secreted and collected in the cavity.

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• This excessive accumulation of fluid in the peritoneal
cavity is known as Ascites.
• Ascitic fluid can be removed by puncturing (taping) the
anterior abdominal wall (abdominal paracentesis)
– This is done above the emptied bladder, half way
between the pubic symphysis and the umbilicus or
– lateral to the epigastric vessels at a point lying
between the upper 2/3 and the lower 1/3 of a line
joining the left ASIS
• This point lies at the lateral border of the rectus abdominis
muscle

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Innervations of the peritoneum
• Parietal peritoneum
1. Supplied by sensory & vasomotor nerves of the adjacent
body wall
2.The subdiaphragmatic part is innervated by the phrenic
nerve
3. Sensitive to oain and touch

Visceral peritoneum
1. Sensitive to distension and chemical irritation
2. Insensetive to touch, laceration or pain
3. innervated by autonomic visceral nerves of associated organs 66
Peritoneal folds

• Unlike other serous membranes the peritoneum contains


large folds that weave in between the viscera.

• These folds bind the organs together and to the wall of the
abdominal cavity and contain blood vessels and nerves
that supply the respective organs.

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• These peritoneal reflections between the organs or between the
body wall and the organs are termed as ligaments.
E.g. 1. Hepatogastric ligament
2. Hepatoduodenal ligament
They form the lesser omentum that suspends the
stomach and duodenum from the liver)
3. Gastrocolic lig.
4. Gastrolienal (Gastrosplenic) lig.
5. Lienorenal (splenorenal) lig.
6. Gastrophrenic lig.
7. Falciform ligament
8. Umbilical folds or ligaments
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• A broad reflection of peritoneum that attaches the stomach to the
neighbouring organs is called Omentum and is divided in to two
parts.

1. Lesser omentum – two layer od peritoneum between the liver on


one side and the stomach and duodenum on the other side
2. Greater Omentum - is a four layer of peritoneum hanging from
the greater curvature of the stomach.
• storehouse of fat
• protects the peritoneal cavity against infection
• Limits the spread of infection by moving to the site of
infection & sealing it off hence called the policeman of the
abdomen.
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The Stomach

• The stomach is a muscular bag forming the widest & most dilated
part of the alimentary canal.

• It extends from the esophagus above to the duodenum below.

• Location- it lies obliquely under the diaphragm in the epigastric,


and left hypochondriac regions of the abdomen.
• most of it lies under cover of the left costal margin & the ribs.

• Shape - when empty it commonly resembles the letter “ J “

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• Size - it is a very distensible organ with a maximum length
of about 25 cm and a maximum breadth of about 14 cms.

• its Average capacity is:

~ 30 ml at birth

~ 1 L at puberty

~ 2 L or more in adults.

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PARTS OF THE STOMACH
A. stomach has four part:
1. Cardia - adjacent to the esophagogastric junction found at the level
of T10-11
2. Fundus - above the entrance of the oesophagus and usually
contains 50 ml of swallowed air.
3. Body - between the fundus and the
pyloric part
4. Pylorus - between the body and1st part of the duodenum

found at the level of L2

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B. There are two curvatures of the stomach

1. Greater - convex

2. Lesser - concave

C. Two walls of the stomach

1. Posterior

2. Anterior

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D. The stomach has also two openings:

1.Cardiac opening
- the cardiac orifice lies about 3 cms to the left of and below
the xiphoid process .
- is fixed
2. Pyloric opening
- the pyloric part of the stomach is movable.
- surrounded by the pyloric sphincter, the circular fibres of
which may be congenitally thickened, a condition known
as infantile (congenital) hypertrophic pyloric stenosis
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• infantile (congenital) hypertrophic pyloric stenosis

– This causes a characteristic projectile vomiting in


newborn infants.

– Therefore, it must be surgically corrected by


pylorotomy (a longitudinal incision of the muscularis
up to the submucosa) early during infancy.

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Relations of the stomach
Peritoneal relation
• lined on both sides i.e both anteriorly & posteriorly by
peritoneum.

