Clinical Anatomy of GIT and Urinary Tract

astari anggara

Embriology
Foregut : Pharynx primordial
(cavum oris, lingua, glandula salivarius), respiratory system, esofagus sampai papilla duodeni mayor, hepar, pankreas

Midgut: Duodenum sisanya

sampai 2/3 proksimal colon transversum

Hindgut: sisanya ditambah

epitel vesica urinaria dan uretra

Conted
Cavitas peritonii: Coeloem intraembryonic Peritoneum parietal: mesoderm somatic Peritoneum visceral: mesoderm splachnic Mesenterium: double layer peritoneum Mesogastrium dorsal omentum majus, lig. Gastrolienalis, lig.
Gastrophrenica, lig. Gastrocolica lig. Falciformis, lig hepatoduodenal, lig hepatogastrica

Mesogastrium ventral

Esophagus
VC6-VT11 Pars cervical, thoracal, abdominal Inner circular, outer longitudinal Penyempitan (angustia) superior, media, inferior

Klinis
Fistula tracheoesophageal

GERD, kelemahan sphincter lower. Yg mana sphincter lower? Achalasia Varises esofageal (portocaval shunt)

Gaster
Fundus, cardia, corpus, pars pylorus, pylorus Incissura cardiaca & incissura angularis Tunica mucosa: rugae gastrica, canalis gastricus Tunica muscularis: outer longitudinal, middle circular, inner oblique Tunica serosa: peritoneum visceral
Inervasi Parasimpatis: trunkus vagus ant & post Simpatis: T6-T9 n. splachnicus mayor

Vaskularisasi a. gastrica dexter & sinister anastomosis di curvatura minor a. gastroepiploica dex & sin anastom di curvatura mayor a. gastrica brevis & posterior suplai fundus v. gastrica dex et sin v. Porta hepatica v. gastroepiploica sin & brevis v. Lienalis v. gastroepiploica dex v. Mesenterica sup

Sliding hernia

Cont ed
Paraesophageal hernia

Klinisnyaa..
Hiatal hernia Hernia diafragma congenital (bochdalek) Hypertrophic pyloric stenosis Ca gaster, sering di pylorus Gastroscope (nasally/orally) Gastrectomy (total dan parsial) Gastritis dan gastric ulcer Vagotomy
truncal: jarang! selective: Cuma dipilih yg menuju ke segmen gaster tertentu

Ini dia hernia bochdalek

Ada kelemahan diafragma posterolateral sinistra, jadi ususnya protrusi ke thorax Disertai agenesis pulmo sinistra

Duodenum
Pars superior (ada ampullanya lho), pars descenden, pars horizontal, pars ascenden Yang mana yg intraperitoneal dan retro? Lig. hepatoduodenal Flexura duodeni superior (L1) et inferior (L3) Flexura duodenojejunales (L2) ligamentum suspensorium duodenojejunales (Treitz) Papilla duodeni mayor dan acessorius Plica circularis
Vaskularisasi A. Gastroduodenal A. Pancreaticoduodenal sup inf Venanya ke v. Porta hepatis Inervasi n. Vagus dan n. Splachnicus mayor et minor

Lanjoot..
Klinisnya apaan dong? Duodenal ulcer: bisa erosi ke a. gastroduodenal Peptic ulcer: karna asam lambung berlebih Hernia paraduodenal: di sekitar flexura duodenojejunales melalui fossa duodeni sup et inf, fossa paraduodenal, plica paraduodenal

Jejunum & ileum

Bedanya apa hayo? Junctio duodenojuejunalesjunctio ileocaecal Radix mesenterii (L2 sinistra-art. Sacroiliaca dex) Isi mesenterium: vasa mesenterica sup, limfonodi (juxta-mesenterica, mesenterica, centralis superior), nervus Vaskularisasi: a. Jejunales dan a. Ileales (masih inget cabang dari apa?)

Conted
Nah klinisnya.. Diverticulum ilei (Meckel):
gagalnya penutupan duct omphalomecentericus
74% free 26% nempel ke umbilicus Mucosa: ileal type, gastric type, pancreatic, jejunale, atw colonic

Iskemia small intestine: occlusi vasa recta oleh emboli nekrosis ileus Ileus: nyeri colic, distensi, vomiting, fever dan dehidrasi Ileostomy: stoma dari ileum ke kulit dinding anterolateral Megacolon (Hirschprung)

Large Intestine

Caecum, appendix, colon ascenden, transversum, descenden, sigmoid, rectum, dan canalis analis Haustra & incissura semilunaris Appendices epiploica Taenia coli (libera, mesocolica, omentalis) Plica semilunaris Mesocolon transversum Mesocolon sigmoid Flexura hepatica & lienalis Junctio rectosigmoid Posisi appendix? Retrocaecal, preileal, retroileal, pelvica, dll

Klinisnyaa
Appendicitis, McBurney di garis Monroe Colectomy (removal) Colitis Colostomy, pembuatan stoma di pars terminal colon IBD Diverticulosis, diverticulitis Volvulus, hanya untuk yg intra

Rectum & Anus

Retroperitoneal dan subperitoneal Canalis analis Linea pectinata (dentata), batas embriologis Junctio anocutan M. Levator ani M. Sphincter ani internus (involunter) M. Sphincter ani externus (volunter)

Klinisss
Atresia ani Stenosis ani Hemorrhoid Internal: plexus venosus rectalis internal Eksterna: plexus venosus rectalis externa, sakit Batesnya si linea dentata

Hepar
Intraperitoneal Fascies diaphragmatica & visceralis Recessus subphrenicus & hepatorenal Area nuda, sulcus vena cava inferior Fossa vesica fellea, porta hepatis (apa aja? ) Impressio Lobus anatomis, fisiologis Segmen?

