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Radiological Anatomy ofEsophagus, Stomach, Small
Intestine and Large Intestine
Talat H. Sharif MD
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Objective
To identify the structures of the GI
tract on X-Rays, Barium Study, CT
Scan and UltrasoundTo be able to understand therelationship of various parts of the
intestinal tract and the structuresaround them.
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Digestive Tract
BEGINS AT THE LIPS
ENDS AT THE ANUS
MAJOR DIVISIONS
MOUTHOROPHARYNX
ESOPHAGUS
STOMACH
DUODENUM
JEJUNUM
ILEUM
COLON
RECTUM
ANUS
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Methods of Examination
Fluoroscopic-radiographic examinationwith barium sulfate is the standardexamination
Single contrast or double contrastDouble contrast provides improvedvisualization of mucosal folds
Water-soluble contrast is used whenperforation is suspected
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Methods of Examination
CT and Ultrasound can detect masses butbasically used for staging of cancer
Non-radiological methods
Fibero-optic endoscopy is a the methodto visualize the mucosa of the stomachand duodenum. In some parts of the worldendoscopy has replaced radiologicmethod as the primary examination
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Oropharynx
PHARYNX DIVIDED INTO 3 SEGMENTS
Nasopharynx
Oropharynx
mechanical breakdown offood through the chewing, chemicalbreakdown through salivary amylase,speech and swallowing occur here.
Hypopharynx
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Pharynx
Three pharyngeal recesses: Food bolusescan lodge in these recesses.
The vallecula is the space or depressionbetween the base of the tongue and theepiglottis.
The two pyriform sinuses are located in the
pharynx, beside the larynx. They are formedby the shape of muscle attachments to thepharyngeal walls.
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Oropharynx
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Esophagus
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What to ExamineMotility disorderAbnormal dilatation / narrowingDiverticulumInflammationUlcerationFilling defect
Mucosal nodularity / plaque
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Esophagus
The adult human esophagus is an 18- to25-cm long muscular tube
Esophagus develops from foregut and byweek 10 is lined by ciliated epithelial cells.
Esophageal peristalsis appears in the firsttrimester,gastro-esophageal reflux can bedocumented in the second trimester
Proximal 1/3-striated muscle
Distal 2/3- smooth muscle
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Esophagus (Course)
Esophagus connect pharynx with the stomach. Begins inthe neck at the lower border of the cricoid cartilage,opposite the C5 and C6 vertebra
Descends in front of the vertebral column, through thesuperior and posterior mediastinum
Passes through the diaphragm and enters the abdomenand ends at the cardiac orifice of the stomach, oppositethe T11 vertebra
General direction of the esophagus is vertical, but itpresents two slight curves in its course
Just before it perforates diaphragm it presents a distinctdilatation
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Esophagogram
Esophagogramshowing thecourse of the
esophagus
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Different parts of Esophagus
Topographically, esophagus has threedistinct regions: cervical, thoracic, andabdominal. The cervical part is 4 to 5cmlong & extends from pharyngoesophagealjunction to the suprasternal notch.
In cervical part, the esophagus is borderedanteriorly by the trachea, posteriorly by thevertebral column, and laterally by thecarotid sheaths and the thyroid gland.
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Different parts of Esophagus
Thoracic esophagus extends from thesuprasternal notch to the diaphragmatichiatus, passes posterior to the trachea and
its bifurcation, and the left main stembronchus. The esophagus lies posteriorand to the right of the aortic arch at the T4
vertebral level. From the level of T8 untilthe diaphragmatic hiatus the esophaguslies anteriorly to the aorta.
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Different parts of Esophagus
Abdominal esophagus extends from thediaphragmatic hiatus to the orifice of thecardia of the stomach.
The abdominal esophagus lies in theesophageal groove on the posteriorsurface of the left lobe of the liver.
Measures about 1.25 cm in length
Is somewhat conical in appearance as itenters in the orifice of the stomach
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Esophagogram
Study of esophagus by orally takingbarium sulphate is called anEsophagogram
Patient is asked to drink a thick mixture ofBarium.
