Clinical Anatomy of GIT

and Urinary Tract

astari anggara

Embriology

• Foregut : Pharynx primordial (cavum oris, lingua, glandula salivarius), respiratory system, esofagus sampai papilla duodeni mayor, hepar, pankreas

• Midgut: Duodenum sisanya sampai 2/3 proksimal colon transversum

• Hindgut: sisanya ditambah epitel vesica urinaria dan uretra

Cont’ed• Cavitas peritonii: Coeloem intraembryonic

• Peritoneum parietal: mesoderm somatic

• Peritoneum visceral: mesoderm splachnic

• Mesenterium: double layer peritoneum

• Mesogastrium dorsal omentum majus, lig. Gastrolienalis, lig. Gastrophrenica, lig. Gastrocolica

• Mesogastrium ventral lig. Falciformis, lig hepatoduodenal, lig hepatogastrica

Esophagus• VC6-VT11• Pars cervical, thoracal, abdominal• Inner circular, outer longitudinal• Penyempitan (angustia) superior, media, inferior

Klinis• Fistula tracheoesophageal

• GERD, kelemahan sphincter lower. Yg mana sphincter lower?

• Achalasia• Varises esofageal

(portocaval shunt)

Gaster• Fundus, cardia, corpus, pars

pylorus, pylorus• Incissura cardiaca & incissura

angularis• Tunica mucosa: rugae gastrica,

canalis gastricus• Tunica muscularis: outer

longitudinal, middle circular, inner oblique

• Tunica serosa: peritoneum visceral

Vaskularisasi • a. gastrica dexter & sinister anastomosis di

curvatura minor• a. gastroepiploica dex & sin anastom di

curvatura mayor• a. gastrica brevis & posterior suplai fundus• v. gastrica dex et sin v. Porta hepatica• v. gastroepiploica sin & brevis v. Lienalis• v. gastroepiploica dex v. Mesenterica sup

InervasiParasimpatis: trunkus vagus ant & postSimpatis: T6-T9 n. splachnicus mayor

Con’t ed

Klinisnyaa..• Hiatal hernia • Hernia diafragma congenital (bochdalek)• Hypertrophic pyloric stenosis• Ca gaster, sering di pylorus• Gastroscope (nasally/orally)• Gastrectomy (total dan parsial)• Gastritis dan gastric ulcer• Vagotomy

truncal: jarang!selective: Cuma dipilih yg menuju ke segmen

gaster tertentu

Sliding hernia

Paraesophageal hernia

Ini dia hernia bochdalek

• Ada kelemahan diafragma posterolateral sinistra, jadi ususnya protrusi ke thorax

• Disertai agenesis pulmo sinistra

Duodenum• Pars superior (ada ampullanya lho), pars descenden, pars horizontal, pars

ascenden• Yang mana yg intraperitoneal dan retro?• Lig. hepatoduodenal • Flexura duodeni superior (L1) et inferior (L3)• Flexura duodenojejunales (L2) ligamentum suspensorium

duodenojejunales (Treitz)• Papilla duodeni mayor dan acessorius• Plica circularis

VaskularisasiA. GastroduodenalA. Pancreaticoduodenal sup infVenanya ke v. Porta hepatisInervasi n. Vagus dan n. Splachnicus mayor et minor

Lanjoot..

Klinisnya apaan dong?• Duodenal ulcer: bisa erosi ke a. gastroduodenal• Peptic ulcer: karna asam lambung berlebih• Hernia paraduodenal: di sekitar flexura duodenojejunales

melalui fossa duodeni sup et inf, fossa paraduodenal, plica paraduodenal

Jejunum & ileum• Bedanya apa hayo?• Junctio duodenojuejunales-

junctio ileocaecal• Radix mesenterii (L2 sinistra-art.

Sacroiliaca dex)• Isi mesenterium: vasa

mesenterica sup, limfonodi (juxta-mesenterica, mesenterica, centralis superior), nervus

• Vaskularisasi: a. Jejunales dan a. Ileales (masih inget cabang dari apa?)

Cont’edNah klinisnya..

• Diverticulum ilei (Meckel): gagalnya penutupan duct omphalomecentericus

– 74% free 26% nempel ke umbilicus

– Mucosa: ileal type, gastric type, pancreatic, jejunale, atw colonic

• Iskemia small intestine: occlusi vasa recta oleh emboli nekrosis ileus

• Ileus: nyeri colic, distensi, vomiting, fever dan dehidrasi

• Ileostomy: stoma dari ileum ke kulit dinding anterolateral

• Megacolon (Hirschprung)

Large Intestine• Caecum, appendix, colon

ascenden, transversum, descenden, sigmoid, rectum, dan canalis analis

• Haustra & incissura semilunaris• Appendices epiploica• Taenia coli (libera, mesocolica,

omentalis)• Plica semilunaris• Mesocolon transversum• Mesocolon sigmoid• Flexura hepatica & lienalis• Junctio rectosigmoid• Posisi appendix? Retrocaecal,

preileal, retroileal, pelvica, dll

Klinisnyaa• Appendicitis, McBurney di

garis Monroe• Colectomy (removal)• Colitis • Colostomy, pembuatan stoma

di pars terminal colon• IBD• Diverticulosis, diverticulitis• Volvulus, hanya untuk yg intra

Rectum & Anus• Retroperitoneal dan

subperitoneal• Canalis analis• Linea pectinata (dentata), batas

embriologis• Junctio anocutan• M. Levator ani• M. Sphincter ani internus

(involunter)• M. Sphincter ani externus

(volunter)

Klinisss• Atresia ani• Stenosis ani• Hemorrhoid

– Internal: plexus venosus rectalis internal

– Eksterna: plexus venosus rectalis externa, sakit

Batesnya si linea dentata

Hepar• Intraperitoneal• Fascies diaphragmatica &

visceralis• Recessus subphrenicus &

hepatorenal• Area nuda, sulcus vena cava

inferior• Fossa vesica fellea, porta

hepatis (apa aja? )• Impressio• Lobus anatomis, fisiologis• Segmen?