• at the lesser curvature the layers meet & become


continuous with lesser omentum.

• at the greater curvature the two layers meet to form the


greater omentum

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Structure of the stomach

• Like all parts of the GIT, the wall of the stomach consists
of 4 layers: mucosa, submucosa, muscularis and serosa.

• It contains numerous folds or ridges known as Gastric


rugae, which vary in height and number with the degree
of distension of the organ.
• When the organ is fully distended, they almost disappear.

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• There are parallel longitudinal folds of the mucosa along
the lesser curvature extending from the region of the
oesophagogastric junction in the direction of the pylorus.

• Between these parallel folds there are depressions called


gastric canals.

• The entire area of the gastric areas is studded by minute


depressions, called the gastric pits.

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Blood vessels of the stomach

A. Arteries

• Arteries to the stomach arise directly or indirectly from the


celiac trunk and run along its lesser and greater curvatures.

• Those along its lesser curvature are:

 Right gastric artery (from the common hepatic)

 Left gastric artery (directly from the celiac trunk).

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• Those along its great curvature are:
 Right gastroepiploic artery (from gastroduodenal artery)

 Left gastroepiploic artery (from splenic artery)

 Short gastric arteries (from splenic artery)

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B. Veins of the stomach

• The veins of the stomach accompany the arteries and open


in to the portal vein or one of its branches in a variable
manner.

• Veins along the lesser curvature:

 Right & left gastric vein - directly drains into the portal
vein
 Prepyloric vein - drains into the right gastric vein

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• Veins along the greater curvature:

 Right gastroepiploic vein - drains into superior


mesenteric vein

 Left gastroepiploic vein - drains into the splenic vein

 Short gastric vein - drain into the splenic vein

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• Portal vein also form anastomosis with veins of the
neighbouring organs connecting the portal vein to the
systemic circulation, which is important for
portosystemic circulation during portal hypertension
E.g.

1. portal vein  left gastric vein oesophageal venous


plexus azygos  superior vena cava
– development of oesophageal varices the rupture of
which leads to life threatening bleeding
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Lymphatic drainage
• The lymphatic plexus of the stomach communicates with
similar plexuses in the oesophagus and duodenum and empty
into a lymphatic vessel that ultimately drains in to the thoracic
duct.

• This serves as an important way for the spread of metastatic


cancer of the stomach

• The regional lymph nodes lie along the arteries and are named
accordingly.

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• The proximal part of the stomach drains in to the short
gastric, splenic and left gastroepiploic lymph nodes.

• The distal part into right gastroepiploic, pyloric and hepatic


lymph nodes.

• The final drainage is to the celiac lymph nodes then to the


intestinal trunk.

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Innervations of the stomach
• Sympathetic innervation – from sympatheric trunk

• Parasympathetiv innervation – anterior and posterior


parasympathetic plexus from vagus nerve
– Sympathetic stimulation reduces the peristaltic movement and
parasympathetic stimulation enhance the movement and
secretion.
– Therefore surgically vagotomy (truncal, selective or highly
selective) can be done for the treatment of peptic ulcer disease
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The Small intestine

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Function

• The digestion and major part of absorption occurs in


the small intestine.

• In the small intestine the food is broken down in to its


molecular components by the secretion of the intestine,
pancreas and liver enzymes and then absorbed through
the intestinal mucous membrane into the blood or
lymphatic capillaries

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PARTS & LENGTH

• It begins at the pyloric valve of the stomach, coils


through central and lower abdominal cavity to open in
to the large intestine at the ileocaecal valve

• It is divided in to 3 segments:

Duodenum, Jejunum and Ileum.

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• The small intestine measures about 2.5 cm in diameter and
about 6.35m (5-8m) in length.

• Out of this 25 cm is duodenum, 2.5m is jejunum & 3.6m is


ileum.

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Duodenum
• The shortest, widest & most fixed part of the small intestine.

• Extends from the pylorus to the duodenojejunal flexure.

• Has a shape like the letter “C“ the concavity of which encloses the
head of the pancreas.

