GIT 301 Final 2021

SECTION TWO
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- Camper’s Fascia (Subcutaneous)

-Scarpa’s fascia (membranous layer)
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- Transversalis fascia
- Extra peritoneal fat
 - Parietal (wall) peritoneum
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Linea Semicircularis (Arcuate Line)
Is a crescent-shaped line marking the inferior limit of the posterior layer of the rectus sheath
just below the level of the iliac crest.
At a point midway between the umbilicus and the pubic symphysis, corresponding to the
beginning of the lower one-quarter of the rectus abdominis muscle, all of the aponeuroses
move anterior to the rectus muscle. There is no posterior wall of the rectus sheath and the
anterior wall of the sheath consists of the aponeuroses of the external oblique, the internal
oblique, and the transversus abdominis muscles. From this point inferiorly, the rectus
abdominis muscle is in direct contact with the transversalis fascia. Marking this point of
transition is an arch of fibers (the arcuate line) It is a site of weakness on the abdominal wall.

Omphalocele
• Failure of bowel loops to return to abdominal cavity after physiologic herniation through
umbilical cord at 10wks.

• Failure of body folds to complete migration

• Lateral fold defects

• Rectal muscles insert far apart on costal margins

In omphalocele, there is failure of central fusion at the umbilical ring due to defective
mesodermal growth.
• This causes incomplete closure of the abdominal wall and persistent herniation of the midgut.
The midgut fails to return to the abdominal cavity.
• The abdominal viscera are contained in a translucent sac, which is composed of amnion,
Wharton jelly, and peritoneum.
• The umbilical vessels radiate onto the wall of the sac.
• The contents of the sac include: intestines, the liver, spleen, and ovaries or testes.
Covered by Amnion, Wharton jelly and Peritonium
Or

Exomphalos or omphalocele: This anomaly results from failure of coils of the small intestine to
return into abdominal cavity from their physiological herniation into extraembryonic celom
during sixth to tenth week of IUL. It occurs in 2.5/10,000 births and could be associated with
cardiac and neural tube defects. Clinically, it presents as a rounded mass protruding from the
umbilicus. This mass contains coils of the small intestine and is covered by a transparent
amniotic membrane.
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Gastroschisis: In this anomaly, there is a linear defect in anterior abdominal wall through which
abdominal contents herniate out. It occurs lateral to the umbilicus, usually on to the right. This
defect is produced when lateral folds of embryo fail to fuse with each other around connecting
stalk. In gastroschisis, there is no covering sac and the defect in the abdominal wall is nearly
always to the right of the umbilicus.
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Anterior wall formed by mainly-External Oblique Muscle aponeurosis
Posterior wall formed by-Transversalis Fascia
Roof formed by-arching fibers Transversus Abdominis Muscle and Internal Oblique Muscle
from inguinal ligament attaching to the pubic tubercle
Floor formed by-inguinal ligament
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Spermatic Cord in Males

Round ligament of the uterus in the female

Ilioinguinal nerve in both

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 Suprarenal glands.
 Aorta and Inferior vena cava.
 Duodenum. (Distal part)
 Pancreas (except the tail)
 Ureter.
 Colon (ascending and descending)
 Kidneys.
 Esophagus.
 Rectum (Lower third)
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 S: stomach
 A: appendix
 L: liver
 T: transverse colon
 D: duodenum (first part)
 S: small intestines (jejunum and ileum)
 P: pancreas (only tail)
 R: rectum (upper third)
 S: spleen
 S: sigmoid colon
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Functions of Spleen
1. Spleen plays important role in immunity. Macrophages in spleen help in
phagocytosis of pathogens or antigens. Spleen is the site for production of B and
T cells. Germinal centers in the spleen helps in development of lymphocytes.
Spleen also helps in production of antibodies.
2. Spleen removes old and abnormal red cells, white cells and platelets. Cells of
MPS detect these senescent and abnormal cells and remove them from blood.
3. Spleen helps in hepatic stage of hemopoiesis during intrauterine life.
Extramedullary hemopoiesis takes place in spleen in postnatal life in pathological
conditions.
4. Spleen acts as an important reservoir of blood in mammals.
5. Macrophages in spleen recycle iron, which has been released from destroyed
red cells. This iron is reutilized for synthesis of hemoglobin. (Storage and
Metabolism of Iron)
6. Role in regulating portal blood flow. The vasculature of spleen also plays a role
in regulating the portal blood flow.

