ANATOMY AND

CORRELATES
Dr. Jerald L. Pelayo
WITH GOD I CAN DO ALL THINGS
“I can do ALL things through Christ who gives me
strength!”
-Philippians 4:13
 PRAYER
”Lord I set aside all thoughts of doubt and fear about the
exams as I choose to hold on to Your promise that with You, I
can do all things!”
EMBRYOLOGY AND HISTOLOGY
 DISORDERS OF SEXUAL DEVELOPMENT
Diagnosis Cause Breast Reproductive Axially/Pubic Karyotype
Develop- Organs Hair
ment

Complete X-linked Yes Absent Minimal to 46, XY

Androgen mutation of uterus/upper absent
Insensitivity androgen vagina;
Syndrome receptor cryptorchid
testes

MRKH Syndrome Hypoplastic Yes Absent or Normal 46, XX

(Mullerian or absent rudimentary
agenesis) mullerian uterus and
ductal upper vagina;
system normal
ovaries
 DISORDERS OF SEXUAL DEVELOPMENT
Diagnosis Cause Breast Reproductive Axially/Pubic Karyotype
Develop- Organs Hair
ment
Transverse Malformation Yes Normal Normal 46, XX
vaginal septum of urogenital uterus,
sinus and abnormal
mullerian ducts vagina;
normal
ovaries

Turner syndrome Complete/ Variable Normal uterus Normal 45, X

partial absence and vagina;
of 1 X STREAK
chromosome ovaries
What is the histology of male
gonads at birth?
a. Primordial germ cells
b. Spermatogonia A
c. Spermatogonia B
d. All of the above
What is the histology of male
gonads at birth?
a. Primordial germ cells
b. Spermatogonia A
c. Spermatogonia B
d. All of the above
What is the histology of female
gonads at birth?
a. Primary oocyte, 46 4n
b. Primary oocyte, 46 2n
c. Secondary oocyte, 23 2n
d. Mature oocyte, 23 1n
What is the histology of female
gonads at birth?
a. Primary oocyte, 46 4n
b. Primary oocyte, 46 2n
c. Secondary oocyte, 23 2n
d. Mature oocyte, 23 1n
Week 1
A 32 yo female presents with RLQ abdominal pain and
vaginal bleeding. After stabilizing the patient’s condition,
what is the next appropriate step?

A. Order transvaginal ultrasound

B. Order urine and serum hCG
C. Order CT scan – abdomen
D. Order hysteroscopy
A 32 yo female presents with RLQ abdominal pain and
vaginal bleeding. After stabilizing the patient’s condition,
what is the next appropriate step?

A. Order transvaginal ultrasound

B. Order urine and serum hCG
C. Order CT scan – abdomen
D. Order hysteroscopy
 CLINICAL CORRELATE
ECTOPIC PREGNANCY

• Most common form; TUBAL

• Most common site of rupture: ISTHMUS
• Risk factors: Previous ectopic pregnancy, PID, tubular pelvic surgery, DES exposure,
endometriosis
• Clinical signs: TRIAD of bleeding, abdominal pain and amenorrhea; hypovolemic
shock, cervical motion tenderness
• Differentials: Abortion, molar pregnancy, appendicitis, ruptured ovarian cyst, ovarian
torsion, PID
• Management: Stable --> methotrexate; Unstable  surgery
• ABDOMINAL form: Rectouterine pouch (pouch of Douglas)
Which of the following statements is
most accurate about implantation?
a. Blastocyst implants within the anterior wall of the uterus with the
embryonic pole
b. Blastocyst implants within the posterior wall of the uterus with the
embryonic pole
c. Blastocyst implants within the basalis layer of the endometrium
d. Blastocyst implants during the follicular phase of the menstrual
cycle
Which of the following statements is
most accurate about implantation?
a. Blastocyst implants within the anterior wall of the uterus with the
embryonic pole
b. Blastocyst implants within the posterior wall of the uterus with
the embryonic pole
c. Blastocyst implants within the basalis layer of the endometrium
d. Blastocyst implants during the follicular phase of the menstrual
cycle
Week 2
Week 2
hCG is produced by syncytiotrophoblast. Which of the
following clinical conditions would reveal high hCG
level?

a. Abortion
b. Edwards syndrome
c. Down syndrome
d. Both B and C
hCG is produced by syncytiotrophoblast. Which of the
following clinical conditions would reveal high hCG
level?

a. Abortion
b. Edwards syndrome
c. Down syndrome
d. Both B and C
 SECOND-TRIMESTER QUADRUPLE
TESTING
DIAGNOSIS AFP HCG ESTRIOL INHIBIN A
Trisomy 18 Normal
Trisomy 21
Neural
Tube/Abdominal Normal Normal Normal
Wall Defect
 HIGH
HCG
Inhibin
DOWN SYNDROME
LOW
Alpha-fetoprotein
Estriol
 MAJOR DIFFERENCES
PATAU SYNDROME (Trisomy 13) EDWARDS SYNDROME (Trisomy 18)
More severe Severe
Polydactyly Overlapping fingers
Microphthalmia Micrognathia
Microcephaly/Holoprosencephaly Prominent occiput
Cleft palate No cleft palate
Week 3-8 (Embryonic Period)
 CLINICAL CORRELATES

CONDITIONS COMMENTS
Sacrococcygeal teratoma Arises from remnants of PRIMITIVE STREAK
Chordoma Arises from remnants of NOTOCHORD
H. mole Partial or complete replacement of
TROPHOBLAST with dilated villi
 FEATURE COMPLETE H. MOLE PARTIAL H. MOLE
Karyotype 46, XX or 46, XY Usually 69, XXX or 69, XXY
(paternal, p27)
Embryo Absent Often present
Villous edema Diffuse Focal
Trophoblastic proliferation Variable, slight to severe Focal, slight to moderate

Uterine size 50% large for dates Small for dates

Theca-lutein cysts 25-30% Rare
Medical complications Frequent Rare
Persistent trophoblastic 15-20% 1-5%
disease
 Hydatidiform Mole
Clinical Abnormal vaginal bleeding, uterine enlargement, abnormally
Presentation elevated bete-hCG, theca lutein cysts, hyperemesis gravidarum,
preeclampsia with severe features, hyperthyroidism

Risk factors Extremes of maternal age, history of H. mole

Diagnosis “Snowstorm appearance” on UTZ, quantitative serum b-hCG,
histologic evaluation of uterine contents