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• Lies above the umbilicus at the level of L1- L3 vertebra.

• Is mostly retroperitoneal & fixed except at its Superior part where it


is intraperitoneal.

• Is about 25 cm in length & has four parts:

1. superior or 1st part – pyloric sphincter to doudenal flexure,


about 5cm, also called cup or bulb of doudenum

2. Descending or 2nd part – doudenal flexure to first end of 3rd


Part, about 7-10cm long, Bile and pancreatic duct insert here

3. Horizontal, inferior or 3rd part - passes horizontally infront


of IVC & joins fourth part, about 6-8 cm long

4. Ascending or 4th part – ascends from L3 – L2, about 5cm105


• The superior part of the duodenum is attached to the liver by
the hepatoduodenal ligament.

• Because of the close relationship between the duodenum and


the gallbladder with its ducts, the duodenum in cadaver is
usually stained with bile that leaks after death

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• The bile duct and the main pancreatic duct usually open
together in to the greater duodenal papilla (about 8 -10cms
from the pylorus)

• In most of the cases the bile and pancreatic ducts unite and form
a short hepatopancreatic ampulla (ampulla of Vater), which
opens into the duodenum at the greater duodenal papilla being
controlled by the hepatopancreatic sphincter (sphincter of Odi)

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• In case the accessory pancreatic duct (duct of Santorini)
persists, it opens into the duodenum at the lesser (minor)
duodenal papilla which is found on the anteromedial aspect of
the second part of the duodenum about 2 cm above the greater
papilla.

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Blood vessels of the duodenum

A. Arteries

1. Superior pancreaticoduodenal artery from gastroduodenal

2. Inferior pancreaticoduodenal artery from superior mesenteric

3. Right gastric artery from the common hepatic

4. Supraduodenal artery from the gastroduodenal

5. Retroduodenal artery from the gastroduodenal


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C. B. Veins

- follow the arteries with slight difference

C. Lymphatics - the lymph from the duodenum is drained into


the pancreaticoduodenal lymph nodes that lie in front and
behind the pancreas and into the intestinal trunk and then
to the thoracic duct.

D. Nerves - the duodenum is innervated by fibres from the


celiac and superior mesenteric plexuses.

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Jejunum and Ileum

• Of the coiled part of the small intestine the jejunum constitutes


the proximal 2/5 while the ileum comprises the distal 3/5

• They are suspended from the posterior abdominal wall by the


mesentery of the small intestine.

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Mesentry

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Blood vessels of the jejunum & ileum

1. Arteries - jejunal and ileal arteries from the superior


mesenteric artery.

• Near the wall of the intestine these arteries branch to smaller


branches that form anastomosis with one another to form
arterial arches (arcades) which are important for the
collateral circulation.

• From the arcades arise straight arteries that supply the


intestine
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2.Veins

- accompany the arteries and drain blood via the superior


mesenteric vein into the portal vein.

3. Lymphatic

- the lymph from the jejunum and ileum flows into the
lymphatic vessels accompanying the blood vessels and is
drained into the superior mesenteric lymph nodes.

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Structure of the small intestine
• The luminal surface of the small intestine is composed of a
series of parallel folds that run in a circular manner
• These folds are known as plicae circulares or valves of
Kerckring or semilunar folds.
• Unlike the rugae of the stomach the folds cannot be flattened
by distension.
• Such folds are absent in the upper part of the duodenum and
most part of the ileum.

• The mucosa is further carried up into finger like projections


that cover the entire surface of the small intestine called
intestinal villi.
123
124
125
The Large intestine

126
• The large intestine has a length of 1.2 -1.5m.

• It consists of the caecum, appendix, ascending colon,


transverse colon, descending colon, sigmoid (pelvic)
colon rectum and anal canal.

• The colon normally contains air bubles in its lumen.

127
Structure of the large intestine
• Except for the rectum and anal canal the mucosa of the large
intestine is characterised by goblet cells, glands and
absorptive cells.

• Its external surface is characterised by:

1. Appendicis epiploicae - are small masses of fat, enclosed in a


peritoneum, which extends from the surface of the colon.