Blood flowTruncus coeliacus - a. Hepatica communis – a. Hepatica propria – porta hepatis - ramus dex et sin v. Mes sup + v. Lienalis = v. Porta hepaticav. Mes inf ke v. lienalisVena2 abdomen – v. Porta hepatica – sinusoid – v. Centralis – v. Hepatica – VCI

Portocaval shuntLetak Porta Cava

Esofagus v. gastrica sinistra v. esofageales

Paraumbilical v. paraumbilicalis v. Epigastrica superficialis

Anus v. Rectalis sup v. Rectalis med&inf

Retroperitoneal v. Colica sinistra v. Lumbalis ascenden

Klinisnya..• sirosis hepatis• hepatomegaly• hepatitis

Organ aksesoris lainnya• Lien: splenomegaly (inget

schuffnernya), splenectomy• Vesica fellea: cholecystitis,

cholelithiasis (termasuk choledocolithiasis, cholecystolithiasis) bikin nyeri colic biliarry

Referred Painnya kemana?Gaster : T6-T9 ke epigastricCholelithiasis, hepar, ductus cysticus: T6, bisa sampe scapula dorsal dexter

Summary Inervasi dan VaskularisasForegut• badan sel preganglionik di nucleus intermediolateralis (IML) T6-9• serabut preganglionik : T6-9 (N. Splachnici mayor)• badan sel postganglionik : Ganglion coeliacum

Midgut• bdn sel preganglionik : IML T10-12• serabut preganglionik : T10-12 (n. Splachnici minor)• Bdn sel postganglionik : Ganglion mesentericus superior

Hindgut• IML L1-3• L1-3 (N. Splachinici lumbales)• G. Mesentericus sup

URINARY & ABDOMINAL WALLLanjut dikit lagii, smangat!

Abdominal Wall

• 9 Regio• M. Obliqus externus (V)• M. Obliqus internus (A)• M. Transversus

Subcostal (costa 10)

2 versi garis transversa:• transpyloric & interspinosa• subcostal & transtubercular

Clinical oriented?• Incisi abdomen• Peritonitis • Adhesi peritoneum: perlekatan

viscera, bsa jadi volvulus• Adhesiotomy• Ascites: excavatio douglas (cewe),

excavatio rectovesica, recessus hepatorenal (supine)

• Abdominal paracentesis : untuk ambil cairan, adm antibiotik. Melalui dinding abdomen anterolateral (linea alba)

• Intraperitoneal dialysis: seperti menyaring cairan (darah). Peritoneum sebagai membran semipermeabel. Digunakan temporer

• Injeksi intraperitoneal

Hernia AbdominalesLocus minoris resistante• Fossa inguinalis media (trigonum

Hasselbach)• Fossa inguinalis lateral• Trigonum lumbales• Annulus femoralis• Annulus umbilicalesMaka jenis hernianya..• Hernia direct• Hernia indirect• Hernia lumbales• Hernia femorales• Hernia umbilicalis• Hernia epigastrica

Urinary SystemEmbriologi• Pronephros• Mesonephros: glomeruli dan tubulus mesonephros, ductus

mesonephricus• Metanephros: primordia ren permanenRen permanen berkembang dari 2 sumber:• Diverticulum metanephric (ureteric bud): ureter, pelvis renalis, sistema

collectivus• Metanephrogenic blastema: parenkim (nephron)Ren migrasi week 9

Kelainan congenital• Bifid renal pelvis and ureter:

complete – incomplete• Horseshoe kidney : tertahan di

bawah a. Mesenterica inf (L3-L5)

• Ectopic pelvic kidney: ren di pelvis

• Retrocaval ureter• Polycystic kidney: autosomal

dominan

Anatomy normalnya?• T12-L3• Retroperitoneal• Lemak pararenal, fascia

renalis (Gerotta), lemak perirenal, capsula renalis (capsula fibrosa)

• Fiksasi ren : fascia2 dan lemaknya, tekanan intraabdm, vasa renalis dan ureter

• Collecting system : Papilla renalis, calix minor, calix mayor, pelvis renalis, ureter

Cont’ed

• Ureter (pars abdominalis & pars pelvica)• Vesica urinari: ingat detrusor + reflex miksi?

Langsung klinisnya aja ya..• Nephroptosis: turun lebih dari 3cm• Glomerulonephritis, Pyelonephritis• Hydronephrosis + Hydroureter,

obstrusi• Ureterolithiasis, predileksi ada 3• Vesicolithiasis

• Suprapubic cystostomy• Cystoscopy (transurethra)• Incontinensia– True: fistula, extrofi bladder– Stress: kelemahan

diafragma pelvis– Urge: hiperrefleks m.

Detrusor, spastic UMN, flaccid LMN

– Overflow: udh penuh ga bisa kontraksi, atw ga bisa keluar mis. BPH

• ESWL• Cystoscopy• Bladder extrofi

ALHAMDULILLAH