Digestive

System

Digestive tract (GIT)

Dr MUSHTAQ CH ABU AL HAIL

MBCHB CABS DGS FRCS F MAS D MAS

1/10/2023 2
 INTRODUCTION
The digestive system provide body by water
,electrolyte,vitamins,and nutrient.
This required ;
1-movement of food to alimentary tract
2-secretion of digestive juices.
3-absorption of digestive products
4-blood circulation to carry absorbed substances
5-nervous and hormonal control of all these
function
1/10/2023 3

Digestion
The digestive system include 5 steps,that are in
order;
1-Ingestion ;process of taking food to body.
2-Digestion ;process of converted unsoluable
large molecules to small water soluble molecule.
3-Absorption; digested food goes to blood
stream
4-Assimilation ;absorbed food take up by body
cell for growth and energy .
1/10/2023 4
5- Egestion undigested food is discharged as
 Digestion
• Phases Include
1. Ingestion
2. Movement
3. Mechanical and Chemical Digestion
4. Absorption
5. Elimination

Digestion
• Types
– Mechanical (physical)
• Chew
• Tear
• Grind
• Mash
• Mix
– Chemical
• Enzymatic reactions to improve digestion of
– Carbohydrates
– Proteins
– Lipids
 Digestive System Organization
• Gastrointestinal (Gl) tract
– Tube within a tube
– Direct link/path between organs
– Structures
• Mouth
• Pharynx
• Esophagus
• Stomach
• Small intestine
• Large Intestine
• Rectum

Mouth
• Teeth mechanically • Epiglottis is a flap-like
break down food into structure at the back of
small pieces. Tongue the throat that closes
mixes food with saliva over the trachea
(contains amylase, preventing food from
which helps break down entering it. It is located
starch). in the Pharynx.
 Esophagus
• Approximately 20 cm long.
• Functions include:
1. Secrete mucus
2. Moves food from the throat to
the stomach using muscle
movement called peristalsis
• If acid from the stomach gets in
here that’s heartburn.

Stomach
• J-shaped muscular bag that stores the food you
eat, breaks it down into tiny pieces.
• Mixes food with Digestive Juices that contain
enzymes to break down Proteins and Lipids.
• Acid (HCl) in the stomach Kills Bacteria.
• Food found in the stomach is called Chyme.

10
 Somach
The stomach located in the upper part of
abdomen and receive food from esophagus
The most inernal layer called mucosa
There are four type of cells ;
1-mucous cells
2-parietal cell
3-chief cell
4-endocrine cell
Gastric juice produce by exocrine secretion
1/10/2023 11

while gastrin hormone by endocrine cell

Small Intestine
• Small intestines are roughly 7 meters long
• Lining of intestine walls has finger-like
projections called villi, to increase surface
area.
• The villi are covered in microvilli which
further increases surface area for
absorption.

Crash Course Review

12
 Small Intestine
• Nutrients from the food pass into the
bloodstream through the small
intestine walls.

• Absorbs:
– 80% ingested water
– Vitamins
– Minerals
– Carbohydrates
– Proteins
– Lipids

• Secretes digestive enzymes

13

Large Intestine
• About 1.5 meters long
• Accepts what small intestines don’t
absorb
• Rectum (short term storage which
holds feces before it is expelled).
 Large Intestine
• Functions
– Bacterial digestion
• Ferment carbohydrates

– Absorbs more water

– Concentrate wastes

Accessory Organs The Glands

• Not part of the path
of food, but play a
critical role.
• Include: Liver, gall
bladder, and
pancreas
 Liver
• Directly affects digestion by producing
bile
– Bile helps digest fat
• filters out toxins and waste including
drugs and alcohol and poisons.