Management Dilation and SUCTION curettage,serial serum b-hCG post-

evacuation, contraception for 6 months
 ECTODERM
SURFACE ECTODERM
-Epidermis, hair, nails
-INNER & EXTERNAL EAR
-Teeth enamel
-Lens of eyes
-ANTERIOR PITUITARY
-PAROTID GLAND
-Anal canal BELOW pectinate
line
NEUROECTODERM
-CNS
-POSTERIOR PITUITARY
-Retina and optic nerve
-ASTROCYTES &
OLIGODENDROCYTES
MESODERM ENDODERM
-ADRENAL CORTEX -Epithelial lining: GI, Lower
-Muscles respiratory system, GU
-Connective tissue -MIDDLE EAR and EAR
-All serous membranes CANAL
-Bone and cartilage -Palatine tonsils
-SPLEEN -Parathyroid glands
-Kidney and ureter -Thymus
-DURA MATER -LIVER
-MICROGLIA -PANCREAS
-BLOOD, lymph, and -SUBMANDIBULAR AND
cardiovascular organs SUBLINGUAL GLANDS
-Gonads and internal -FOLLICLES of thyroid glands
reproductive organs
NOTOCHORD : nucleus
pulposus
 ECTODERM MESODERM ENDODERM
NEURAL CREST -ADRENAL CORTEX -Epithelial lining: GI, Lower
-ADRENAL MEDULLA -Muscles respiratory system, GU
-PIA AND ARACHNOID -Connective tissue -MIDDLE EAR and EAR
MATER -All serous membranes CANAL
-PARAFOLLICULAR CELLS -Bone and cartilage -Palatine tonsils
-SENSORY AND -SPLEEN -Parathyroid glands
POSTGANGLIONIC NEURONS -Kidney and ureter -Thymus
-Endocardial cushion -DURA MATER -LIVER
-Aorticopulmonary septum -MICROGLIA -PANCREAS
-Schwann cells -BLOOD, lymph, and -SUBMANDIBULAR AND
-Melanocytes cardiovascular organs SUBLINGUAL GLANDS
-Ganglia -Gonads and internal -FOLLICLES of thyroid glands
reproductive organs
Which of the following organs is incorrectly
paired with its embryonic derivatives?

A. Parotid gland – surface ectoderm

B. Spleen – mesoderm
C. Adrenal cortex – neuroectoderm
D. Middle ear – endoderm
E. None of the above
Which of the following organs is incorrectly
paired with its embryonic derivatives?

A. Parotid gland – surface ectoderm

B. Spleen – mesoderm
C. Adrenal cortex – neuroectoderm
D. Middle ear – endoderm
E. None of the above
What is epithelial subtype of the
salivary gland ducts?
A. Simple cuboidal
B. Simple columnar
C. Stratified cuboidal
D. Stratified columnar
What is epithelial subtype of the
salivary gland ducts?
A. Simple cuboidal
B. Simple columnar
C. Stratified cuboidal
D. Stratified columnar
 HISTOLOGY: EPITHELIA
SUBTYPES LOCATIONS
Simple cuboidal Renal tubules, salivary gland acini
Simple columnar Small intestines
Simple squamous Endothelium, mesothelium, Bowman’s capsule
Stratified squamous Esophagus (nonkeratinizing), Skin (keratinizing)
Pseudostratified columnar Trachea, epididymis
Transitional Ureter, bladder
Stratified cuboidal Salivary gland ducts
Which of the following skin layers
houses the tonofibrils?

A. Stratum corneum
B. Stratum lucidum
C. Stratum granulosum
D. Stratum spinosum
E. Stratum basale
Which of the following skin layers
houses the tonofibrils?

A. Stratum corneum
B. Stratum lucidum
C. Stratum granulosum
D. Stratum spinosum
E. Stratum basale
 SKIN LAYERS STRUCTURES
Stratum basale (shed every 15-30 Hemidesmosome
days) Desmosome
Keratinocytes
Melanocytes
Stratum spinosum (thickest) Tonofibrils
Desmosome
Stratum granulosum Keratohyaline granules
Desmosome
Stratum lucidum (thinnest) Desmosome
Stratum corneum 15-20 layers of nonnucleated
keratinized cells
 CYTOSKELETAL ELEMENTS
MICROFILAMENTS Actin (continuous assembly and disassembly); cell contraction
and motility; cytokinesis; linked to cell membranes at tight
junctions and at zonula adherens; forms the core of MICROVILLI

INTERMEDIATE Structural stability to cells

FILAMENTS Type 1 : keratin
Type 2 : desmin (muscle), vimentin (non-muscle), GFAP,
peripherin
Type 3 : neurofilaments
Type 4 : laminin

MICROTUBULES Continuous assembly and disassembly; provide “tracks” for

intracellular transport of vesicles and molecules; dynein
(retrograde) vs. kinesin (anterograde); found in true CILIA
(respiratory epithelium) and FLAGELLA (tail of sperm cell); form
mitotic spindles
MICROVILLLI: MICROFILAMENT
 CYTOSKELETAL ELEMENTS
MICROFILAMENTS Actin (continuous assembly and disassembly); cell contraction
and motility; cytokinesis; linked to cell membranes at tight
junctions and at zonula adherens; forms the core of MICROVILLI

INTERMEDIATE Structural stability to cells

FILAMENTS Type 1 : keratin
Type 2 : desmin (muscle), vimentin (non-muscle), GFAP,
peripherin
Type 3 : neurofilaments
Type 4 : laminin

MICROTUBULES Continuous assembly and disassembly; provide “tracks” for

intracellular transport of vesicles and molecules; dynein
(retrograde) vs. kinesin (anterograde); found in true CILIA
(respiratory epithelium) and FLAGELLA (tail of sperm cell); form
mitotic spindles
 CLINICAL CORRELATE
Changes in INTERMEDIATE filaments are evident in neurons in
Alzheimer’s disease (i.e., neurofibrillary tangles) and in chronic liver
disease (e.g., Mallory bodies)
CILIA : MICROTUBULES
 CLINICAL CORRELATE
DRUGS AFFECTING MICROTUBULES
COLCHICINE Prevents microtubule ASSEMBLY and prevents neutrophil
migration in gout
VINBLASTINE Inhibit ASSEMBLY of the mitotic spindle; chemotherapy
VINCRISTINE
TAXANES Inhibit DISASSEMBLY of the mitotic spindle; chemotherapy
GRISEOFULVIN Binds to alpha and beta tubulin; for tinea capitis
ALBENDAZOLE Binds to beta tubulin preventing ASSEMBLY into microtubules;
MEBENDAZOLE antihelminthic
CLINICAL CORRELATE
 CELL ADHESION MOLECULES
CADHERIN Calcium-ion dependent
SELECTIN Calcium-ion dependent
INTEGRIN Calcium-independent
CELL ADHESION MOLECULES
CADHERIN Calcium-ion dependent
SELECTIN Calcium-ion dependent
INTEGRIN Calcium-independent
 CLINIAL CORRELATE
LEUKOCYTE ADHESION DEFICIENCY I LEUKOCYTE ADHESION DEFICIENCY II

Mutated beta chain of CD11/CD18 Defective Sialyl-Lewis X-modified

integrins proteins

More common Less common

Recurrent bacterial infections, delayed umbilical cord sloughing, omphalitis,
inability to form pus, neutrophilia
 CLINICAL CORRELATE
A first step in the invasion of malignant cells through the epithelium
results from LOSS OF EXPRESSION OF CADHERINS that weakens the
epithelium.
TWO CARCINOMAS WITH LOSS OF
E-CADHERIN GENE
LOBULAR CARCINOMA OF THE BREAST
GASTRIC ADENOCARCINOMA
 CELL SURFACE SPECIALIZATIONS
CELL JUNCTIONS
OCCLUDING JUNCTIONS Tight junction = ZONULA OCCLUDENS
(claudin, occludin, JAM)
ADHESIVE/ANCHORING JUNCTIONS -ZONULA ADHERENS (cadherins, actin)
-Desmosome = MACULA ADHERENS
(structural and mechanical link between
cells)

