Digestive system

(1)

Digestive system

Glands and peritoneum

(2)

Glands of the digestive tube

• glandulae salivariae = salivary glands

• pancreas

• hepar = liver

• vesica fellea + ductus choledochus =

gallbladder + bile duct

(3)

Salivary glands (Glandulae oris)

• major salivary glands (glandulae salivariae majores)

– gl. parotidea

– gl. sublingualis

– gl. submandibularis

• minor salivary glands (glandulae salivariae minores)

– gll. labiales, buccales, molares, palatinae – gll. linguales anteriores (Blandini-Nuhni) – gll. lingulaes posteriores

• pars profunda = gl. gustatoria (von Ebneri)

• pars superficialis = gl. radicis linguae (Weberi)© David Kachlík 30.9.2015

(4)

Glandulae salivariae majores

• capsula

(collagen fibres) 

septa

• secretory part

– serous, mucous and myoepithelial (basket) cells

• system of ducts

– intralobular

• intercalated  striated 

– excretory

   

(5)

Glandulae salivariae - cells

• serous cells

• acinus (pyramid shape)

• produce proteins

• basophillic, ER, GA

• microvilli apically, secretory granules

• mucous cells

• cuboidal, columnar

• form tubules

• produce mucus  light granula (which can fuse)

• viscose secretion  more distally than serous cells

(6)

Glandulae salivariae - cells

• cells of intercalated duct

• simple flat / low cuboidal epithelium

• lactoferin, lysozyme

ductus intercalati

converge in ductus striati

• cells of striated duct

• radial arrangement

• striation = fold of BM + mitochondria

• cells transporting ions

• form hypotonic saliva

(7)

Glandulae salivariae

into intelobular

ducts

(8)

Glandula parotidea

• ductus parotideus Stenoni → above upper M₂

• pars profunda et superficialis

– in between plexus intraparotideus n. VII

• glandula parotidea accessoria

• regio parotideomasseterica innervation:

parasympathetic: n. IX → n. tympanicus → n.

petrosus minor (Jacobson‘s anastomosis)  ganglion oticum → n. auriculotemporalis

sympathetic: truncus sympaticus → ggl. cervicale

(9)

Glandula parotidea – structure

• pure serous, compound acinar gland

• ramified acines, long ducts

• plasmocytes in lamina propria - IgA  complexes with secretory component

(synthetized in serous, intercalated and striated parts)

• PAS+ granule (polysacharids, amylase)

• 25% of saliva volume

(10)

(11)

Glandula submandibularis

• ductus submandibularis Whartoni →

caruncula sublingualis

• trigonum submandibulare

innervation: parasympathetic: n. VII →

chorda tympani → n. lingualis → ganglion submandibulare

sympathetic: truncus sympathicus → ggl.

cervicale sup. → plexus a. facialis

(12)

Glandula submandibularis – structure

• seromucous, compound tubulo-acinar gland

• serous acines adjacent to mucous tubules are transformed in serous demilunes

(semiluna serosa – semiluna Giannuzzi- Heidenhain)

• serous elements prevail

(basophilic cytoplasm)

• PAS+ granule

(13)

(14)

Glandula sublingualis

• ductus sublingualis major Bartholini →

caruncula sublingualis

• ductus sublinguales minores → plicae sublinguales

innervation: identical with glandula

submandibularis

(15)

Glandula sublingualis – structure

• seromucous, compound tubulo-acinar gland

• mucous cells prevail

• no intercalated ducts

• short striated ducts

• 5% of saliva volume

(16)

(17)

Pancreas

• description: caput (processus uncinatus,

incisura), collum, corpus (margines, facies), cauda

• structure: ductus pancreaticus Wirsungi (sphincter d.p.), d.p. accessorius Santorini

• insulae pancreaticae Langerhansi (1%)

• fixation: lig. pancreaticosplenicum, -colicum, vasa mesenterica sup.

• syntopy: duodenal window L2, secondary retroperitoneal organ

(18)

Pancreas

• Popis: caput (processus uncinatus, incisura), collum, corpus (margines, facies), cauda

• Stavba: ductus pancreaticus Wirsungi

(sphincter d.p.), d.p. accessorius Santorini

• Insulae pancreaticae Langerhansi (1%)

• Fixace: lig. pancreaticosplenicum, - colicum, vasa mesenterica sup.

• Syntopie: duodenální okénko L2, sekundárně

(19)

(20)

(21)

Pancreas – arterial supply

caput:

• truncus coeliacus  a. hepatica

communis  a. gastroduodenalis  a.

pancreaticoduodenalis sup. post. + sup.

ant. + aa. retroduodenales

• a. mesenterica sup.  a.

pancreaticoduodenalis inf.  ramus ant.

