clinical anatomy of git and urinary tractnary tract
DESCRIPTION
pembahasan klinis anatomi traktus gastro intestinal dan traktus urinariusTRANSCRIPT
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Clinical Anatomy of GIT
and Urinary Tract
astari anggara
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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
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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
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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)
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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
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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
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Ini dia hernia bochdalek
• Ada kelemahan diafragma posterolateral sinistra, jadi ususnya protrusi ke thorax
• Disertai agenesis pulmo sinistra
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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
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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
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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?)
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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)
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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
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Klinisnyaa• Appendicitis, McBurney di
garis Monroe• Colectomy (removal)• Colitis • Colostomy, pembuatan stoma
di pars terminal colon• IBD• Diverticulosis, diverticulitis• Volvulus, hanya untuk yg intra
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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)
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Klinisss• Atresia ani• Stenosis ani• Hemorrhoid
– Internal: plexus venosus rectalis internal
– Eksterna: plexus venosus rectalis externa, sakit
Batesnya si linea dentata
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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
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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
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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
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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
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URINARY & ABDOMINAL WALLLanjut dikit lagii, smangat!
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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
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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
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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
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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
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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
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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
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Cont’ed
• Ureter (pars abdominalis & pars pelvica)• Vesica urinari: ingat detrusor + reflex miksi?
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Langsung klinisnya aja ya..• Nephroptosis: turun lebih dari 3cm• Glomerulonephritis, Pyelonephritis• Hydronephrosis + Hydroureter,
obstrusi• Ureterolithiasis, predileksi ada 3• Vesicolithiasis
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• 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
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• ESWL• Cystoscopy• Bladder extrofi
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ALHAMDULILLAH