DIGESTIVE SYSTEM LARGE INTESTINE

Large intestine starts at the cecum and ends at the anus For absorption of water, liquid intestinal content, chyme. Sigmoid colon- narrowest part in the large intestines Saculation or Costrations part of the intestine that differentiates large from small intestine when viewed in x-ray. Tinea coli concentration of longitudinal muscles. Shorter than large intestine up to sigmoid colon.

Transverse colon 90 degree downward to become the Descending colon. Has splenomegaly ligaments. Loses mesentery/ mesocolon fixed to posterior abdominal wall. Covered by peritoneum Iliac fossa becomes the sigmoid colon Sigmoid colon mobile because of mesocolon. Can be lifted up to during incisions. Tinea coli diminished; lose saculations and mesentery, no mesocolon S3 ends at the 3rd sigmoidal vertebra Rectum series of sphincters (voluntary and involuntary) When bolus feces are formed; involuntary relaxes for defecation. Internal Sphincter controlled by autonomic nervous system.

Seen, measured Ex. Tenderness, mass, fever, jaundice Abdominal pain Somatic versus visceral Referred pain: visceral in origin poorly localized dull to sever sympathetic nervous system. -Somatic Perception -Stimulus: Distention Diaphragm: pain left shoulder -Appendix (right iliac fossa): pain umbilical region (referred pain) -Referred Pain: -Example: -Kidney -Sympathetic fibers enter the somatic cord up to L1 (lower cervical) -Appendix -Sympathetic fibers enter the cord together with somatic fibers from T10 -Acute Appendicitis -Children Early: 0-12 hours Acute: 12-24 hours Perforated: 24-36 hours -Physical Examination -Inspection visual, flat, globular, distended -Signs: spider angioma/nevus, caput medusa, Grey- tumor sign, distention -AAW abnormalities -Congenital or acquired Congenital -Diastasis recti -Defect of closure 1. Omphalocele 2. Gastrochisis 3. Omphalomesenteric 4. Duct remnants 5. Urachal Anomalies -Omphalomesenteric 1. Duct remnants 2. Umbilical polyp 3. Umbilical sinus 4. Cyst 5. Enteroumbilical fistula Meckels diverticulum out pouching Fistula (communication between 2 spaces) Urachal Anomalies 1. Vesicoumbilical fistula 2. Urachal sinus 3. Cyst 4. Bladder diverticulum Umbilical Hernia 1. Spontaneous closure 2. Incarceration rare Inguinal hernia 1. Indirect patent processus vaginalis 2. High risk of incarceration 3. Unlikely to close Incarceration intestine gets stuck. AAW Abnormalities Hernias 1. Direct/ indirect inguinal 2. Incisional 3. Umbilical 4. Spigelian 5. Femoral Infection 1. Necrotizing fasciitis 2. Omphalitis infection of the umbilicus Tumors

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Auscultation

Lipoma Fibroma desmoids Hemangioma Neurofibroma Sarcoma malignant

Longitudinal Bands: Teaniea Coli 1. Mesocolon to sigmoid colon tinea coli is attached. 2. Greater Omentum omental tinea coli 3. Appendices or omental appendices - fat sac like occlusion, hanging on the wall of large intestine Tinea Libera free (no attachment) Regions of the Abdomen: 9 Cecum located at the iliac region Ascending colon over lumbar region Right colic flexure above, right hypochondriac region Sigmoid colon hypogastric region 1st portion of Large intestine: -Cecum 3 inches long a. Area were ileum is joined to the large intestine. Imaginary line below is the cecum, right iliac fossa Behind (posterior) cecum iliacus Medial Psoas muscle Appendix prominent feature of cecum; full of lymphoid tissue. Vermiform appendix vermis latin; wormlike Appendix pointing the pelvis; retrosecal (behind). Cecum is mobile; no attachments Ileocecal valve - regulates intestinal contents; no true anatomical sphincter. Protruding (in a way that forms a spinchter); enlarged version of papilla(similar to major duodenal papilla). Closes to prevent backflow of contents. Ascending colon diameter is narrower; reaches out up 10-12 inches. a. Attached posteriorly to quadratus lumborum. b. Fixed portion of ascending colon. c. Partially covered of the peritoneum. d. Covered by visceral peritoneum. e. Paracolic peritoneum reflects f. Just below the right lobe of the liver. Right colic flexure/ Hepatic flexure From here, large intestine becomes transverse colon. Can be lifted because it has mesocolon. 20 inches transverse colon Average size: 45cm Left colic flexure

BLOOD SUPPLY Superior Mesenteric Artery Right side appendix to mid transverse colon; branches: iliocolic artery, appendicular artery. Middle colic artery supply the right and left of transverse colon. Left side inferior mesenteric artery Sigmoids anastomose with left colic Terminal branch: sigmoid hemorrhoidal. Collaterals will not become gangrenous because there is blood supply. Continuous collateral or anastomoses of blood supply. Marginal artery/ continuous artery Arc of Ireolan Marginal Artery of Ramund VENOUS DRAINAGE Superior mesenteric vein right side Inferior Mesenteric Vein left side Left side drains into splenic vein. Splenic vein and superior mesenteric vein joins to form the hepatic portal vein Cancer of large intestine deposits first in the LIVER because of the anatomical explanation. LYMPHATICS -Aortic chain lymph trunk (intestinal trunk). -Cancer travels the thoracic duct and travels to the neck to the subclavian vein and goes to the superior vena cava to the right side of the heart -> to the lungs (perfect repository for cancer cells). INNERVATIONS plexus of nerves; mesenteric plexus; contain sympathetic and parasympathetic fibers around the main arteries. CLINICAL ABDOMEN Abdominal region basis A. Chief complaint: B. History Interview skills Establish rapport Present history , past history, personal and social history, family history, obgyne history Accurate history -> DIAGNOSIS Symptoms Subjective Nonspecific Ex. Pain, nausea, vomiting, dizziness body weakness, fatigue, anorexia Signs Objectives

Bowel sounds Absent Hypoactive Hyperactive -Ex: Bowel obstruction Hernias -Diaphragm Bochdaleks hernia Morgagnis hernia Mesentery internal hernias 1. Foramen of Winslow 2. Paraduodenal hernia 3. Transmesenteric 4. Intersigmoid

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Percussion Dull vs. tympanitic Fluid wave Solid/cystic vs air Palpation Soft/rigid Masses Tenderness Diagnostic signs Rovsing signs - appendicitis Murphy signs - cholecystitis Sister mary joseph lymph node masses in the umbilicus Peritoneal cavity Site for fluid accumulation 1. Ascites 2. Chyle 3. Blood 4. Urine Peritonitis 1. Primary vs secondary 2. Septic vs aseptic (chemical) Outcomes of peritonitis Abscess formation Adhesions Secondary bacterial peritonitis Retroperitoneum Nonspecific symptoms Inaccessible Delay in diagnosis -Pancreatitis, retrocecal appendicitis, urinary tract infection Diagnosis of abdominal problem Careful, methodic, systematic, diagnostic approach History Physical Examination Laboratory Tests Radiographic and Imaging Studies Prerequisite knowledge 1. Knowledge of etiology and pathologic processes 2. Anatomy and Physiology