GAP/COMMUNICATING JUNCTIONS 6 Connexins  Connexons (rapid

exchange between cells of molecules
with small diameters (heart muscle)
OTHERS Hemidesmosomes binds cells to basal
lamina
 CLINICAL
CORRELAT
ES
 PEMPHIGUS BULLOUS DERMATITIS PORPHYRIA
VULGARIS PEMPHIGOID HERPETIFORMIS CUTANEA TARDA
Intraepidermal Subepidermal Subepidermal Subepidermal
blister blister blister blister
Flaccid bullae Tense bullae Tense bullae Tense bullae
IgG IgG IgA -
Netlike pattern Linear pattern Granular staining Thickened dermal
(staining) (staining) at the tips of vessels with
dermal papillae minimal
(microabscesses) inflammation
Desmosome Hemidesmosome Celiac sprue Disorder of heme
(desmoglein 3) (bullous (gliadin, synthesis
pemphigoid transglutaminase)
antigen 1 and 2)
Vit B6

Fe2+
Vit B6

Fe2+
 Porphyria Cutanea Tarda
Uroporphyrinogen decarboxylase
deficiency
(+) photosensitivity
Red-brown to deep-red urine
(hallmark)
Exacerbate by alcohol
Most common
Acute Intermittent Porphyria
Porphobilinogen deaminase deficiency
(-) photosensitivity
Port-wine urine in some patients
Exacerbated by barbiturates
Pyschiatric and neurologic symptoms +
abdominal pain
Vit B6

Fe2+
 Iron Deficiency Vitamin B6 Deficiency Lead Poisoning
Dietary insufficiency Isoniazid treatment Lead paint, pottery glaze,
batteries
Microcytic Microcytic Microcytic
- Ringed sideroblast in Ringed sideroblast in
bone marrow bone marrow
Increased protoporphyrin Decreased Increased protoporphyrin
protoporphyrin
Normal ALA Decreased ALA Increased ALA
Decreased ferritin Increased ferritin Increased ferritin
Decreased serum iron Increased serum iron Increased serum iron
 BURDEN BEARER
”Come to Me, all you who are weary and burdened, and I will
give you rest!”
-Matthew 11:28
 PRAYER

“Lord, I have done what I can. What I do not yet know I lay at
your feet. I now rest knowing that everything is in Your
capable hands!”
BACK AND AUTONOMIC NERVOUS
SYSTEM

VERTEBRAE: 712554

NERVES: 812551
What is the most common direction
of the herniation of nucleus
pulposus?
A. Anterolateral
B. Posterolateral
C. Posterior
D. Anterior
What is the most common direction
of the herniation of nucleus
pulposus?
A. Anterolateral
B. Posterolateral
C. Posterior
D. Anterior
Which nerve roots will be
compressed by L4 disk herniation?
A. L3
B. L4
C. L5
D. L6
Which nerve roots will be
compressed by L4 disk herniation?
A. L3
B. L4
C. L5
D. L6
AUTONOMIC NERVOUS SYSTEM
SYMPATHETI
C OUTFLOW
SYMPATHETI
C OUTFLOW
 ORIGIN SITE OF SYNAPSE
(PREGANGLIONIC) (POSTGANGLIONIC)
Spinal cord levels T1-L2 Sympathetic
CHAIN/PARAVERTEBRAL
ganglia
Thoracic splanchnic COLLATERAL/PREVERTE-
nerves (T5-T12) BRAL ganglia (celiac, superior
mesenteric ganglia)
Lumbar splanchnic COLLATERAL/PREVERTE-
nerves (L1-L2) BRAL ganglia (inferior
mesenteric and pelvic ganglia) hindgut
INNERVATION (TARGET)
Smooth muscles, cardiac
muscle and glands or body
wall and limbs (T1-L2),
head (T1-T2), and thoracic
viscera (T1-T5)
Smooth muscle and glands
of foregut and midgut
Smooth muscle and glands
of pelvic viscera and
PARASYMPATHE
TIC OUTFLOW
 ORIGIN SITE OF SYNAPSE
(PREGANGLIONIC) (POSTGANGLIONIC)
Cranial nerves III, VII, IX 4 cranial ganglia (ciliary,
submandibular, sublingual,
pterygopalatine)
INNERVATION (TARGET)
Glands and smooth muscle
of the head

Cranial nerve X Terminal ganglia Viscera of the neck, thorax,

foregut and midgut

Pelvic splanchnic nerves Terminal ganglia Pelvic viscera and hindgut

(S2-S4) (including the bladder,
rectum and erectile tissue)
Which of the following organs is/are
correctly paired with its autonomic
innervation?
A. Descending colon : Lumbar splanchnic nerves
B. Ascending colon : Thoracic splanchnic nerves
C. Heart : Cranial nerve X
D. A & C only
E. All of the above
Which of the following organs is/are
correctly paired with its autonomic
innervation?
A. Descending colon : Lumbar splanchnic nerves
B. Ascending colon : Thoracic splanchnic nerves
C. Heart : Cranial nerve X
D. A & C only
E. All of the above
CLINICAL CORRELATES
 CHEST WALL
The presence of a tumor within the breast can distort
__________ ligaments resulting in dimpling of the skin!

Cooper ligaments
 CHEST WALL
During a radical mastectomy, the ___________ nerve that
supplies __________ muscle may be lesioned during ligation
of the long thoracic artery.

Long thoracic nerve

Serratus anterior muscle
 CHEST WALL
The ________________ nerve supplying the lattisimus dorsi
muscle may also be damaged during mastectomy resulting in
weakness in _______ and ________ rotation of the arm.

Thoracodorsal nerve
Extension and medial rotation
EMBRYOLOGY : LOWER RESPIRATORY
SYSTEM
A tracheoesophageal fistula is an abnormal communication
between the trachea and esophagus cause by a malformation
of the __________ ____________

Tracheoesophageal septum
MOST COMMON TYPE OF TEF (TYPE
C)
EMBRYOLOGY : LOWER RESPIRATORY
SYSTEM
Pulmonary hypoplasia occurs when lung development is
stunted. This condition has 2 congenital causes:
(1)_____________ or (2) ______________

Congenital diaphragmatic hernia

Bilateral renal agenesis
 ADULT THORACIC CAVITY
Passage of instruments through the intercostal spaces is done
in the _________ part of the space to avoid the intercostal
neurovascular bundle (as a during a thoracentesis)

Lower or inferior part

 ADULT THORACIC CAVITY
An intercostal nerve block is done in the _________portion of
the intercostal space.

Upper portion
 PLEURA AND PLEURAL CAVITY
Respiratory distress syndrome is caused by deficiency of
surfactant (type II pneumocytes). This is condition is
associated with ________, ___________, and ____________.

