Abdomen and pelvic circulation 16/4

Sunday, April 28, 2019 5:06 PM

Relations to other organs:

Superiorly-
• upper 4 lumbar vertebrae
Anterior-
1. pancreas
2. Ascending part of duodenum
3. Radix of mesentery
Right-
• IVC
Left-
• Sympathetic trunk

Because it is posterior to the Radix of mesentery it means outside periosteum

most of the vascular distribution of vessels coming out of aorta will reach the
intraperitoneal part of the gut, there should be a way for vessels going there
the way is exactly the mesentery radix just is front of the aorta
way for 2 vessels mesentery to reach the gut

Main branches of the abdominal aorta

1. celiac trunk (middle)
2. superior mesenteric
3. left renal
4. gonadal (2 medial)
5. inferior mesenteric artery
(there are more- those he said to remember)

In general:
number of vessels not so high not complex
To relate them to the abdominal destination
more complex is the kind of anastomosis:
particularly between:
- celiac and superior mesenteric artery
- and superior mes artery and inferior mes

Unpaired branches
1. Celiac trunk (supply organs derived from the foregut) level T12 1 -2 cm, covered by celiac plexus and lies behind lesser sac has 3 terminal
branches
a. splenic - supplies the spleen, large part of the pancreas and part of the stomach
b. Common hepatic artery- gall bladder and the head of the pancreas, some of the stomach and part of duodenum
c. Left gastric artery- lesser curvature of the stomach

2. Superior mesenteric Large part of the abdomen derived from the midgut. Go out at level L1, immediately inferior to the celiac trunk
- the duodenum and pancreas
- Proximal 2/3 of large intestines (ascending and 2/3 of transverse)
- Jejunum and ileum (mobile parts)
BRANCH supply
inferior pancreaticoduodenal artery head of the pancreas and to the ascending and inferior parts of the duodenum (proximal loop)
intestinal arteries branches to ileum, branches to jejunum (proximal loop)
ileocolic artery supplies last part of ileum, cecum, and appendix (distal loop)
right colic artery to ascending colon (distal loop)
middle colic artery to the transverse colon (distal loop)

Anatomical relationship:
-anterior to SMA
pyloric part of the stomach,
Splenic vein
neck of the pancreas
-posterior to SMA
left renal vein, uncinate process of the pancreas and inferior part of the duodenum.

Lower mesenteric
All the rest of the large intestines

Paired
Renal arteries- left is shorter because the aorta is on the left,
Gonadal- take a long pathway to reach the gonads

organs immediately below diaphragm:

liver, stomach, spleen, pancreas
each one gets blood from the celiac artery

Atrial Vasculation by organ:

Pancreas- is supplied by the pancreatic branches of the splenic artery (greater, transverse, dorsal) to the superior part of tail The head is
additionally supplied by the superior and inferior pancreaticoduodenal arteries which are branches of the gastroduodenal (from coeliac trunk)
and superior mesenteric arteries, respectively.

Anastomosis:
1. Stomach
a. Lesser curvature between RIGHT GASTRIC ARTERY AND LEFT GASTRIC ARTERY
b. great curvature between Gastroomental artery (splenic derived) and right gastroepiploic (common hepatic derived)
2. Pancreas
a. Head- pancreaticoduodenal arteries superior- from superior mesenteric artery and inferior from gastroduodenal artery