128
2. Teniae coli - three band like thickenings of the outer
longitudinal layer of the muscularis externa (about 1cm
in width).

 The longitudinal muscle layer becomes complete in the


wall of the appendix and the rectum.

129
3. Haustrations (Sacculations)

- the teniae are shorter than the intestine itself and lead
directly to the root of the appendix.

- due to the shortness of the teniae the wall of the large


intestine is folded and out-pocketings called haustria
are formed.

130
Large Intestine - Unique Features

131
• Abnormal out-pocketings of the wall sometimes appear
between the teniae in the form of diverticula.

• When such diverticula appear in multiples the condition is


known as diverticulosis.

• Diverticula may be inflamed (diverticulitis) and will be a


good differential diagnosis to appendicitis and other diseases
causing lower abdominal pain.

132
Caecum
• Is the beginning part of the large intestine that joins the ileum.

• It is a blindly ending pouch having a length of about 6cms and a


width of about 7.5cms.

• It is one of those organs of the body that have greater width than
length

• It is usually covered by peritoneum and contains a mesocaecum


therefore it is freely movable (mobile caecum)

• contains no appendices epiploicae and is “U” shaped 133


134
135
• Blood supply

- the caecum is supplied by the branches of the ileocaecal artery,


which is a branch of the superior mesenteric artery.

- the ileocaecal artery gives two branches that supply the caecum.

- A smaller anterior caecal artery that descends to the caecum

- A larger posterior caecal artery runs behind the terminal part of


the ileum to supply the major part of the caecum and gives off
the appendicular artery to the appendix

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137
Vermiform Appendix
• Is a small diverticulum of the caecum.

• Arises from the posteromedial aspect of the caecum at the


junction of the three teniae coli about 2-3 cms below the ileal
insertion.

• Is about 9-10 cms long but its length can vary between 2-20
cms; and is about 0.5-1 cm wide.

138
• It contains no sacculations, no appendices epiplocae and no teniae
coli.

• Its mucosa is strongly infiltrated by lymphatic tissue, i.e. a well-


developed lymphatic organ (not vestigial)

• It has a mesentry called mesoappendix that contains the


appendicular artery and vein.

• The artery is a branch of ileocaecal or ileocolic artery.

• The appendix also gets additional arterial supply from the caecal
arteries.
139
0.5%

1%

64%

2-2.5% 32% 140


• The appendix can also be classified as ascending and descending
types.

• The ascending type assumes all positions except pelvic appendix,


which is a descending type.

• A pelvic appendix crosses over the right terminal line and is


closely related to the right ovary and the right uterine tube in
females.

• The inflammation of the appendix is called appendicitis.

141
• The inflammation of the appendix is called appendicitis

• The usual point of maximum tenderness (pain) during


appendicitis on the abdominal wall is at a point between the
lateral 1/3 and the medial 2/3 of a line joining the right anterior
superior iliac spine to the umbilicus.

• This point is called McBurneys point.

142
143
Ascending colon
• The ascending colon extends from the caecum in the right ileac fossa
to the right colic flexure or hepatic flexure and measures about 25
cms in length.

• It is secondarily retroperitoneal.

• Blood supply - the ascending colon is supplied by the right colic


artery from the superior mesenteric artery

144
Transverse colon
• The transverse colon extends from the right colic (hepatic)
flexure to the left colic (splenic) flexure measuring about 50 cms.

• The left colic flexure is usually higher than the right.

• Developmentally its right 2/3 is derived from the midgut and its
left 1/3 from hindgut.

• - its right 2/3 is supplied by the middle colic artery, which is from
superior mesenteric artery, while its left 1/3 is supplied by left
colic artery from inferior mesenteric artery
145
Descending colon
• The descending colon, with a length of 25 cms, extends from the
left colic flexure to the pelvic brim where the sigmoid colon
begins.

• It is secondarily retroperitoneal

146
147
Sigmoid (pelvic) colon
• The sigmoid colon extends from the left sacroiliac joint at the
pelvic brim to the level of the 3rd sacral vertebra in the pelvis,
where it becomes continuous with the rectum.