17

Gall Bladder
• Stores bile from the
liver, releases it into the
small intestine.
• Fatty diets can cause
gallstones
 Pancreas
• Produces digestive
enzymes to digest fats,
carbohydrates and
proteins
• Regulates blood sugar
by producing insulin

Nutrient Digested
• Carboyhdrates;
• Function ;provide energy to body
• Sources ;rice,mango ,potato
• Digestion;in mouth by amylase from
salivary gland and pancreatic amylase
• Protein ;
• Function ; growth and repair
• Sources ;milk ,egg,fish,and meat
•
1/10/2023 Digestion ;stomach pepsin and HCL 20
 Nutrient digestion
• HCL acreate acidic environment for action of
pepsin
• Trypsin release to small intestine from
pancreas
• Fat
• Function ; provide energy
• Source oil cream ,cheese
• Digestion ; in small intestine from bile secrete
fro liver and lipase of panreas
1/10/2023 21

On a sheet of paper, write the name of

each colored organ:
• Green:
• Red:
• Pink:
• Brown:
• Purple:
• Green:
• Yellow:
 How’d you do?
• Green: Esophagus
• Red: Stomach
• Pink: Small Intestine
• Brown: Large Intestine
• Purple: Liver
• Green: Gall Bladder
• Yellow: Pancreas

Great Job!
Salivary gland
D R M U S HTAQ C H A B U A L HA I L
MBCB DGS CABS FRCS F MAS D MAS

SALIVARY GLAND
 TYPES OF SALIVARY GLANG
Major salivary gland;
1- Parotid gland
2- Submandibular gland
3-Sublingual gland

Minor salivary gland

There are many gland around mouth

SALIVA
-Seromucinous liquid has several function ;
1- lubrication
2-protection
3-digestion
Contains ;
-99.5 %water and rest electrolyte ,mucus , enzyme and glycoproteine
Types;
1- purely serous by parotid gland
2-mainly mucous sublingual and minor gland
3-mix submandibular
Amount
1-1.5 liters of saliva per day
 Parotid gland
-largest gland located near to ear
-produce 25% of total daily secretion
-release into stensens duct near to upper molar teath
-has to lobe releated to facial nerve
-purely serous secretion play role in digestion
Disorder
-mump
-infection
-tumour

Submandibular gland
-
-second largest salivary gland
-secrete 70% from total saliva
-whartons duct open at sublingual papilla-
-mix secretion
- Main disease salivary stone
 SUBLINGUAL GLAND
-Smallest gland
-has several duct
-secrete 5% of saliva
-type of secretion mucous-
-main disorder ranula

Salivary gland disorder

1-salivary gland infection (sialadenitis )
-viral mump
-bacterial
2-Sailolithiasis
Comman insubmandibular
3- cancer
Common in parotid gland
-pleomorphic adenoma and warthin s tumour
4- autoimmune disorder Sjogren syndrome
 Symptoms of salivay disorder
-salivary stone

.painful lump under the tongue

.pain increase with eating

Sailoadenitis

. Lump

.pus drain to mouth

.foul-smelling

.fever

--mump

Fever ,joint pain ,swelling on both side of face ,headache

--sjogren syndrome

Dry mouth ,dry eye sore mouth ,dry cough ,fatigue

DIAGNOSIS
-X RAY
-CT SCAN
--MRI
TRETMENT
-WELL HYDRATION
-AVOID DRUGS CAUSE DRY MOUTH
-ANTIBOITIC
-SURGICAL INTRFERENCE
ANASTHETIC SIGNIFCANT OF SALIVARY
GLANG
1- massive enlargement of salivary gland with induction of GA , due to succinylcholine cause
vasodilatation and hyperemia of gland lead to overactive of pharyngeal reflux .