+ ramus post.

corpus et cauda:

• truncus coeliacus  a. splenica  rr.

pancreatici

(22)

(23)

Pancreas – other supply

veins:

• vv. pancreaticoduodenales → v. mesenterica sup.

→ v. portae

• vv. pancreaticae → v. splenica → v. portae lymph drainage:

• n.l. pancreaticoduodenales, mesenterici sup. → n.l.

lumbales nerves:

• parasympathetic – n. X

• sympathetic – truncus sympaticus → nn. splanchnici major + minor → ggl. coeliacum + mesentericum

sup. © David Kachlík 30.9.2015

(24)

(25)

Pancreas – mixed gland

• pars exocrinna – serous, compound tubulo-acinar gland

– serous cells (pancreatocytus exocrinus)

• form acines, ER, GA, granula zymogeni (apically)

– no striated intralobular ducts

– ductus intercalatus  d. intralobularis  d. interlobularis

 d. excretorius  d. pancreaticus (+ d.p. accessorius) – secretion: water, ions, (chymo-)trypsinogen,

carboxypeptidase, (deoxy-)ribonuclase, lipase, amylase, elastase

• secretin  much fluid, HCO₃ ^-, neutralization of chymus

• cholecystokinin  much enzymes (release of granules)

• pars endocrinna – insulae pancreaticae = islets of Langerhans © David Kachlík 30.9.2015

(26)

Pancreas – pars exocrinna

acines surrounded with BM 1 – exocrinne cells of

pancreas

(pancreatocytus exocrinus)

– zymogen granula

2 – centroacinar cells

(cellula centroacinosa) 3 – intercalated duct

(ductus intercalatus)

(27)

(28)

Hepar = Liver

(29)

regio

hypochondriaca dextra

(30)

(31)

Liver – description

• facies diaphragmatica

– area nuda, impressio cardiaca

• facies visceralis – impression of organs (6)

– stomach, oesophagus, kidney, suprarenal gland, duodenum, right colic flexure

• margo inferior – usually non-palpable

• 4 lobes (descriptive)

– lobus dx., sin., caudatus, quadratus

• 8 segments (according to blood vessels

branching)

(32)

Liver – Segments

• segment has in its center: artery, veins (branch from v. portae), bile duct

• vv. hepaticae are between segments !

• plane along v. hepatica media divides liver into lobus dx. et sin.

– surface projection called line of Rex-Cantlie (between center of fossa vesicae felleae → v. cava inf.)

• v. hepatica dx. divides right lobe into anterior (V+VI) and posterior segments (VII+VIII)

• v. hepatica sin. divides left lobe into lateral (II+III) and medial segments (IV)

(33)

(34)

Liver classification (Claude Couinaud 1957) Segmentum Pars hepatis sinistra

Divisio lateralis sinistra

Segmentum posterius laterale sinistrum II Segmentum anterius laterale sinistrum III Divisio medialis sinistra

Segmentum mediale sinistrum IV

Pars posterior hepatis; Lobus caudatus

Segmentum posterius; Lobus caudatus Spigeli

I

Pars hepatis dextra

Divisio medialis dextra

Segmentum anterius mediale dextrum V Segmentum posterius mediale dextrum VIII Divisio lateralis dextra

(35)

Segmenta hepatis

• borders by vv. hepaticae

• lobus

caudatus = segmentum I

(36)

Bismuth‘s clasification

(USA)

• 4 sectors

• 8 segments

• segmentum IV

– IVa – IVb

(37)

(38)

Liver

vazy a fixace

• lig. teres hepatis

• lig. venosus

• lig. falciforme

• lig. coronarium dx.+sin.

• lig. triangulare dx.+sin., appendix fibrosa hepatis

• lig.hepatorenale; lig. venae cavae

fixation: suspended on v. cava inf., grows together

(39)

Liver

facies visceralis

• porta hepatis:

– v. portae

– a. hepatica propria

– ductus hepaticus dx. et sin.

– lymph nodes + nerves

• fissura lig. venosi, fissura lig. teretis

• sulcus venae cavae

• fossa vesicae biliaris

(40)

• v. portae

– dorsally

• a. hepatica propria

→ r. dx. et sin.

– ventromedially

• ductus hepaticus dx. et sin.