• It is an S-shaped intra-peritoneal structure with a variable


length (average length being about 45 cm)

148
149
• It has a mesosigmoid that has an inverted V-shaped and attaches
it to the posterior abdominal wall, pelvic brim and front part of
the sacrum.

• The sigmoid mesocolon is usually long and this predisposes it


to “volvulus” (a twisting of the intestine causing obstruction).

• Blood supply

- sigmoidal arteries from the inferior mesenteric artery.

150
151
Rectum
• The rectum is a retroperitoneal segment, which is covered by
peritoneum only anteriorly in its upper part.

• It has no sacculations; no epiploic appendages

• the teniae coli blend and form two muscular bands

• It begins at the 3rd sacral vertebra and is about 12 cms long.

• Its lower part is dilated to form the rectal ampulla.

152
• Three sharp lateral flexures of the rectum (superior and
inferior on the left side, and intermediate on the right)

• The lateral flexures are formed in relation to three


internal infoldings (transverse rectal folds)

• Peritoneum covers the:

– anterior and lateral surfaces of the superior third of


the rectum,

– only the anterior surface of the middle third, and

– no surface of the inferior third because it is


subperitoneal
153
154
155
• Blood supply

- the rectum is supplied by superior rectal artery from the


inferior mesenteric artery, middle rectal and inferior
rectal arteries from internal iliac artery and median
sacral artery from the last part of the abdominal aorta.

- Veins follow the same arterial pattern

156
Anal canal
• The anal canal extends from the pelvic diaphragm to the anus.

• It has a length of about 3cm, but its length from the pectinate line
to the anus is 1.5 cm.

• Sometimes it fails to communicate with the exterior in a congenital


anomaly called imperforate anus.

157
• The external longitudinal and internal circular layers of its
muscularis are continuations from the rectum, but the fibres
of the levator ani muscle join the longitudinal layer and
form a conjoined longitudinal muscle, which is a
combination of smooth and skeletal muscle fibres.

• The inner circular layer forms the internal anal sphincter.

158
• The external anal sphincter, a striated muscle that encircles
the lower part of the anal canal, consists of three parts:

1. subcutaneous part,

2. superficial part, and

3. deep part.

• It is innervated by perineal and inferior rectal nerves from


pudendal nerve and by a branch from S4

159
• The anal mucosa is divided into 3 zones.

1. Columnar zone (zona columnaris)

2. Intermediate zone (zona intermedia)

3. Cutaneous zone (zona cutanea)

160
161
1. The columnar zone:

- Forms the upper half of anal canal

- Is marked by a series of 5-10 vertical folds of the mucosa called


anal or rectal columns (of Morgagni)

- The depressions between the columns are called anal sinuses


(crypts).

- The lower ends of the anal columns are joined together by small
crescent shape folds of the mucosa, the anal valve

162
• The serrated edges of the anal valves form the so-called
pectinate (dentate) line.

2. The intermediate zone (zona Alba):

- Lies below the sphincter ani muscle at the transition between


the intestinal epithelium and the cutaneous epithelium.
- This area is marked by the whitish or bluish line
3.The Cutaneous zone (anal verge):
- Extends down from the linea alba to the anus.
- It is the part covered by the epithelium of the skin
- This area has an extensive sensory innervation
163
• Blood supply:
A. Arteries
- Similar to the rectum
B. Veins
- Drain into the rectal venous plexus which drains into the superior
rectal and inferior rectal veins.
- These veins therefore may dilate due to various causes and become
varicosed causing haemorrhoids.
- There are two types of haemorrhoids:
- Internal hemorrhoids
- External haemorrhoids

164
165
Pancreas
• The pancreas is a soft, tadpole-shaped gland
• It extends across the posterior abdominal wall from
the duodenum, on the right, to the spleen, on the
left.
• The pancreas is retroperitoneal and lies deep
to the greater curvature of stomach between
duodenum and spleen