Premature infants
Infants of diabetic mothers
Prolonged intrauterine asphyxia
 PLEURA AND PLEURAL CAVITY
Inflammation of the parietal pleural layers (pleurisy) produces
sharp pin upon respiration. Costal inflammation produces local
dermatome pain of the chest wall via the _________ nerves.

Intercostal nerves
 PLEURA AND PLEURAL CAVITY
Mediastinal irritation produces referred pain via the ________
nerve to the shoulder dermatomes of _________.

Phrenic nerve
C3-C5
 PLEURAL REFLECTIONS
MARKER VISCERAL PLEURA PARIETAL PLEURA
Midclavicular line 6th rib 8th rib
Midaxillary line 8th rib 10th rib
Paravertebral line 10th rib 12th rib
 LUNGS
A tumor at the apex of the lungs (Pancoast tumor) may result
in __________ ________ syndrome.

Thoracic outlet syndrome

 LUNGS
The superior lobe of the right lung projects _______ on the chest
wall above the ______ rib and the middle lobe projects anteriorly
below the ______ rib.

anteriorly
4 rib
th
 LUNGS
A small portion of the inferior lobe of both lungs projects below
the _______ rib anteriorly and primary projects to the
___________ chest wall.

6th
posterior
 LUNGS
Aspiration of a foreign body will more often enter the ________
main bronchus, which is shorter, wider and more vertical than the
________ main bronchus.

right
lef
 LUNGS
When the individual is vertical, the foreign body usually falls
into the _________ segment of the right lower lobe

Posterior basal segment

 LUNGS
The lymphatic drainage from the lower lobe of the lef lung also drains across the
midline into the ________ _________ lymphatic trunk and nodes, then continues
along the right pathway to the ________ lymphatic duct.

Right bronchomediastinal
Right
 LUNGS : HISTOLOGY
Patients lacking dynein have immotile cilia or __________
syndrome.

Kartagener syndrome
 LUNGS:HISTOLOGY
The columnar and goblet cells are sensitive to irritation. The ciliated cells become taller,
and there is an increase in the number of goblet cells and submucosal glands. Intensive
irritation from smoking leads to a ________ _________ where the ciliated epithelium is
transformed.

Squamous metaplasia
 LUNGS : HISTOLOGY
Bronchial metastatic tumors arise from _________ cells.

Kulchitsky cells
 LUNGS : HISTOLOGY
Cystic fibrosis which results in abnormally thick mucous is in
part due to defective _______ transport by ______ cells.

Chloride transport
Clara cells
 LUNGS : HISTOLOGY
Alveolar macrophages have several names: _______,
_________

Dust cells
Heart failure cells
 LOCATION MACROPHAGE
Skin Langerhans cells
Connective tissue Histiocytes
Liver Kupffer cells
Placenta Hofbauer cells
Brain Microglia
Lungs Dust cells
Kidneys Mesangial cells
Bone Osteoclast
Bone marrow Monocytes
Granuloma Epithelioid cells
Lymph nodes Sinus histiocytes
BELIEVE AND YOU WILL ACHIEVE
“Therefore I tell you, whatever you ask for in prayer, believe that you
have received it, and it shall be yours!”

- Mark 11:24
 PRAY AND CLAIM GOD’S PROMISE
“Lord, as the prospect of the board exam dominates my mind, I take
this time to claim Your promise that whatever we pray for in faith shall
be ours. I believe in You, Lord!”
HEART : EMBRYOLOGY
 HEART : EMBRYOLOGY
EMBRYONIC DILATATION
Truncus arteriosus
Bulbus cordis
Primitive ventricle
Primitive atrium
Sinus venosus (the only dilatation
that does not become subdivided
by a septum)
ADULT STRUCTURE
Aorta; Pulmonary trunk; Semilunar valves
Smooth part of the RV (conus arteriosus)
Smooth part of the LV (aortic vestibule)
Trabeculated part of the RV and LV
Trabeculated part of the RA and LA (pectinate ms)
Right – smooth part of the RA (sinus venarum)
Left – coronary sinus and oblique vein of the LA
*smooth-walled part of the LA: pulmonary veins
 ADULT VESTIGES DERIVED FROM
THE FETAL CIRCULATORY SYSTEM
CHANGES AFTER BIRTH
Closure of right and left umbilical
arteries
Closure of umbilical vein
Closure of ductus venosus
Closure of foramen ovale
Closure of ductus arteriosus
REMNANTS IN ADULTS
Medial umbilical ligaments
Ligamentum teres of liver
Ligamentum venosum
Fossa ovalis
Ligamentum arteriosum
ATRIAL
SEPTATION
VENTRICULAR SEPTATION
COARCTATION OF THE AORTA
CARDIAC MUSCLE : HISTOLOGY
 HEART
In myocardial infarction, the ____________ artery is
obstructed in 50% of the cases, the ____________ artery in
30%, and the _____________________ in 20% of cases.

Lef anterior descending artery

Right coronary artery
Circumflex artery
 HEART
__________ is the main vein of the coronary circulation. It lies in the
posterior coronary sulcus and drains to an opening in the _______
_______. It develops from the _______ _______ _______.

Coronary sinus
Right atrium
Lef sinus venosus
PRACTICE QUESTIONS
1. All the veins of the heart drain to
the coronary sinus, except:
A. Great cardiac vein
B. Middle cardiac vein
C. Small cardiac vein
D. Anterior cardiac vein
QUESTIONS
2. The part of the conducting system found in the right
atrium near the entrance of the SVC is the__?

A. SA node
B. AV node
C. AV Bundle of His
D. Purkinje fibers
QUESTIONS
3. Which of the following structures forms the basis of
electrical discontinuity between the myocardia of the atria
and the ventricles?

A. AV Bundle of His
B. AV valves
C. Cardiac skeleton
D. Purkinje fibers
QUESTIONS
4. From the placenta via IVC, oxygenated blood in the RA
would go directly to the LA by passing thru which of the
following structures?

A. Ductus venosus
B. Ductus arteriosus
C. Foramen ovale
D. Pulmonary trunk
QUESTIONS
5. In general, the right coronary supplies the following
structures EXCEPT:

A. Right ventricle
B. SA node
C. AV node
D. Anterior left ventricle
QUESTIONS
6. Which structure/s compress/es the posterior surface of the
heart during cardiopulmonary resuscitation?

A. Body of the sternum

B. IVC
C. Heads of the ribs
D. Bodies of the thoracic vertebrae
 QUESTIONS
7. In a chest PA film, the right lower cardiac border is formed by
the:

A. Right ventricle
B. Right atrium
C. Superior vena cava
D. Ascending aorta
 QUESTIONS
8. Pericardiocentesis is best achieved by passing a needle through:

A. Fourth intercostal space

B. Sixth intercostal space, left paravertebral border
C. Second ICS, MCL
D. Subcostal angle
QUESTIONS
9. The fossa ovalis of the heart is seen in which chamber:

A. Right atrium
B. Left atrium
C. Right ventricle
D. Left ventricle
QUESTIONS
10. A heart murmur was heard over the medial end of the 2nd
right ICS. It was probably coming from which valve?