Superior mesenteric:
Inferior Pancreaticoduodenal Artery
the first branch of the SMA. It forms anterior and posterior vessels, which anastomose with branches of the superior pancreaticoduodenal artery
Jejunal and Ileal Arteries
The superior mesenteric artery gives rise to numerous arteries that supply the jejunum and ileum.
The arteries pass between the layers of the mesentery and form anastomotic arcades – from which smaller, straight arteries
(known as the “vasa recta”) arise to supply the organs
The jejunal blood supply is characterized by a smaller number of arterial arcades, but longer vasa recta. In contrast, the ileal blood supply is
marked by more arterial arcades with shorter vasa recta.
Clinical Relevance: Characteristic Features of the Jejunum and Ileum
During surgery, it is often necessary to be able to distinguish between the jejunum and ileum of the small intestine:
Jejunum Ileum
Located in upper left quadrant Located in lower right quadrant
Thick intestinal wall Thin intestinal wall
Longer vasa recta (straight arteries) Shorter vasa recta
Less arcades (arterial loops) More arcades
Red in colour Pink in colour
Middle and Right Colic Arteries
The right and middle colic arteries arise from the right side of the superior mesenteric artery to
supply the colon:
• Middle colic artery – supplies the transverse colon.
• Right colic artery – supplies the ascending colon.
(can see that the anastomosis on the top part is much less there than in the mesentery
Vessels)
Ileocolic Artery
The ileocolic artery is the final major branch of the superior mesenteric artery. It passes inferiorly

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 The right and middle colic arteries arise from the right side of the superior mesenteric artery to
supply the colon:
• Middle colic artery – supplies the transverse colon.
• Right colic artery – supplies the ascending colon.
(can see that the anastomosis on the top part is much less there than in the mesentery
Vessels)
Ileocolic Artery
The ileocolic artery is the final major branch of the superior mesenteric artery. It passes inferiorly
and to the right, giving rise to branches to the ascending colon, appendix, cecum, and ileum. In
cases of appendectomy, the appendicular artery is ligated.
("amount of vessels is enormous a lot of tissue to vascularize lots of anastomosis
hard to have infarction on that side easier infarction on large bowel") (he talked about jeujenum
and iliac)

highlight
marginal artery
vessel that puts in
contact the 2
circulations

3. Kidneys:
The kidneys are supplied with blood via the renal arteries, which arise directly from the abdominal
aorta, immediately distal to the origin of the superior mesenteric artery. Due to the anatomical position
of the abdominal aorta (slightly to the left of the midline), the right renal artery is longer, and crosses
the vena cava posteriorly.
Each renal artery enters the kidney via the renal hilum, dividing into segmental branches. These
branches undergo further divisions to supply the renal parenchyma:
• Each segmental artery divides to form interlobar arteries. They are situated either side every renal
pyramid.
• These interlobar arteries undergo further division to form the arcuate arteries.
• At 90 degrees to the arcuate arteries, the interlobular arteries arise.
• The interlobular arteries pass through the cortex, dividing one last time to form afferent
arterioles.
• The afferent arterioles form a capillary network, the glomerulus, where filtration takes place. The
capillaries come together to form the efferent arterioles.
ADRENAL GLAND:
superior - comes from phrenic
Middle - directly from aorta
Inferior- from r and l kidney artery

4. Gonadal arteries: Paired visceral arteries that arise laterally at the level of L2. Note that the male
gonadal artery is referred to as the testicular artery and in females, the ovarian artery.
testicular and ovarian arteries organs are not in abdomen but they are in the pelvic, quite close to
abdominal artery due to embryo origin of them.

5. Inferior mesenteric artery: A large, unpaired visceral artery that arises anteriorly at the level of L3.
It supplies the large intestine from the splenic flexure to the upper part of the rectum.

Splitting to iliac arteries

Common iliac artery:
Abdominal aorta bifurcate at level of L4 Each common iliac artery ends at pelvic inlet in from of
sacroiliac joint by dividing into the internal and external arteries.

The internal iliac artery supplies the peritoneum, gluteal region and the walls and viscera of the pelvis.
(External- lower limb vasculation)

Anatomical Course
The intern iliac artery begins at the common iliac bifurcation, which is anterior to the sacroiliac joint, at
the level of the intervertebral disc between the L5 and S1 vertebrae. The artery is 4 cm long and
traverses infer posteriorly to the superior margin of the greater sciatic foramen. Here it bifurcates into
two main trunks, referred to as the:
• Anterior trunk, gives rise to numerous branches that supply the pelvic organs, the perineum, and
the gluteal and adductor regions of the lower limb

• Posterior trunk, which passes towards the greater sciatic foramen.