166
Pancreas
• mixed gland, both exocrine and endocrine
– Exocrine portion forms the bulk of the gland and secretes enzyme
rich fluid

– Endocrine tissue forms islets of Langerhans scattered throughout


exocrine tissue, secrete hormone

• An accessory organ, the pancreas is important to the digestive


process because it produces a broad spectrum of enzymes

• These enzymes break down all categories of foodstuffs

• This exocrine product is called pancreatic juice


167
Pancreas
• Parts
– Head
• Expanded part
• Embraced by C-shaped curve of duodenum
• Uncinate process projection from its inferior part
– Neck
• Overlies superior mesenteric vessels
– Body
• Main part
– Tail
• Related to hilum of spleen
• Structure
– Highly lobulated
– Invested by thin collagenous capsule which sends septa
between lobules
168
Pancreas…
• The main pancreatic duct begins in the tail
– to the pancreatic head to unite to form the short, dilated
hepatopancreatic ampulla (of Vater)
 opens into the descending part of the duodenum at the
summit of the major duodenal papilla

 The accessory pancreatic duct opens into the


duodenum at the summit of the minor duodenal papilla

169
170
171
Blood supply and innervation
• Vessels
– Pancreatic arteries from splenic artery
– Pancreaticoduodenal arteries from superior
mesenteric artery
– Pancreatic veins drain to splenic and superior
mesenteric veins
• Nerves
– From vagus and abdominalpelvic splanchnic nerves

172
173
Spleen
• In the adult, the spleen lies against the diaphragm, in
the area of rib T9-T11.

• It is therefore in the left upper quadrant, or left


hypochondrium, of the abdomen.

The spleen is connected: to the greater curvature of


the stomach by the gastrosplenic ligament, which
contains the short gastric and gastro-omental vessels;

To the left kidney by the splenorenal ligament, which


contains the splenic vessels.
• Largest lymphoid organ
• Location:
– Left superior quadrant of abdominal cavity
– Posterior to stomach
• Highly vascular
• Function:
– Removes blood-borne antigens
– Removes and destructs aged blood cells
– Site of hematopoiesis in fetus
– Stores blood platelets and RBCs
The neurovascular supply
• Arteries
– from the splenic artery, the largest branch of the celiac trunk

• Veins
– Venous drainage from the spleen flows via the splenic vein

• Lymphatic
– pass along the splenic vessels to the pancreaticosplenic
lymph nodes en route to the celiac nodes
• The nerves of the spleen, derived from the celiac plexus

176
The Liver and Gallbladder
• The liver and gallbladder are accessory organs
associated with the small intestine
• Liver Functions
– Detoxification
– Synthesis of bile
– Synthesis of plasma proteins
– Metabolic activities
• The gallbladder is a storage site for bile

177
The Liver: gross anatomy
• The reddish, blood rich liver is the largest
gland in the body weighing about 1.5 kg
in the average adult
• Above the liver is the diaphragm, to its left is
the stomach and below is the transverse
colon and right colic flexure

178
The Liver: gross anatomy
• Shaped like a wedge, it occupies most of the
right hypochondriac and epigastric regions
extending farther to the right of the body
midline than the left
• Located under the diaphragm, the liver lies almost
entirely within the rib cage
• The location of the liver within the rib cage offers this
organ some degree of protection

179
180
181
182
The Liver: gross anatomy
• The liver has four lobes; right, left, caudate
and quadrate
• Falciform ligament separates the right and left
lobes anteriorly and suspends the liver from
the diaphragm and anterior abdominal wall
– Running along the free inferior edge of the
falciform ligament is the ligamentum teres,
a remnant of the fetal umbilical vein

183
The Liver: gross anatomy
• Except for the superiormost liver area,
which is fused to the diaphragm, the
entire liver is enclosed by a serosa
(visceral peritoneum)
• The lesser omentum, anchors the liver to
the lesser curvature of the stomach