A. Aortic
B. Tricuspid
C. Pulmonary
D. Mitral
QUESTIONS
11. The most anteriorly located great vessel of the heart is the:

A. Superior vena cava

B. Aorta
C. Inferior vena cava
D. Pulmonary artery
ANSWERS
1. All the veins of the heart drain to
the right atrium thru coronary sinus,
except:
A. Great cardiac vein
B. Middle cardiac vein
C. Small cardiac vein
D. Anterior cardiac vein
QUESTIONS
2. The part of the conducting system found in the right
atrium near the entrance of the SVC is the_______?

A. SA node
B. AV node
C. AV Bundle of His
D. Purkinje fibers
QUESTIONS
3. Which of the following structures forms the basis of
electrical discontinuity between the myocardia of the atria
and the ventricles?

A. AV Bundle of His
B. AV valves
C. Cardiac skeleton
D. Purkinje fibers
QUESTIONS
4. From the placenta via IVC, oxygenated blood in the RA
would go directly to the LA by passing thru which of the
following structures?

A. Ductus venosus
B. Ductus arteriosus
C. Foramen ovale
D. Pulmonary trunk
QUESTIONS
5. In general, the right coronary supplies the following
structures EXCEPT:

A. Right ventricle
B. SA node
C. AV node
D. Anterior lef ventricle
QUESTIONS
6. Which structure/s compress/es the posterior surface of the
heart during cardiopulmonary resuscitation?

A. Body of the sternum

B. IVC
C. Heads of the ribs
D. Bodies of the thoracic vertebrae
 QUESTIONS
7. In a chest PA film, the right lower cardiac border is formed by
the:

A. Right ventricle
B. Right atrium
C. Superior vena cava
D. Ascending aorta
 QUESTIONS
8. Pericardiocentesis is best achieved by passing a needle through:

A. Fourth intercostal space

B. Sixth intercostal space, left paravertebral border
C. Second ICS, MCL
D. Subcostal angle
QUESTIONS
9. The fossa ovalis of the heart is seen in which chamber:

A. Right atrium
B. Left atrium
C. Right ventricle
D. Left ventricle
QUESTIONS
10. A heart murmur was heard over the medial end of the 2nd
right ICS. It was probably coming from which valve?

A. Aortic
B. Tricuspid
C. Pulmonary
D. Mitral
QUESTIONS
11. The most anteriorly located great vessel of the heart is the:

A. Superior vena cava

B. Aorta
C. Inferior vena cava
D. Pulmonary artery
QUICK GLANCE
 MEDIASTINUM
• Thoracic cavity is divided into 3
subdivisions:
1. single mid-portion (mediastinum)
2. 2 lateral portions (lungs & pleural
coverings)

• Mediastinum is divided by line drawn

between sternal angle & T4/T5:
1. superior
2. inferior = a. anterior
b. middle
c. posterior
 PERICARDIUM
• Double-walled fibroserous sac
• Encloses the heart & root of the great
vessels
• lies posterior to the sternum & the
2nd – 6th costal cartilages
• Functions:
* Restricts excessive
movement of the heart
* Serve as a lubricated
container
 FIBROUS PERICARDIUM
• Strong fibrous part
the central tendon of the
diaphragm (pericardiophrenic
ligament)
• Fuses with outer coats of the great
vessels  mesocardia
• Attached as sterno –pericardiac
ligament to posterior sternum
• Protects heart from sudden
overfilling
SEROUS PERICARDIUM
(MESOTHELIUM)

• Parietal layer : lines the

fibrous pericardium;
reflected around the
great vessels to become
continuous with the
visceral layer
• Visceral layer : closely
applied to the heart;
epicardium
 PERICARDIAL CAVITY
• Slit like space between parietal and visceral layers
• Contains small amount of fluid, pericardial fluid  a lubricant to
facilitate frictionless movements of the heart
 PERICARDIAL SINUSES

• Transverse Sinus: between arterial

& venous mesocardia
**significantly important in
coronary bypass

• Oblique Sinus: space between

venous mesocardia covering the
pulmonary veins
 BORDERS OF THE HEART

• Right : RA + SVC & IVC

• Inferior : RV mainly +L V
• Left : LV mainly and L auricle
• Superior : RA, LA & L auricles,
ascending aorta, pulmonary
trunk, SVC
 THE HEART WALL

THREE layers of the chamber wall:

1. Endothelium – thin internal

layer or lining membrane

2. Myocardium – thick middle

layer; composed of cardiac ms
3. Epicardium – thin external layer
(mesothelium); formed by the
visceral layer of the serous
pericardium
 RIGHT ATRIUM
• R auricle : an earlike, conical muscular
pouch; increase the capacity of the
right atrium

• Sulcus terminalis: external vertical

groove betwee the RA and the R auricle

• Crista terminalis: internal to vertical

groove below the sulcus terminalis;
separates the smooth-walled from the
rough-walled atrium
 RIGHT ATRIUM
= smooth walled atrium is posterior to the crista
terminalis ;
= where SVC, IVC & coronary sinus open

= Musculi pectinati  derived from the

primitive atrium
= Atrial septum
=Fossa ovalis: depression on the atrial septum;
site of fetal foramen ovale
* floor of fossa = is persistent septum primum
=Annulus ovalis: upper margin of the fossa;
derived from the lower edge of the septum
secundum
 RIGHT ATRIUM ( OPENINGS)
• Superior vena cava: opens at 3rd costal
cartilage; no valve
• Inferior vena cava: level of 5th costal
cartilage; rudimentary non-functioning
valve
• Coronary sinus: drains blood from the heart
wall;
= located between IVC & Right AV orifice;
= guarded by rudimentary,
nonfunctioning valve
• Right AV orifice
 LEFT ATRIUM
• Similar to RA
• Consists of main cavity & L auricle
• Located behind the RA
• Forms base of the heart
• Smooth interior
• Left auricle contains muscular ridges
• OPENINGS:
1. Pulmonary veins (4)- no valves
2. Left atrioventricular orifice – guarded
by the mitral valve
 RIGHT VENTRICLE
= RA (AV orifice)  RV
=  pulmonarytrunk via pulmonary orifice
• Infundibulum
• Much thicker wall than RA
• Interventricular septum
• Cavity crescentic in shape
• Trabeculae carnae: projecting ridges of
muscle bundles
3 types:
1. Papillary muscles
2. Moderator band
3. Prominent ridges
RIGHT VENTRICLE
• OPENINGS:
1. AV orifice - Tricuspid valve
2. Pulmonic orifice – Pulmonic valve

• Chordae tendinae: threadlike

structures that attach the cusps to the
papillary muscles
LEFT VENTRICLE
• thicker wall (3x) than RV
• Cavity is circular in shape
• Well developed trabeculae carneae
• 2 large papillary muscles; no moderator band

• OPENINGS:
1. Left AV orifice guarded by the mitral
valve
2. Aortic orifice – guarded by the aortic valve
SKELETON OF THE HEART
1. Annuli fibrosi
2. Septum membranaceum
3. Fibrous trigone : separate the muscular walls of the
atria from those of the ventricles