2-Anesthesia mump ; swelling of parotid gland after GA MAY due to ;

A- obstruction of glandular excretory duct by patient position
B-increase viscosity of saliva due to dehydration .
C-Medications like atropine
D-Chemical agent used for strerilizing ofnon disposable air way equipment

Salivary MCQ
1-The majority of saliva produce by ;
A-parotid gland
B-submandibular
C- sublingual
D-minor salivary gland

2-the gland that is most serous in overall saliva composition is

A-lingual
B-minor
C-submandibular
D-parotid
M CQ
3-The most common site of occurrence of salivery gland tumour
A-parotid
B-sublingual
Csub mandibular
D minor gland
4-the parotid glands open through the ;
A-stensen s duct
B-whartons duct
C-Bartholin duct
D-common bile duct

M CQ
5- Sialolithiasis is common in
A –sub lingual
B- parotid
C-submandibular
D- minor
6- daily averge volume of saliva secretion is
A-3-6 liter
B-3-5 liter
C-8-10 liter
D-1-1.5 liter
MCQ
7- IN patients with diabetes melliutes the parotid gland ;
A-shrunken
B-cystic in nature
C-fibrosed
D-enlarged
8- the parotid secretions constitute about
A-1/5th of salivary secretion
B-90% of secretion
C-100% of secretion
D-70% of secretion

M CQ
9- parotid gland
A- mucinous gland
B-serous gland
C-mix gland
D- all above
10- salivary enzyme digested
A-protein
B-carbohydrates
C lipid
D- vitamin
TONGUE AND ORAL
CAVITY
DR MUSHTAQ CH ABU AL HAIL
MBCHB DGS CABS FRCS FMAS D MAS
CONSULTANT SURGEON

INTRODUCTION

-Mass of striated muscle cover with mucous membrane.

-Movement ; voluntary muscular structure .
-Length ; 3 inches
-Location ;floor of the mouth .
-Shape ;triangular .
-Attachement ;base of tongue to hyoid bone
-parts ;apex ,body and root
Parts of the Tongue

. Root ;
-Located between hyoid bone and mandible
-Attaches tongue to roof of mouth
.Body ;
-makes up anterior two-thirds of tongue .
-rough surface du to lingual papilla .
-surrounded anterior and lateral by teeth
-Mobile portion of tongue
Apex ;
-Also known as the tip , is anterior one-thirds of tongue
-Rest against incisor teeth
-Highly mobile

Tongue surfaces

-Two surfaces ;
.superior surface
.inferior surface
Suprerior surfaces divided to 3 parts
1-anterior oral part
2-posterior pharangreal part
3-base of tongue
TERMINAL SULCUS
V-shaped sulcus divided tongue into anterior and posterior
-apex of sulcus marked by apit -foramen cecum
TONGUE surface

Different type of papilla present on surfaces of tongue

1-Fungiform papilla located on dorsal surface and sides nerve supply facial
neve
2-foliate papilla - on lateral border nerve supply glossopharyngeal
3-circumvalliate at back near to sulcus terminalis
4-filiform papilla ;not have taste [Link] in mechanical aspect of digestion

Tongue blood and nerve supply

A-Blood supply ;
-Lingual artery branch of external carotid artery

B-Nerve supply
1- Motor
- Vagus nerve to palatoglossal muscle
All other muscle by hypoglossal neve

2-SENSORY
Anterior 2 third facial nerve
Posterior one third glossopharangeal nerve
FUNCTION OF TONGUE

. Taste
.Speech
.Mastication
.Deglutition
.Secretion
.Defence mechanism
.Sucking
.Maintenance of oral hygeine

Taste buds

The taste receptors located in papilla of tongue ,soft palate ,upper

esophagus cheek and epiglottis
5 type of taste perception ;
1- salt ; NACL receptor located in front of tongue
2-sweet ; sugar receptor in front of tongue
3-Bitter ; receptor on back of tongue
4-Sour ;HCL receptor on along the side of tongue
5-umami ;receptor every site of tongue
TONGUE MAP

Signs of tongue problems

1-pain ; Glossodynia
2- swelling big tongue ; macroglossia
3-inability to taste
4-diffuclty speaking
Causes of tongue disease