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-Use of PPIs
-Use of Antibiotics
-Histamine 2 Blockers
-Anti Acids
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Abnormalities of persistent remnant vitelline duct

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Management
• Not a surgical emergency. Initial resuscitation is key
• Give IV fluids: solution of 5% dextrose with 0.45% NaCl (+20mmol/L KCl)
• Important to replace electrolytes, and monitor urine output.
• Monitor blood glucose concentrations
• Once electrolytes and blood gas corrected, surgery can be done
Surgery – Ramstedt Pyloromyotomy
• Incising the hypertrophied pyloric muscle
• Keep submucosa intact
• Open or laparoscopic
OR
Treatment (ABCDEF)
A: Aspiration with Ryle's tube-good stomach wash, twice a day is given to keep the stomach
empty. Saline is used as it decreases oedema of the stomach wall. Stomach wash
should be given for at least 3-5 days before surgery.
B: Blood is arranged for surgery. Blood may be required preoperatively to treat anaemia.
C: Charts: Adequate urine output is maintained by infusion of intravenous fluids.
D: Drug: Antibiotics for surgery.
E: Exploratory laparotomy: Vagotomy followed by GJ is done. Pyloroplasty should not be done
because the duodenum is scarred, cicatrised, fibrosed and narrowed.
F: Fluids to correct electrolyte abnormalities. Pyloric stenosis patients can develop
"Hyponatraemic, Hypochloraemic, }Jypokalaemic alkalosis", Ringer lactate is an ideal
supplement.
• Postoperatively these patients recover very fast. Dehydration improves and nutritionally they
show dramatic improvement. Even the gastric tone may return after a few years.
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-Atresia-Development is incomplete/no lumen(common) or Discontinuation of lumen
-Fistulae-Abnormal communication between two epithelial surfaces (aspiration,
suffocation, pneumonia and severe fluid and electrolyte imbalance)
-Stenosis-Narrowing of lumen due to fibrous thickening of the wall
 congenital
 acquired-inflammation (radiation, GERD etc.)
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Hirschsprung’s Disease
Hirschsprung’s disease is a developmental disorder of the enteric nervous system and is
characterized by an absence of ganglion cells, commonly in the distal colon, resulting in a
functional intestinal obstruction.

Hirschsprung’s disease is caused by a defect in the craniocaudal migration of neuroblasts

originating from the neural crest that occurs during the first 12 weeks of gestation.
• This leads to absence of ganglion cells in the myenteric and submucosal plexus of a variable
segment of bowel, causing failure of relaxation in the aganglionic segment and functional
intestinal obstruction.

Classically affects rectum & sigmoid (70%); can affect varying lengths; and even entire large
bowel 8-10% (Total Colonic Aganglionosis); extensive small bowel involvement uncommon
(<2%).

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Exocrine
-Conjugated bilirubin

-Bile Salts

-Cholesterol

-Phospholipids

-Liproproteins
Endocrine
-Thrombopoeitin

-Angiotensinogen

- Somatomedin

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1. Secretory functions: Liver forms and secretes bile into biliary tract.
2. Metabolic functions: Liver is involved in metabolism of major nutrients such as carbohydrate, fat,
proteins,
and fat soluble and water-soluble vitamins. Liver plays a central role in the metabolisms of urea, iron, and
alcohol.
3. Synthetic functions: Liver is the major organ for the synthesis of proteins that include clotting factors,
acute phase proteins that mediate inflammation, hormone binding proteins, lipids, carbohydrates, vitamins
and bile salts.
4. Storage functions: Liver stores glucose, protein, fat, and vitamins. These nutrients are released from liver
and utilized during their scarcity, and are stored in liver when they are in excess.
5. Detoxifying action: Liver detoxifies many chemicals. Toxins released from infecting organisms are
neutralized in liver.
6. Degradation of drugs and chemicals: Liver is the site of inactivation of many drugs. Liver degrades
enzymes, hormones, cytokines, and various other chemicals.
7. Excretory function: Liver excretes bile pigments, cholesterol, and some metals.
8. Immunity: Kupffer cells of liver are part of mononuclear phagocyte system (reticuloendothelial system)
that forms the nonspecific defenses of the body. These cells phagocytose and kill microorganism.
9. Endocrine functions: Liver converts vitamin D3 to 25-hydroxyvitamin D3. Liver is a major site for
conversion
of T4 to T3. Somatomedin (insulin-like growth factor) that mediates important functions of growth factor is
secreted from liver. Many hormones like insulin, glucagon, growth hormone, GI hormones, etc., are
degraded in liver.