– ventrolaterally

Porta

hepatis

(41)

Liver

blood supply – 2 circulations

• nutritive (arteries) – 25% of blood truncus coeliacus → a. hepatica

communis → a. hepatica propria (+ a.

hepatica accessoria) → r. dx.+ sin. → aa.

interlobulares

• functional (veins) – 75% of blood

• v. portae → vv. interlobulares →

capillaries → vv. centrales → v. hepaticae

(dx.+ media+ sin.) → v. cava inf.

(42)

(43)

(44)

(45)

Liver – lymph and nerves

lymph: 3 directions

• n.l. coeliaci

• n.l. mediastinales ant.

• n.l. mediastinales post.

nerves:

• parasympathetic – n. X

• sympathetic – truncus sympathicus  plexus coeliacus  plexus hepaticus

• viscerosensory – n. phrenicus

– peritoneum under liver as far as gallbladder !!!© David Kachlík 30.9.2015

(46)

Liver – internal structure

• tunica fibrosa (capsula Glissoni)

• hepatocytes

– lamina hepatocytica = trabecules of hepatocytes – spatium perisinusoiodeum = Disse‘s space

– sinusoides in between (= irregulary extended capillaries with fenestrated endothelium)

• von Kupffer´s cells = macrocytophagus stellatus

• Ito´s cells = cellulae perisinusoidalis (fat storing cell)

– production of collagen for trabecules, storage of vitamin A

– canaliculus bilifer (bile canaliculus) – wall is formed

(47)

Hepatocyte

• polyhedric

• oeosinophilic

• large spheroid nucleus

– can be polyploid

• GER + SER

•  mitochondria

• bile canaliculus

• tight junction

• microvilli

• Disse‘s space

• endothelium © David Kachlík 30.9.2015

(48)

Classical hepatic lobule

Lobulus hepaticus classicus = polygonalis

• Weppler 1665

• 3 zones

– central III

– intermediate II – peripheral I

• structural unit of liver parenchyma

• hexagonal shape

• v. centralis

• hepatocytes in radiate trabecules

• spatium portale

(49)

• portal triad (trias hepatica)

– venula ( v. portae), PV – arteriola ( a. hepatica), A – interlobular bile duct (

ductus hepaticus), B

• simple cuboidal epithelium

perivascular fibrous capsule space of Mall

lymph capillaries

• portal lobule (lobulus portalis)

– centre = portal triad

Portal

area/canal/zone (spatium portale)

(50)

(51)

(52)

Liver acinus of Rappaport

Acinus hepaticus

• rhomboid

• functional unit

• according to blood supply (preterminal branch of hepatic arteriole)

• 3 zones

(53)

Spatium portale (PA):

branch of a. hepatica bile ductule

branch of portal vein

Classical hepatic lobule

Liver acinus

Portal lobule

Central vein (CV)

(54)

Liver – function

• synthesis of proteins

– continuous release into blood

– albumin, fibrinogen, prothrombin, transferrin, lipoproteins...

• secretion of bile

– water, ions, bile acids, phospholipids, cholesterol, bilirubin

• metabolic

– accumulation of metabolits: TAG, glycogen, vit. A

– gluconeogenesis, glycogenolysis, deamination of AA – detoxication: oxidation, methylation, conjugation

• hemopoiesis

(55)

Intrahepatic bile ducts

bile canaliculi (canaliculus bilifer) – no own wall

intralobular bile ducts (Hering‘s canals;

canalis bilifer)

bile ductules (ductulus bilifer)

interlobular bile ducts (ductus bilifer interlobularis)

ductus hepaticus dx. et sin.

(56)

(57)

(58)

Bile ducts

Ductus biliferi

• intrahepatic:

canaliculus bilifer  canalis bilifer of Hering

 ductus bilifer interlobularis 

• extrahepatic:

 ductus hepaticus dx. et sin.  d.h. communis  connection with d. cysticus  d. choledochus (m.

sphincter d. ch.)  ampulla hepatopancreatica (m.

sphincter a. h. Oddi) 

(59)

Ductus choledochus

• pars supraduodenalis

• pars retroduodenalis

• pars pancreatica

• pars intramuralis

• ampulla

hepatopancreatica (77%)

(60)

Vesica fellea/biliaris = Gallbladder

• description: fundus, corpus,

infundibulum, collum, ductus cysticus (plica spiralis Heisteri)

• arteries: truncus coeliacus → a.

hepatica communis  a. hepatica propria → r. dx. → a. cystica

• veins correspond to arteries

 v. portae

• lymph: n.l. hepatici

• trigonum cystohepaticum Caloti

(61)

(62)

(63)

(64)