184
185
The Liver: gross anatomy
• The bile duct, hepatic artery and portal
vein, enter the liver at the porta hepatis
• External surface is invested by thin
collagenous capsule=Glisson’s capsule
– Thick at hilum, surround vessels and ducts to
interior
– Fine meshwork of reticular fibers radiate from
this to support liver cells

186
The Liver: Microscopic Anatomy
• Liver lobule
– Liver parenchymal cells (hepatocytes) are arranged into
lobules
• structural & functional units called liver lobules
– around one million liver lobules
– Each lobule is roughly hexagonal in shape
– Bounded by thin septa of collagenous tissue
– Angle of lobule are portal tracts (triad)
• Terminal braches of portal vein and hepatic artery and
bile duct
– Center of lobule is a centrolobular venule (central vein)

187
188
The Liver: Microscopic Anatomy
• Liver parenchyma

– Hepatocytes or liver cells are organized to radiate


out from a central vein running the length of the
longitudinal axis of the lobule
– Hepatocytes form flat anastomosing plates

– Plates are directed from periphery of lobules to its center

– Spaces between plates very leaky capillaries, the

liver sinusoids 189


The Liver Lobule
• At each of the six corners of a lobule is a portal
triad so named because three basic structures
are always present there: A branch of
– hepatic artery
– portal vein
– bile duct

190
The Liver Lobule
• blood comes from the hepatic artery (20%) and
portal vein (80%)
– The hepatic artery supplies oxygen rich arterial blood
to the liver
– The hepatic vein carries blood laden with nutrients
from the digestive viscera
• A bile duct carry secreted bile toward the
common bile duct and ultimately to the
duodenum
• Inside the sinusoids are star shaped hepatic
macrophages, also called Kupffer cells
191
192
Portal vein, hepatic artery,
hepatic veins and bile duct

193
Liver regeneration
• Liver cells have extraordinary capacity for
regeneration
• Loss of hepatic tissue triggers cell division and
restore original mass
• Regenerated tissue is similar to the removed
but if there is repeated damage, regeneration
and production of connective tissue occurs
simultaneously which results in
disorganization of liver structure=cirrhosis

194
The Gallbladder
• The gallbladder is a thin-walled, green
muscular sac
• Pear-shaped muscular sac
• Store and concentrate bile
• ~10cm long
• It snuggles in a shallow fossa on the
posteroinferior surface of the liver

195
196
The Gallbladder
• Expels bile when acidic chyme enters the
duodenum or as a result of cholecystokinin
release
• When empty, its mucosa adopts the ridge like
folds or rugae
• Its muscular walls can contract to expel its
contents into the cystic duct which then flows
into the bile duct
• Like most of the liver it is covered by visceral
peritoneum
197
The Gallbladder
• When digestion is not occurring, the
hepatopancreatic sphincter is tightly closed
• Bile then backs up the cystic duct into the gallbladder
where it is stored until needed

198
Gall bladder: microscopic anatomy
• Mucosa
– In non distended state is thrown into many folds
– Lined by simple columnar epithelium
• Submucosa
– Loose, rich in elastic fibers, blood and lymph vessels
• Muscular layer
– Thin, fibers are disposed obliquely
– In neck region, epithelium invaginate and form mucous glands
• Serosa/adventitia
– Binds superior surface to liver (adventitia)
– Opposite surface is lined by serosa (peritoneum)
• Cystic duct
– Wall formed into twisted mucosa covered folds=spiral valve of
Heister
199
200
Blood supply

• The cystic artery


comes form the
right hepatic
artery which
comes off the
hepatic artery
which comes off
the common
hepatic artery
which comes off
the coeliac trunk
• The cystic veins
drain into the
portal vein 201
Bile flow
• 800 ml of bile is secreted by the hepatocytes into the biliary
canaliculi each day.
• The canaliculi flow into the bile ductules in the portal triad
• The bile ductules join to flow into the right and left hepatic
ducts
• These join to form the common hepatic duct
• The cystic duct from the gall bladder joins the common
hepatic duct outside the liver to form the common bile duct
• Bile flows though the ampulla of Vater when the sphincter of
Oddi relaxes and flows into the duodenum

202

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