○ Iliolumbar
○ Lateral sacral
○ Superior gluteal

Muscles in the anterior

• obturator artery – It supplies the muscles of the thigh’s adductor region.
• Umbilical artery – Gives rise to the superior vesical artery
○ In utero, the umbilical artery transports deoxygenated blood from the fetus to the placenta. In
adult solid fibrous cord
• superior vesical artery- supplies the superior aspect of the urinary bladder, upper part of the uterus, in
males- ductus deference
• Inferior vesical artery – lower aspect of the bladder. In males supplies the prostate gland and seminal
vesicles, ureter.
• Vaginal artery (female) – Equivalent of IVA. Descends to the vagina, supplying additional branches to
the inferior bladder and rectum.
• Uterine artery (female) Travels within the cardinal ligament to reach the cervix, where it ascends along
the lateral aspect of the uterus. At origin of the fallopian tubes, it anastomoses with the ovarian artery.
During its course, it crosses the ureters superiorly.
• Middle rectal artery – Travels medially to supply the distal part of the rectum. It also forms
anastomoses with the superior rectal artery (derived from the inferior mesenteric) and the inferior
rectal artery (derived from the internal pudendal)
• Internal pudendal artery – Moves inferiorly to exit the pelvis via the greater sciatic foramen. it then
enters the perineum via the lesser sciatic foramen. It is the main artery responsible for the blood supply
to the perineum..
• Inferior gluteal artery – The terminal branch of the anterior trunk. It contributes to the blood supply of
the gluteal muscles and hip joint.

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 Venous drainage: (pelvis introduction, after abdomen)
"pelvic distribution is to create large and complex plexus more or less continuous plexus around the
organs until they collect into major vessels that reach the internal iliac vein
1 of the 2 branches that join to form the common iliac vein
easier to understand how it works on the venous side venous: big complex plexus on top of organs"
(from the book) - Extensive interconnected venous plexuses are associated with the surfaces of the
viscera (bladder, rectum, prostate, uterus, vagina) together form the pelvic plexus of veins
• In General the venous drainage parallel to the arterial supply except for the Umbilical artery and
Iliolumbar artery

Venous Drainage of the Abdomen

There are two venous systems that drain abdominal structures – the portal venous system and
the systemic venous system. The portal system transports venous blood to the liver for processing,
whilst the systemic venous system returns blood to the right atrium of the heart.
In this article, we shall consider the anatomy of these two venous systems – the major vessels involved,
their anatomical course, and their tributaries.
Systemic Venous System
The systemic venous system transports deoxygenated blood to the right atrium of the heart. The major
vessel in this system is the inferior vena cava.
Inferior Vena Cava
The inferior vena cava is the common convergence of venous drainage from all structures below the
diaphragm. It is located on the posterior abdominal wall; anteriorly to the vertebral column and to the
right of the abdominal aorta.
The vessel is formed by the union of the common iliac veins at the L5 vertebral level. Its ascends
superiorly, and leaves the abdomen by piercing the central tendon of the diaphragm at the T8 level (the
caval hiatus). Within the thorax, the inferior vena cava drains into the right atrium of the heart.
During its long course, the inferior vena cava shares an anatomical relationship with numerous
abdominal structures – including the right common iliac artery, the root of the mesentery, the head of
the pancreas, the bile duct, the portal vein and the liver.
Tributaries
The inferior vena cava is responsible for the venous drainage of all structures below the diaphragm. It
receives tributaries from:
• Common iliac veins – formed by the external and internal iliac veins. They drain the lower limbs and
gluteal region. Different rules of the liver(to put in mind):
• Lumbar veins – drain the posterior abdominal wall. • Hemostasis is intimately related to liver function, because most coagulation factors are
• Renal veins – drain the kidneys, left adrenal gland and left testis/ovary. synthesized by liver parenchymal cells and the liver's reticuloendothelial system serves an
• Right testicular/ovarian vein – drain the right testes or ovary respectively in men and women (the left important role in the clearance of activation products.
testicular/ovarian vein drains into the left renal vein). • Make lipoproteins- lipids become soluble
• Right suprarenal vein – drains the right adrenal gland (the left adrenal vein drains into the left renal • hepatic coma: too much ammonia arrive to the brain
vein).
• Inferior phrenic veins – drain the diaphragm.
• Hepatic veins – drain the liver.