FUNCTIONS:
1. Keeps the orifices of the AV & semilunar valves
patent & from overly distension by the volume of
blood pumping through them.
2. Provides attachments
4. Forms an electrical insulator, by separating the
myenterically conducted impulses of the atria and
ventricles; contract independently & by providing
passage for the initial part of the AV bundle
 CONDUCTING SYSTEM OF THE HEART
• Specialized cardiac muscle

SINO-ATRIAL (SA) NODE:

* Site of initiation of contraction
* at the upper part of the
sulcus terminalis just to the
right of the SVC opening

ATRIOVENTRICULAR (AV)NODE
* at the lower part of the atrial septum
above the septal cusp of the tricuspid valve
 CONDUCTING SYSTEM OF THE HEART
ATRIOVENTRICULAR BUNDLE:
* The only muscular connection between the
myocardia of the atria and ventricle
* Descends behind septal cusp of tricuspid valve to
reach the inf. border of the membranous
ventricular septum
* Divides into 2 branches

RIGHT BUNDLE BRANCH :

* Passes down to reach the moderator band and
crosses to
the anterior wall of the RV
* Becomes continuous with the PURKINJE FIBERS
VENOUS DRAINAGE

1. Coronary sinus drains

the ff:
=Great cardiac vein
=Small cardiac vein
=Middle cardiac v.

2. Anterior cardiac v.
3. Smallest cardiac v.
 LOOK TO THE CREATOR
“I lift up mine eyes to the hills – where does my help come from? My
help comes form the Lord, the Maker of heaven and earth.”
- Psalm 121:1,2
 PRAYER
“Lord, as the board exam dates draw near, I am holding on to the
assurance that I am not taking the exams alone because You are with
me. Help me, Lord, to look up more often and remember that my
Helper is the Maker of heaven and earth!”
ABDOMEN
DIAPHRAGMATI
C
APERTURES
 APERTURES OF THE DIAPHRAGM
CAVAL HIATUS T8 Inferior vena cava
(Central tendon) RIGHT phrenic nerve
ESOPHAGELAL T10 Esophagus
HIATUS (Right crus) Vagus nerves (LA-RP)
AORTIC HIATUS T12 Aorta
(Behind the 2 crura) Thoracic duct
Azygos vein
LAYERS OF ANTERIOR ABDOMINAL WALL
Skin
Superficial fascia (Camper : Fatty)
Superficial fascia (Scarpa : Membranous)
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Extraperitoneal connective tissue
Parietal peritoneum
COUNTERPART IN THE PERINEUM
Skin
Dartos fascia
Colles’ fascia
External spermatic fascia
Cremasteric muscle and fascia
-
Internal spermatic fascia
 ABDOMEN
The gonads develop from the urogenital ridge within this layer.

Extraperitoneal layer
 A ________ develops when the blood collects in the
pampiniform plexus and causes dilated and tortuous veins.

Varicocele
A collection of serous fluid in the _______ _______ forms a
hydrocele, resulting in enlarged scrotum.

Tunica vaginalis
 Cancers of the penis and scrotum will metastasize to the
_________ lymph nodes. Testicular cancer will metastasize to
the ______ nodes.

Superficial inguinal lymph nodes

Aortic (lumbar) nodes
 In males, a cremasteric reflex can de demonstrated by lightly touching
the skin of the upper medial thigh, resulting in a slight elevation of the
testis. The sensory fibers of the reflex are carried by the L1 fibers of the
_________ nerve and the motor response is a function of the genital
branch of the ___________ nerve that innervates the cremaster
muscle.

Ilioinguinal nerve
Genitofemoral nerve
Which of the following statements
is/are correct about hernias?

A. A persistent processus vaginalis often results in a congenital direct

inguinal hernia
B. Direct hernias are found lateral to the inferior epigastric vessels
C. Both direct and indirect hernias exit through the superficial ring
D. Femoral hernias pass above the inguinal ligament.
Which of the following statements
is/are correct about hernias?

A. A persistent processus vaginalis often results in a congenital direct

inguinal hernia
B. Direct hernias are found lateral to the inferior epigastric vessels
C. Both direct and indirect hernias exit through the superficial ring
D. Femoral hernias pass above the inguinal ligament.
 FOREGUT MIDGUT HINDGUT
Artery: Celiac Artery: Superior mesenteric Artery: Inferior mesenteric
PNS: Vagus nerves PNS: Vagus nerves PNS: Pelvic splanchnic nerves
SNS: SNS: SNS:
Preganglionic: Thoracic Preganglionic: Thoracic Preganglionic: Lumbar
splanchnic nerves (T5-T9) splanchnic nerves (T9-T12) splanchnic nerves (L1-L2)
Postganglionic: Celiac Postganglionic: Superior Postganglionic: Inferior
ganglion mesenteric ganglion mesenteric ganglion
Referred pain: Epigastrium Referred pain: Umbilical Referred pain: Hypogastrium
FOREGUT DERIVATIVES MIDGUT DERIVATIVES HINDGUT DERIVATIVES
Esophagus Duodenum (2nd, 3rd, and Transverse colon (distal
4th parts) 1/3)
Stomach Jejunum Descending colon
Duodenum (1st and 2nd Ileum Sigmoid colon
parts)
Liver Cecum Rectum
Pancreas Appendix Anal canal (above
pectinate line
Biliary apparatus Ascending colon
Gallbladder Transverse colon
(proximal 2/3)
MAJOR INTRAPERITONEAL MAJOR SECONDARY MAJOR PRIMARY
ORGANS RETROPERITONEAL ORGANS RETROPERITONEAL
ORGANS

Suspended by a mesentery Lost a mesentery during the Never had a mesentery

development
Stomach Duodenum, 2nd and 3rd parts Kidneys
Liver and gallbladder Head, neck, body of pancreas Adrenal glands
Spleen Ascending colon Ureters
Duodenum, 1st part Descending colon Aorta
Tail of pancreas Upper rectum Inferior vena cava
Jejunum Lower rectum
Ileum Anal canal
Appendix
Transverse colon
Sigmoid colon
ESOPHAGEAL CONSTRICTIONS