1-infection , bacterial or fungal

2-black hairy tongue
3-0ral thrush; small white bumps and patches on surface
4-burning mouth syndrome
5-Glossitis inflamed tongue
6-oral cancer
7- congenital disease like Ankyloglossia ( tongue-tie )

ORAL CAVITY
PARTS OF ORAL CAVITY

 1-Salivary gland .
 2-Tongue .
 3- mouth
 -teeth
 -lips
 -gums
 -oral vestibule
 -mouth proper
 -soft and hard palate

Mouth proper
Floor of mouth

Teeth ;permenant 32 teeth ,deciduous 20

start develobe at 6 month , 4 type of teeth
CLINICAL COSIDERATION OF ORAL
CAVITY IN GENERAL ANASTHESIA
 Anasthetic must assess ;
 1-look in your mouth.
 2-ask you to move neck
 3-ask about your teeth ,crowns ,implants ,loose teeth and false teeth
 Following factors lead to damage ;
 -reduce mouth movement and neck movement
 -prominent upper teeth and small lower jaw .
 -certain medical condition like rheumatoid arthritis .
 People at risk of damage teeth,lips and tongue;
 1- obese patient 2- emergency anesthesia 3-macroglossia 4-false and loose
teeth

MCQ

1- Base of tongue is attached to the ;

A-hyoid bone
B-mandible bone
C-hyoid and mandible bone
D- none of the above
2-In which of the following papillae of tongue taste buds not present ;
A-circumvallate
B-filiform
C-foliate
D-fungiform
MCQ

 3-WHICH of the following taste receptors are present largely in the front portion
of tongue ;
 A-sweet
 B-salt
 C-bitter
 D- a and b
 4-which of the following taste buds present at back of tongue ;
 A- salt
 B-sour
 C-bitter
 D-sweet

MCQ

 5- Which of the following taste buds located alonge side of tongue

 A-sour
 B-sweet
 C-salt
 D-umami
 6-what is Ankylogossia also known as ;
 A-split tongue
 B-tongue tie
 C-a black tongue
 D-white tongue
MCQ

 7-Glossadynia mean ;
 A-swelling tongue
 B-white patch on the tongue
 C-burning on the tongue
 D-pain in the tongue
 8- How many type of teeth
 A-four type
 B-six type
 C-nine type
 D- sixteen type

MCQ

 9- WHICH TEETH NOT PRESENT IN CHILD

 A-molar
 B-Incisor
 C-canine
 D- premolar
 10-Teeth begin to appear at the age of ;
 A-tow month
 B-two years
 C-six month
 D- six years
 DR MUSHTAQ CH ABU ALHAIL

ESOPHAGUS CONSULTANT SURGEON

MBCHB DGS CABS FRCS F MAS
D MAS

INTRODUCTION
-The esophagus serve as conduit between pharynx and stomach .
-it begins at cricopharyngeus (C5 –C6 )
-Pass through the diaphragm to join the cardia of stomach (D10)
-Length 25 cm correleated with person height and it longer in male than femal
-Width 2cm
Function ; 1-passage of ingested food.(food pipe)
2-secreti mucous for lubricate bolus.
3-conduit for endoscopic evaluation
4-Evaluation of heart and aorta (TEE)
LOCATION AND DESCRIPTION
Anteriorly ;
-the trachea.
-the recurrent laryngeal nerves ascend on each side ,in the groove between trachea
and esophagus .
Posteriorly ;
-the prevertebral layer of deep cervical fascia
-thoracic duct .and vertebral column
-Laterally
-on each side thyroid gland and carotid sheath

PARTS OF THE ESOPHAGUS

A- Cervical part ( 4cm ) .
-extend from lower border of cricoid cartilage to superior border of manubrium sterni
-blood supply inferior thyroid artery
B-THORACIC PART (20 CM )
-extended from superior border of manubrium sterni to diaphragm
-blood supply thoracic aorta .
C-ABDOMINAL PART (1-2CM 0.
-extended from diaphragm to cardia of stomach
-blood supply from left gastric artery and phrenic artery
PART OF ESOPHAGUS