Blood flow Truncus coeliacus - a. Hepatica communis a. Hepatica propria porta hepatis - ramus dex et sin v. Mes sup + v. Lienalis = v. Porta hepatica v. Mes inf ke v. lienalis Vena2 abdomen v. Porta hepatica sinusoid v. Centralis v. Hepatica VCI

Portocaval shunt
Letak Esofagus Paraumbilical Anus Retroperitoneal Porta v. gastrica sinistra v. paraumbilicalis v. Rectalis sup v. Colica sinistra Cava v. esofageales v. Epigastrica superficialis v. Rectalis med&inf v. Lumbalis ascenden

Klinisnya..
sirosis hepatis

hepatomegaly hepatitis

Organ aksesoris lainnya

Lien: splenomegaly (inget schuffnernya), splenectomy Vesica fellea: cholecystitis, cholelithiasis (termasuk choledocolithiasis, cholecystolithiasis) bikin nyeri colic biliarry

Referred Painnya kemana?

Gaster : T6-T9 ke epigastric Cholelithiasis, hepar, ductus cysticus: T6, bisa sampe scapula dorsal dexter

Summary Inervasi dan Vaskularisas

Foregut badan sel preganglionik di nucleus intermediolateralis (IML) T6-9 serabut preganglionik : T6-9 (N. Splachnici mayor) badan sel postganglionik : Ganglion coeliacum Midgut bdn sel preganglionik : IML T10-12 serabut preganglionik : T10-12 (n. Splachnici minor) Bdn sel postganglionik : Ganglion mesentericus superior Hindgut IML L1-3 L1-3 (N. Splachinici lumbales) G. Mesentericus sup

URINARY & ABDOMINAL WALL

Lanjut dikit lagii, smangat!

Abdominal Wall
9 Regio M. Obliqus externus (V) M. Obliqus internus (A) M. Transversus

Subcostal (costa 10)

2 versi garis transversa: transpyloric & interspinosa subcostal & transtubercular

Clinical oriented?

Incisi abdomen Peritonitis Adhesi peritoneum: perlekatan viscera, bsa jadi volvulus Adhesiotomy Ascites: excavatio douglas (cewe), excavatio rectovesica, recessus hepatorenal (supine) Abdominal paracentesis : untuk ambil cairan, adm antibiotik. Melalui dinding abdomen anterolateral (linea alba) Intraperitoneal dialysis: seperti menyaring cairan (darah). Peritoneum sebagai membran semipermeabel. Digunakan temporer Injeksi intraperitoneal

Hernia Abdominales
Locus minoris resistante Fossa inguinalis media (trigonum Hasselbach) Fossa inguinalis lateral Trigonum lumbales Annulus femoralis Annulus umbilicales Maka jenis hernianya.. Hernia direct Hernia indirect Hernia lumbales Hernia femorales Hernia umbilicalis Hernia epigastrica

Urinary System
Embriologi Pronephros Mesonephros: glomeruli dan tubulus mesonephros, ductus mesonephricus Metanephros: primordia ren permanen Ren permanen berkembang dari 2 sumber: Diverticulum metanephric (ureteric bud): ureter, pelvis renalis, sistema collectivus Metanephrogenic blastema: parenkim (nephron) Ren migrasi week 9

Kelainan congenital
Bifid renal pelvis and ureter: complete incomplete Horseshoe kidney : tertahan di bawah a. Mesenterica inf (L3L5) Ectopic pelvic kidney: ren di pelvis Retrocaval ureter Polycystic kidney: autosomal dominan

Anatomy normalnya?
T12-L3 Retroperitoneal Lemak pararenal, fascia renalis (Gerotta), lemak perirenal, capsula renalis (capsula fibrosa) Fiksasi ren : fascia2 dan lemaknya, tekanan intraabdm, vasa renalis dan ureter Collecting system : Papilla renalis, calix minor, calix mayor, pelvis renalis, ureter

Conted
Ureter (pars abdominalis & pars pelvica) Vesica urinari: ingat detrusor + reflex miksi?

Langsung klinisnya aja ya..

Nephroptosis: turun lebih dari 3cm Glomerulonephritis, Pyelonephritis Hydronephrosis + Hydroureter, obstrusi Ureterolithiasis, predileksi ada 3 Vesicolithiasis

 Suprapubic cystostomy Cystoscopy (transurethra) Incontinensia

True: fistula, extrofi bladder Stress: kelemahan diafragma pelvis Urge: hiperrefleks m. Detrusor, spastic UMN, flaccid LMN Overflow: udh penuh ga bisa kontraksi, atw ga bisa keluar mis. BPH

 ESWL Cystoscopy Bladder extrofi

ALHAMDULILLAH