Constriction Constriction Endoscopy

(from incisors)
Cervical Cricopharyngeal/ 6 inches
Pharyngoesophageal (15 cm)
Thoracic Aortic arch & left 10 inches (25 cm)
(Broncho- bronchus
aortic)
Diaphragmatic Esophageal opening 16 inches
(40-41 cm)
 Muscular Blood Venous LN
Layer supply Drainage
Upper 1/3 Skeletal Inf. Thyroid Inf. Thyroid Deep
cervical
Middle 1/3 Skeletal & Bronchial & Azygos Mediastinal
Smooth aorta
Lower 1/3 Smooth Left gastric Left gastric Celiac
& inf. & inf.
phrenic phrenic
 Lesser Greater Fundus
curvature curvature
Left Left gastric Left
side gastroepiploic Short
(Splenic gastric
artery) artery
(splenic
Right Right gastric Right artery)
side (Common Gastroepiploic
hepatic (Gastroduo-
artery) denal artery)
 PRACTICE QUESTIONS
1. Which combination of the arteries supplies the lesser curvature of
the stomach?
A. Right and left gastric
B. Short gastric, right and left gastric
C. Right and left gastroepiploic
D. Short gastric, right gastric, left gastroepiploic
2. A patient previously diagnosed with ulcer on the posterior wall of the
stomach was brought to the emergency room with signs and symptoms
of hypovolemic shock. Which of the following arteries is most likely
eroded?
A. gastroduodenal
B. retroduodenal
C. splenic
D. hepatic
3. Which of the following statements is true about the ileum?
A. Plicae circulares are absent in the terminal portion.
B. The mesenteric vessels form 1 or 2 arcades.
C. The mesenteric fat is scanty near the wall.
D. It lies in the lower part of the lesser sac.
4. The structure/s that divide/s the liver anatomically into the
right and left lobes is/are:
A. Falciform ligament
B. Porta hepatis
C. Gall bladder fossa
D. Ligamentum teres
5. Total gastrectomy for gastric cancer does not include the removal of:
A. lower end of esophagus
B. head of the pancreas
C. first part of duodenum
D. spleen
6. Swallowed gas within the proximal GIT will almost always collect in
this region, as appreciated on antero-posterior X-ray views of the
abdomen:
A. Esophageal hiatus
B. Fundus
C. Cardia
D. Pylorus
7. This structure can be traced towards the base of the appendix and be
used as a guide for looking for the appendix:
A. haustra
B. appendices epiplocae
C. taeni coli
D. mesoappendix
8. Part of the duodenum which does not lie in the retroperitoneal
space?
A. Part 1
B. Part 2
C. Part 3
D. Part 4
ANSWERS
1. Which combination of the arteries supplies the lesser curvature of
the stomach?
A. Right and lef gastric
B. Short gastric, right and left gastric
C. Right and left gastroepiploic
D. Short gastric, right gastric, left gastroepiploic
2. A patient previously diagnosed with ulcer on the posterior wall of the
stomach was brought to the emergency room with signs and symptoms
of hypovolemic shock. Which of the following arteries is most likely
eroded?
A. gastroduodenal
B. retroduodenal
C. splenic
D. hepatic
3. Which of the following statements is true about the ileum?
A. Plicae circulares are absent in the terminal portion.
B. The mesenteric vessels form 1 or 2 arcades.
C. The mesenteric fat is scanty near the wall.
D. It lies in the lower part of the lesser sac.
4. The structure/s that divide/s the liver anatomically into the
right and left lobes is/are:
A. Falciform ligament
B. Porta hepatis
C. Gall bladder fossa
D. Ligamentum teres
5. Total gastrectomy for gastric cancer does not include the removal of:
A. lower end of esophagus
B. pancreas
C. first part of duodenum
D. spleen
6. Swallowed gas within the proximal GIT will almost always collect in
this region, as appreciated on antero-posterior X-ray views of the
abdomen:
A. Esophageal hiatus
B. Fundus
C. Cardia
D. Pylorus
7. This structure can be traced towards the base of the appendix and be
used as a guide for looking for the appendix:
A. haustra
B. appendices epiplocae
C. taeni coli
D. mesoappendix
8. Part of the duodenum which does not lie in the retroperitoneal
space?
A. Part 1
B. Part 2
C. Part 3
D. Part 4
 LIVER

• largest mass of glandular tissue in the body

• largest internal organ: 1.5 Kg. (2.5% of adult body
weight)
• found in the abdominal cavity beneath the
diaphragm
BLOOD SUPPLY OF THE LIVER

 portal vein – 70-80%

 hepatic artery – 20%
 FUNCTIONS

• production and secretion of bile

• synthesis and endocrine secretion of major plasma
proteins
• gluconeogenesis
• detoxification and conjugation of ingested toxins,
including many drugs
• amino acid deamination
• storage of glucose, triglycerides, vitamin A and iron
in complexes with ferritin
• removal of worn-out RBCs
 PERITONEAL ATTACHMENTS

FALCIFORM LIGAMENT
 PERITONEAL ATTACHMENTS

• CORONARY
LIGAMENT

• RIGHT
TRIANGULAR
LIGAMENT

• LEFT
TRIANGULAR
LIGAMENT
LOBES OF THE LIVER

A. CLASSICAL
(ANATOMICAL)

- via falciform ligament

1. RIGHT LOBE
a. QUADRATE
b. CAUDATE

2. LEFT LOBE
LOBES OF THE LIVER

B. FUNCTIONAL
- via IVC and GB

1. RIGHT LOBE
2. LEFT LOBE
(caudate and
quadrate lobe)
 LIVER HISTOLOGY : Hepatocyte

• 80% liver cell

population
• frequently
binucleated,
prominent nucleoli
• eosinophilic
cytoplasm with
basophilic bodies
• numerous microvilli
Hepatocyte: ORGANELLES

• Rough ER
• abundant
(basophilic)
• sites for synthesis
of plasma
proteins
Hepatocyte: Organelles

• Smooth ER
• abundant
• important in CHO
metabolism, bile
formation, catabolism of
drugs and other toxic
compounds
• conjugate bilirubin to
glucuronate
 Smooth ER : Clinical Correlation

• NEONATAL HYPERBILIRUBINEMIA
• frequent cause of jaundice in newborns
• due to underdeveloped state of smooth ER in hepatocytes
(enzyme: glucoronyl transferase)

• TREATMENT
• phototherapy or exposure to blue light
LIVER HISTOLOGY: STRUCTURAL
ORGANIZATION

I. STROMA
II. PARENCHYMA
III. SINUSOIDAL
CAPILLARIES
LIVER HISTOLOGY: STRUCTURAL
ORGANIZATION
I. STROMA
- thin CT capsule
(Glisson’s capsule)
- thicker at hilum
- vessels and ducts
covered with CT
all the way to their
termination
(or origin)
LIVER HISTOLOGY: STRUCTURAL ORGANIZATION

II. PARENCHYMA

- irregular plates
of hepatocytes
arranged radially
around a central
vein
 LIVER HISTOLOGY: STRUCTURAL
ORGANIZATION

III. SINUSOIDAL
CAPILLARIES
(SINUSOIDS)
- vascular
channels
between plates
of hepatocytes
 SINUSOIDAL CAPILLARIES (SINUSOIDS)

- lined by
fenestrated
endothelium
 LIVER HISTOLOGY: STRUCTURAL
ORGANIZATION

PERISINUSOIDAL SPACE
(space of Disse)

- where exchange of nutrients

and waste products occur
 Cells in Sinusoids

• Stellate macrophages (Kupffer cells)

• recognize and phagocytose aged erythrocytes
• antigen presenting cells

• Hepatic stellate cells (Ito cells)

• store vitamin A and other fat-soluble vitamins
• mesenchymal cells which produce ECM ( myofibroblasts)
and cytokines
Kupffer cells
HEPATIC LOBULE : structural unit of
the liver
 PORTAL HYPERTENSION

CAUSES:
• block in intrahepatic portal vein tree (cirrhosis)