Rectum:
1. the part of the plexus surrounding the rectum and anal canal drains via superior rectal veins →
into the hepatic portal vein
Vs
2. Middle and inferior rectal veins → caval system
When the superrior is blocked the plexus has longitudinal ways to the internal inferior plexus -
portocaval shunt

Caval vs portal systems

Portal Venous System
*spleen, pancreas, gallbladder and the abdominal part of the gastrointestinal tract doesn’t
drain into the caval venous system

Reasons :
1. The portal system carries venous blood (rich in nutrients that have been extracted from food) to
the liver for processing. The hepatocytes need to handle and exploit the absorbed nutrients in the
best way for the body (glycogen, albumin production, F.A distribution etc.)
2. Neutralize toxic substances from food we don’t want to get to all the body areas
a. e.g. ammonia from intestinal bacteria
3. Spleen- take care of destruction of rbc, doesn’t know how to exploit the Fe and HB which are
scarce
The major vessel of the portal system is the portal vein. It is the point of convergence for the venous
drainage of the spleen, pancreas, gallbladder and the abdominal part of the gastrointestinal tract. The
portal vein is formed by the union of the splenic vein and the superior mesenteric vein, posterior to the
neck of the pancreas, at the level of L2. As it ascends towards the liver, the portal vein passes posteriorly
to the superior part of the duodenum and the bile duct. Immediately before entering the liver, the
portal vein divides into right and left branches which then enter the parenchyma of the liver separately.
Tributaries
The portal vein is formed by the union of the splenic vein and superior mesenteric vein.
It receives additional tributaries from:
• Right and left gastric veins – drain the stomach.
• Cystic veins – drains the gallbladder.
• Para-umbilical veins – drain the skin of the umbilical region.

4 Anastomoses between the portal and caval systems

• Esophageal- between the left gastric veins, which are portal veins, and the lower branches of
esophageal veins that drain into the azygos and hemiazygos veins, which are systemic veins. The site of
this anastomosis is the lower esophagus.
Diagnostic: endoscopy and blood in feces, if there is a rupture it is dangerous patient can die after short
time
• Rectal- between the superior rectal veins, which are portal veins, and the inferior and middle rectal
• Short gastric veins – drain the fundus of the stomach.
veins, which are systemic veins. The site of this anastomosis is the upper part of the anal canal. • Left gastro-omental vein – drains the greater curvature of the stomach.
• Also caused in pregnancy • Pancreatic veins – drain the pancreas.
• Paraumbilical- between the paraumbilical veins, which run in the ligamentum teres as portal veins, • Inferior mesenteric vein – drains the colon.
and small epigastric veins, which are systemic veins (connect to the femoral). The site of this
anastomosis is the umbilicus. not harmful for patient but its diagnostic for you
- main reason is hepatic cirrhosis means increase resistance blood flow of portal venous system
2 main causes:
• alcohol abuse and hepatitis
• Hepatitis C - drug addicted
○ Can be caused also during pregnancy Portal hypertension in pregnancy
• Retroperitoneal - between the intraparenchymal branches of the right division of the portal vein
and retroperitoneal veins (systemic veins) that drain into the azygos, hemiazygos and lumbar veins
(systemic veins). The site of this anastomosis is the bare area of the liver.

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