Gallbladder – structure

• tunica mucosa

– simple columnar epithelium – frequent folds

– missing lamina muscularis mucosae – collum – mucosal glands

– pouches of mucosa into muscle layer

= Aschoff-Rokitansky‘s sinuses

(65)

Gallbladder – structure

• tunica muscularis

– plexiform

– cholecystokinin + ANS  contraction

• tunica serosa

– thick tela subserosa

– largely sessile to liver in fossa vesicae biliaris

• function:

– accumulation and concentration of bile (reabsorption of water to 10%)

(66)

(67)

Bile ducts – structure

• simple columnar epithelium

– cholangiocytes

– scattered goblet cells

• glandulae ductus choledochi – mucinous

• wall made of connective tissue predominantly

• missing continuous muscle layer

• thin wall can be easily compressed → jaundice

(68)

(69)

Basic division of abdominal cavity

• cavitas peritonealis

• spatium retroperitoneale

• spatium subperitoneale

• spatium preperitoneale

(70)

Cavitas peritonealis

• pars supramesocolica – bursa omentalis

• pars inframesocolica – levé + pravé srůstové

pole

– radix mesenterii

– excavatio rectouterina Douglasi + excavatio vesicouterina ♀

(71)

(72)

Mesos – pars supramesocolica

• mesogastrium ventrale

– lig. falciforme

– omentum minus

• lig. hepatoduodenale

• lig. hepatogastricum

• mesogastrium dorsale

– lig. phrenicosplenicum, gastrophrenicum, gastrosplenicum

– lig. gastrocolicum

(73)

(74)

Bursa omentalis

• ventrally: stomach, omentum minus, lig.

gastrocolicum

• dorsally: peritoneum (up), peritoneum +

pancreas, duodenum (in the middle), omentum majus – posterior layer (down)

• cranially: lobus caudatus hepatis, left diaphragmatic vault

• caudally: colon transversum, mesocolon

transvesum, omentum majus (sometimes with recessus inferior b.o.)

• left: spleen, lig. gastrophrenicum , lig.

gastrosplenicum (-lienale), lig. splenorenale (lieno-) (containing vasa splenica+cauda

(75)

Foramen omentale

(epiploicum s. Winslowi)

• entrance to omentalis from the right side

• ventrally: omentum minus (lig.

hepatoduodenale)

• dorsally: peritoneum (lig. hepatorenale)

• cranially: játra (processus caudatus lobi caudati)

• caudally: bulbus (ampulla) duodeni

• recessus superior, inferior, splenicus

(76)

(77)

Mesos – pars inframesocolica

• mesenterium

– radix mesenterii

• mesoappendix

• (mesocolon ascendens + descendens) → faded out

• mesocolon transversum

• mesocolon sigmoideum

• mesorectum – short

(78)

(79)

(80)

Recessus peritonei

• rec. subhepaticus + subphrenicus dx.+sin.

– r.s-h.dx. = Morison‘s space

• 4 at flexura

duodenojejunalis

• 3 at ostium ileocaecale

• rec. intersigmoideus Treitzi

• 1 ♂ / 2 ♀excavationes

• fossae paravesicales

(81)

Recessus peritonei

• rec. subhepaticus + subphrenicus dx.+sin.

– r.s-h.dx. = Morison‘s space

• 4 at flexura

duodenojejunalis

• 3 at ostium ileocaecale

• rec. intersigmoideus Treitzi

• 1 ♂ / 2 ♀excavationes

• fossae paravesicales + pararectales

(82)

Peritoneal recesses

Recessus peritonei

(83)

Peritoneal recesses Recessus peritonei

(84)

Peritoneal recesses

Recessus peritonei

(85)

Anterior abdominal wall from dorsal point of view

• plica umbilicalis mediana

• fossa supravesicalis

• plica umbilicalis medialis

• fossa inguinalis medialis = trigonum inguinale Hesselbachi

• plica umbilicalis lateralis = anulus inguinalis profundus

tříselné kýly

(86)

Recessus peritonei

• pars supramesocolica cavitatis peritonealis

– bursa omentalis (recessus sup.,inf.,splenicus)

– recessus subphrenicus, subhepaticus (hepatorenalis

= spatium Morisoni)

• pars inframesocolica cavitatis peritonealis

– recessus duodenalis sup., inf., paraduodenalis, retroduodenalis

– recessus ileocaecalis sup., inf., retrocaecalis – recessus intersigmoideus (Treitzi)

– sulci paracolici

– fossa supravesicalis, inguinalis med. et lat.

– fossa paravesicalis, pararectalis

– žena: excavatio vesicouterina, rectouterina (spatium

(87)