Study is done under flouroscopy by aRadiologist
Images are captures on hard copy (film)during swallowing and after to study
motility and to rule abnormality
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Esophagogram
Performed in dysphagia and to ruleout pharyngeal or esophageal
abnormalityIt is a contrast study
AP & Lateral projections are taken
Valsalva maneuver is done andadditional films are taken
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Stages of Esophagogram
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Stages of Esophagogram
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Stages of Esophagogram
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Normal esophageal narrowing
At the site of its
origin
Aortic archLeft mainbronchus
Diaphragm
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Impressions on Esophagus
Aortic arch
Left main
bronchusLeft atrium
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Relationship of thoracic Part ofEsophagus
Anterior Trachea Left main stem bronchus
Pericardium Behind and to the right of aortic archPosterior
Vertebral column Hemiazygous vein Right aortic intercostal arteries Aorta near diaphragm
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Relationship of Thoracic Part ofEsophagus
Right
Right pleura
Azygous veinLeft
Aortic arch
Left subclavian artery Left pleura
Descending aorta
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Relations in thoracic inlet
Anterior
Trachea
Thyroid gland
Posterior Vertebral column
Longus coli muscles
Either side
Common carotid artery
Thyroid gland
CT Scan Showing the esophagus
and its adjoining structures
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Thoracic Esophagus
Relations insuperiormediastinum
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Relations at the level of heart
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Relations of distal part
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Stomach
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Anatomical drawing of stomach
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Anatomical relations of Stomach
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StomachIt is a muscular, elastic, pear-shaped bagMost dilated part of GI tractLies crosswise in the abdominal cavity in the lefthypogastric and epigastric regionsCapable of gross alterations in size and shapeIs about 30 cm long and 15 cm wide at its widestpointHas a capacity of about 1500 cc in adultsMucosa is honeycombed with over 35,000gastric glands and is folded into numerousridges that almost disappear when the stomachis distended with food
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Plain Film of the Abdomen
Things to look for Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
Foreign body
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Normal Gas Pattern on plainfilm
Stomach Always
Small Bowel Two or three loops of non-distended
bowel
Normal diameter = 2.5 cm
Large Bowel In rectum or sigmoid almost always
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Plain film abdomen
Normal Postoperative
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Barium Meal Study
B i M l St d
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Barium Meal Study
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Parts of Stomach
Cardia
Fundus
Body
Antrum
Pylorus
Greater curvatureLesser curvature
Barium Meal Study
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Barium mealstudy of
Stomach andDuodenum
StomachFundus ofStomach
GastroesophagealJunctionBody of
Stomach
Barium Meal Study
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GASTRICFUNDUS
ANTRUM
DUODENALBULB
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Fundus ofStomachshowing
mucosal folds
Pyloric Antrum andDuodenal Bulb
C-Loop ofDuodenum
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Stomach
Cardia is the intersection of the stomachand esophagusA ring of muscle known as the cardiacsphincter is present in this part.Fundus is the most superior part of thestomach and lies above the entrance ofesophagus
On Chest X-ray, air is usually seen in thefundus, producing the gastric bubble
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Chest X-ray (stomach bubble)
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Stomach
Distal stomach consists of the antrum andpylorusAntrum forms the beginning of the distalstomach followed by pylorusPyloric canal is 3 cm in length and leads tothe duodenumPyloric sphincter separates the stomach
from duodenumPyloric sphincter remains closed until thefood here is modified & is suitable to passinto the small intestine
Stomach Relations
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Stomach Relations
Antero superior surface Diaphragm
Left
Spleen
Right
Liver - left and quadrate lobes
Posterior inferior surface
Diaphragm
Left adrenal
Left kidney
Splenic artery Anterior surface of pancreas
Left colon
Transverse mesocolonCT Scan of Abdomen
CT Scan of abdomen
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CT Scan of abdomen(stomach relations)
CT Scan of abdomen
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CT Scan of abdomen(stomach relations)
can o a omen
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can o a omen(stomach relations)
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Small Intestine
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Small Intestine
Small intestine is the longest part(about 7m) of the gastrointestinal tract
Extends from pylorus to ileocecal valve
Is located in the center of the abdomenDiameter is about 2.5 cm and is tubelike structure winds compactly back
and forth within the abdominal cavityThe small intestine is identified byvalvulae circulares / conniventes orcircular folds of mucosa on barium x-
ra stud
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Parts of small Intestine
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Parts of small Intestine
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The small intestine is identified by valvulaecirculares / conniventes or circular folds ofmucosa on barium x-ray study
Parts of Small Intestine
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Parts of Small Intestine
Duodenum
(proximal)
Jejunum (middle)Ileum (distal)
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Small Intestine
Small bowel islocated in the
center ofabdomen
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General relations of Small bowel
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General relations of Small bowel
Anterior
Greater omentum
Abdominal wall
Surrounded by colon