• impaired outflow of blood from the liver

• excessive flow of splanchnic or hepatic arterial blood

to the liver
PORTOCAVAL ANASTOMOSES

1. Esophageal
2. Para-umbilical
3. Rectal
4. Retroperitoneal
 ESOPHAGEAL
ANASTOMOSIS

1. ESOPHAGEAL BRANCHES OF
LEFT GASTRIC (PORTAL)

WITH

ESOPHAGEAL VEINS DRAINING

middle 3rd OF ESOPHAGUS
(SYSTEMIC)
ESOPHAGEAL
VARICOSITIES

ESOPHAGEAL
HEMORRHAGE

most dangerous complication

of portal HPN
ESOPHAGEAL HEMORRHAGE
 RECTAL
ANASTOMOSIS

2. SUPERIOR RECTAL VEINS

(PORTAL)

WITH

MIDDLE AND
INFERIOR RECTAL VEINS
(SYSTEMIC)
HEMORRHOIDAL PILES
 PARA-UMBILICAL
ANASTOMOSIS

3. PARAUMBILICAL VEINS
(PORTAL)
WITH
SUPERFICIAL VEINS OF ANTERIOR
ABDOMINAL WAL (SYSTEMIC)

“CAPUT MEDUSAE”
CAPUT MEDUSAE
CAPUT MEDUSAE
 RETROPERITONEAL
ANASTOMOSIS

4. VEINS OF ASCENDING COLON,

DESCENDING COLON, DUODENUM,
PANCREAS & LIVER (PORTAL)
WITH
RENAL, LUMBAR & PHRENIC VEINS
(SYSTEMIC)

“RETROPERITONEAL VARICOSE
PORTOCAVAL ANASTOMOSIS”
NERVE SUPPLY OF LIVER & BILIARY TRACT

• MOTOR
• SYMPATHETIC :
7-10th spinal segments
splanchnic nerves
celiac ganglion

• PARASYMPATHETIC:
anterior and posterior vagal
trunks
NERVE SUPPLY OF LIVER & BILIARY TRACT

• SENSORY
• via sympathetic
afferent fibers
through both
splanchnic nerves &
right phrenic nerve

• pain: dull type

FUNCTIONAL UNITS OF LIVER
STRUCTURE
I. CLASSIC HEPATIC LOBULE
II. PORTAL LOBULE
III. LIVER ACINUS
 I. CLASSIC HEPATIC LOBULE
• portal triads
(3-6 per lobule)
• portal vein
• hepatic artery
• bile duct
• lymphatic vessels

• blood flows from portal area to central vein

 I. CLASSIC HEPATIC LOBULE

• emphasizes the major

endocrine function
of the liver
- synthesize and secrete
the major plasma proteins
(albumin, fibrinogen,
transferrin, etc.)
PORTA
HEPATIS
II. PORTAL LOBULE

• triangular in shape
• center: portal triad
• angles : central vein at each tip
• bile flow: from hepatocytes
to bile duct of
portal triad
II. PORTAL LOBULE

• emphasizes the major

exocrine function
of the liver :

– bile secretion
PORTAL LOBULE
 III. LIVER ACINUS
• diamond or rhomboid shaped
• smallest functional unit of the hepatic parenchyma
• area irrigated by a terminal branch of the
distributing vein
III. LIVER ACINUS
• short axis: terminal branches of portal triad
• long axis: line drawn bet. 2 central veins
 III. LIVER ACINUS
• ZONE 1 - periphery of classic lobule
• ZONE 2
• ZONE 3 - closest to central vein (most central part of classic lobule
 III. LIVER ACINUS

• emphasizes the
different oxygen and
nutrient contents
at different distances
along the sinusoids
• ZONE 1
• 1st to receive O2, nutrients, and toxins
• 1st to show morphologic changes afer bile duct
occlusion
• last to die if circulation impaired
• 1st to regenerate
• ZONE 3
• 1st to show ischemic necrosis (centrilobular necrosis)
• last to respond to toxic substances and bile stasis
III. GALLBLADDER

• pear-shaped sac
• capacity of 30-50ml
• attached to inferior
surface of liver

• stores and
concentrates bile
 PARTS
OF THE GALLBLADDER

• FUNDUS
• BODY / CORPUS
• NECK
• INFUNDIBULUM (Hartmann’s pouch)
 Cystic Duct
• spiral valve (of Heister) or
spiral fold
• mucosal duplications
• regulate filling and emptying of
GB
 BLOOD SUPPLY OF GB
• CYSTIC ARTERY
• from right hepatic artery

• CYSTIC VEIN
• neck & cystic duct : drain
into the portal vein
• fundus & body : directly to
visceral surface of liver
PANCREAS

CYSTOHEPATIC
TRIANGLE
Lymphatic Drainage

cystic lymph nodes

hepatic nodes

celiac nodes
 NERVE SUPPLY OF GB
• SYMPATHETIC AND PARASYMPATHETIC VAGAL
FIBERS form the CELIAC PLEXUS

• GB contracts in response to CCK (enteroendocrine cells

of duodenum)
• stimulus: fatty food
 HISTOLOGY OF GB
1. MUCOSA
• lined by simple columnar
epithelium with microvilli
• tubuloacinar glands
(mucous glands are found
only in the neck)
• no submucosa and
muscularis mucosa
2. MUSCULAR
LAYER
• discontinuous
• inner layer
• longitudinally
• outer layer
• diagonally

3. SEROSAL
LAYER
• pseudodiverticula (Rokitansky- Aschoff sinuses)
• aberrant vestigial bile ducts
(true ducts of Luschka)
EXTRAHEPATIC BILIARY SYSTEM
RIGHT AND LEFT HEPATIC BILE DUCT

COMMON HEPATIC DUCT

+
CYSTIC DUCT

(COMMON) BILE DUCT

+
MAIN PANCREATIC DUCT

2ND PART OF DUODENUM

(major duodenal papilla)
 PANCREATIC
• MAIN PANCREATIC DUCT (of DUCTS
Wirsung)

• ACCESSORY PANCREATIC DUCT

(of Santorini)
MAIN PANCREATIC DUCT
(of Wirsung)
+
(COMMON) BILE DUCT

AMPULLA of Vater
(hepatopancreatic
ampulla)
SPHINCTER
major duodenal papilla OF ODDI
 BLOOD SUPPLY OF
PANCREAS

• ARTERIAL SUPPLY

1. SPLENIC
2. SUPERIOR &
3. INFERIOR PANCREATICO-
DUODENAL
 BLOOD SUPPLY OF
PANCREAS

VENOUS DRAINAGE
• pancreatic veins
- splenic
- SMV
 LYMPH
DRAINAGE

• celiac
• superior
mesenteric
nodes

• EXTENSIVE LYMPHATIC
DRAINAGE
 MY GOD, MY GUIDE
“I will instruct thee and teach thee in the way which thou shalt go; I will
guide thee with Mine eye!”
-Psalm 32:8
 I HAVE CONFIDENCE IN THE ONE
WHO LEADS THE WAY
“Lord, with You as my guide, I know my destination is sure. Thank you
for the assurance that You are constantly watching over me, leading
every step I take. I often stay from Your path, O Lord, but time and time
again You have redirected me. Thank you for being my Guide in life!”