Some small bowel extends topelvis
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Duodenum
Duodenum is the first part of the smallintestine
It has no mesentery
It is about 25 cm long
Duodenum forms a C-loop around thehead of the pancreas
Whole of the duodenum except for thebulb is retroperitoneal
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Duodenal C Loop
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DifferentParts of the Duodenum
Duodenum is divided into four partsThe first part Measures 5 cm From pylorus to gall bladder neck
is encased in the hepato-duodenal ligamentThe second part (Descending part)- Its 8-10 cm long
From neck of Gall bladder to L3
This part is retroperitoneal It has ampulla, where the openings of pancreatic duct
and common bile duct are seen
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Duodenal Bulb
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Different Parts of the Duodenum
The third part (Transverse)
Extends from L3 across left and upwards
About 10 cm in length
The fourth part
Continues as jejunum at L2
Held in place by the ligament of Treitz
This ligament connects the duodenum to theright crus of the diaphragm
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3rd Part of the Duodenum
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DUODENALULCER
Relationships of 1st part of
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Relationships of 1st part of
Duodenum
Above and anterior
Quadrate lobe of liver
Gall bladder
Behind
Gastrodudenal artery
Bile duct and portal vein
Head and neck of
pancreas
d
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2nd part of the Duodenum
Relationships of 2nd part of
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Relationships of 2nd part of
Duodenum
Anterior Liver Transverse colon JejunumPosterior Right kidney Right renal vein IVC PsoasMedial Head of pancreas
Bile duct Pancreatic ductLateral Right colic flexure
Relationships of 3rd part of
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Relationships of 3rd part of
Duodenum
Anterior SMA
SMV
Posterior
Right ureter Psoas
IVC
Abdominal
aortaUpper
Pancreas
Lower
Jejunum
CT S d f d d
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CT Scan- 2nd part of duodenum
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Relationships of 4th part of
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Relationships of 4th part of
Duodenum
Right Aorta
Left
Left Ureter Left kidney
Above
Body of pancreas
Anterior
Transverse colon
Mesocolon
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Jejunum
J j
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Jejunum
Middle part of small intestine is the Jejunum
It is 8 feet long and 4 cm in diameter
Stays mostly in umbilical regionSurface area increased by plica circulares(circular folds) carrying villi: cells of villi carrymicrovilli
Jejunum and Ileum are attached to posteriorabdominal wall by mesentery
B i St d
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Barium Study
CT S f th bd
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CT Scan of the abdomen
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Ileum
Ileum
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Ileum
Distal part of the small intestine
It is 3.5 m long
Located mostly in hypogastric region
Ileum joins the large intestine (cecum) atthe ileo-cecal junction in the right lowerabdominal cavity
Jejunum and Ileum are attached toposterior abdominal wall by mesentery
B i St d
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Barium Study
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Barium Study (ileocecal
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y (junction)
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
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Large Intestine
Large Intestine
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g
Large intestine / Colon is about 1.5 mlong
Extends from the ileocecal valve to anus Direction
Cecum starts in right lower flank andextend upward (ascending colon)Lie across the abdominal cavity
(transverse colon) beneath thestomach
CT Scan of the abdomen
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CT Scan of the abdomen
Large Intestine
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g
Then extend downward(descending colon) on the left sideof the abdominal cavity
make a sharp turn in the left lowerportion (sigmoid) to merge with therectum
Caliber decreases from cecum torectum which is a dilatation abovethe anal canal
Large intestine occupy the superior
and lateral edge of the abdomen
Different parts of Colon
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p
Ascending colon
Transverse colon
Descending colonSigmoid
Rectum
Anus
Barium EnemaTransverse Colon
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Barium EnemaStudy (DoubleContrast Study) ofLarge Intestine
Descending Colon
Ascending
Colon
HepaticFlexure ofColon
Splenic Flexure
of Colon
SigmoidColon
Rectum
Large Intestine
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Large Intestine
Large intestine has three longitudinalmuscle bands (taenia coli) with bulges inthe wall (haustra) between them
On X-ray, the colon is identified by thesacculations called haustra scattered allalong the colon
Colon has fat filled tags called appendices
epiploicae on its surfaceThese haustra and epiploicae separate thelarge from the small intestine
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
Ascending Colon
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Ascending Colon is thefirst part of the colon
Extends from appendixup to a flexure at the liver
It lies on the right side ofthe abdomen
It is 15 cm long
Its direction as it leaves
the cecum is upwardIt is intraperitoneal
Ascending Colon
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Only the transverse and part of theascending colon are considered to beintra-peritoneal organs
CecumMeasures about 6 cm by 7.5 cmIt is the first part of the ascending
colonIleum enters it at its medial surfaceAppendix is attached to the cecum
at its posterior and medial aspect
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
Transverse Colon (Barium Enema)
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This part of the colon isintraperitoneal
It begins at the hepaticflexure and ends at the
splenic flexureTransverse colon is thelongest part of the colon
It is about 50 cm long
It may dip down to thepelvis. Its position isvariable
CT Scan of the abdomen
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CT Scan of the abdomen
Descending Colon
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Descending Colon
Begins at the Splenic flexure anddescends downward to left groin
About 25 cm longLocated on the left side of the abdomenand lies along the left paracolic gutter
Retroperitoneal and connected to theposterior abdominal wall from the splenicflexure to the pelvic part
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
CT Scan of the abdomen
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CT Scan of the abdomen
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Relationships of the HepaticFl
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Flexure
Above and anterior Liver
Behind
Kidney
Medially
Gall bladder fundus
Duodenum
Splenic flexure
CT Scan of the mid abdomen
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CT Scan of the mid abdomen
Relationships of the Splenic
Fl
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Flexure
Splenic flexture is attached todiaphragm by phrenico-colic ligament
Related to
Spleen
Tail of PancreasLeft Kidney
Splenic flexture
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Splenic flexture
Sigmoid Colon
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Sigmoid Colon
Descending colon becomessigmoid at the level of pelvic inlet
It is about 40 cm longSigmoid makes a sharp turn in
the lower portion to merge with
rectum
Blood Supply of the Colon
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Blood Supply of the Colon
Arterial blood supply to the cecum is from theileocecal branch of the superior mesentericartery
Arterial supply to the ascending colon comesfrom the ileocolic and the right colic branches ofthe superior mesenteric artery
Transverse colon is supplied by the middle colic
artery, a branch of the superior mesentericartery
Descending colon derives its blood supply fromthe left colic branch of the inferior mesenteric
arter
Relationships of Sigmoid Colon
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Relationships of Sigmoid Colon
LateralExternal iliac veinOvary
PosteriorInternal iliac vein
UreterPiriformesSacral plexus
InferiorBladder in male
Uterus and bladder in female Above
Small bowel
Barium Enema w/ air
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CT Scan of the abdomen
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CT Scan of the abdomen
Sigmoid colon
CT Scan of the abdomen
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C Sca o t e abdo e
CT Scan of the abdomen
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C Sca o t e abdo e
CT Scan of the abdomen
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RectumC i f i id S l h i
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Continues from sigmoid at S3, along the anteriorsurface of sacrum, passes through the pelvicdiaphragm and continue with anal canal
Length is 12 cm
Upper part 4cm in diameter
Lower part more dilated and called rectalampulla
Anorectal junction
2-3 cm below the tip of coccyx
Peritoneum from front reflects to form
rectovescical pouch anteriorly
recto uterine pouch posteriorly (female)
CT Scan of the pelvis
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p
Anterior relations of rectum
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MaleBladderSeminal
vescicle
Rectovesicalpouch
Small bowelSigmoid
UretersProstate
FemaleUterusCervixRectouterine
pouchSmall bowelSigmoid
- UretersVagina
Posterior relations of rectum
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Posterior relations are similar in maleand female
Sacrum
Sacral plexus and vessels
Lateral
Pararectal fossa
Piriformes
Levator ani
Coccyges
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CT Scan of the lower abdomen
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CT Scan of the lower abdomen
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CT Scan of the pelvis
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p
CT Scan of the pelvis
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p
Rectum, bladder and seminal vesicles
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Single-contrast barium enema study shows burnt-out
ulcerative colitis.
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Mesentery
Peritoneum, Mesentery and
Omentum
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Omentum
Parietal peritoneum lines the abdominal wallVisceral peritoneum lines the organsBetween the two lies the peritoneal cavityReflections of the parietal peritoneum between
organs are called ligaments Ligaments that connect the stomach to other
organs are called omentaMesentery connects the bowel to the posterior
abdominal wallAll of these contain fat, blood vessels,lymphatics and nerves
Greater Omentum
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Greater Omentum
Extends inferiorly from the greatercurvature of the stomach and foldsover to insert into the transverse
colonOn CT Scan, it is the fatty areabehind the anterior abdominal wall
Lesser OmentumExtends between the lesser
curvature of the stomach and the
liver
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Small Bowel Mesentery
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Fan shaped Connects jejunum and ileum to the
posterior abdominal wall
Root is at duodenojejunal junction It contains SMA and branches
On CT, it is seen to contain fat and
blood vessels
Mesentery
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Radiological Differences Between
Small and Large Intestines
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Small and Large Intestines
Small Intestines
Located in the center ofthe abdomen
Has valvulae conniventes
Smaller in caliber andlonger
Large Intestines
Located at the periphery
Has haustrations
Larger in caliber andshorter
Difference Between Small and
Large Intestines
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Large Intestines
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Appendix
Appendix
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Appendix, is a blind pouch projecting fromthe postero-medial wall of cecum on theright side of the lower abdominal cavity
Small, worm-shaped blind tube, about 2-20 cm in length
Mostly seen 2 cm below Ileo cecal valve
Retrocecal position is most commonlyseen although retrocolic or Pelvic positionsare also seen.
CT Scan of the lower abdomen
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CT Scan of the lower abdomen
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CT Scan of the lower abdomen
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CT Scan of the lower abdomen
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Where to look for normal appendix
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