CONSTRICTION OF ESOPHAGUS
FIRST CONTRICTION ; crico pharangeus junction 9cm from incisors teeth at c6
narrowest cervical part
SECOND ; AORTIC arch 22.5 cm from incisors at T4
THIRD ;LEFT BRANCHIUM at T5-T6 27.5 cm from incisors
FOUR ; PIERSE the diaphragm at T10 40 CM FROM incisors
CONSTRUCTION

CLINICAL IMPORTANT OF CONSTRUCTIONS

1- Site of foreign body obstruction .

2-site of stricture after ingestion of caustic substances

3-site for prediction of carcinoma of esophagus

4-site of difficult pass of nasogastric tube and endoscopy .

ESOPHAGEAL SPHINCTERS
1-upper esophageal sphincter ;
-anatomical ,striated muscle at junction between pharynx and esophagus
-prevent air entrance into esophagus

2-LOWER ESOPHGEAL SPHINCTER ;

-FUNCTIONL , smooth muscle
--prevent reflux of gastric juice to esophagus

DISORDER OF ESOPHGUS
1-GERD
-reflux of gastric content through esophagus
-may cause laryngitis ,cough ,heartburn
Etiology ;
Inperfect function of LES LOW TONE
-Tobacco ,alcohol ,obesity
-fatty food ,chocolates
-hiatal hernia
-drugs
GERD
SYMPTOMS ;-
-HEATRBURN
-Regurgitation
-Dysphagia
-chest pain
Signs
-laryngitis

Congested arytenoid
Nasal congestion

GERD
DIAGNOSIS ;
1- ENDOSCOPY
2-CLINICAL
3-BARIUM SWALLOW
4- CHEST X RAY

TREATMENT
-Life style modification
-Antacids
-proton-pump inhibitors-rabeprazole
-H2-RECEPTOR antagonist –ranitidine
-prokinetic drug
-surgery
BARRETTS ESOPHAGUS
-Metaplasia of lower esophageal epithelium from sequmous to columnal.
-pre cancerous lead to adeno carcinoma
-seen GERD due to sever inflammation
-smoker
Diagnosis ;
Barium swallow and endoscopy
Treatment
Anti reflux and regular endoscopy

ACHALASIA
-Spasm of LES LEADING TO OBSTRUCTION
-Etiology
.hereditary
.infection Chagas disease
.Auto immune
C-F
-Dysphagia ,weight loss ,chest pain and regurgitation.
DX ; barium swallowing and endoscopy
Treatment
-pneumatic dilatation
-botulinum toxin injection
-calcium channel blockers
-surgery
BENIGN TUMOUR
-RARE

-SEEN IN YOUNGER AGE GROUP

-LIOMYOMA ,LIPOMA ,FIBROMA HAEMANGIOMA

-MUCOSAL POLYPD

CARCINOMA
-COMMON

-SEQUMOUS CELL CARCINOMA IN UPPER AND MIDDLE ONE THIRD

-AGE 50-70 YEARS

-SMOKER ,MALE ,ALCOHLIC ,HOT AND SPICY FOOD

-ADENOCARCINOMA LOWER ONE THIRD
FOREIGN BODY OF ESOPHAGUS
-swallowing of coin ,food bolus and dentures
-type of patient ;children ,psychiatric and edentuos
-symptoms
.FB SENSATION
DYSPHAGIA
SITE OF OBSTRUCTION
-UPPER ESOPHAGUS
-CROSSOVER AORTA
-LES

ESOPHAGEAL VARICES
-Occur at lower esophagus

-cause sever upper GIT bleeding

-due liver cirrhosis

-treated by endoscopic cautery or banding

ANASTHETIC SIGNIFICANT OF ESOPHAGUS
-Patient present for esophageal surgery frequently have co morbidity so attention
should be paid to symptoms and signs of GERD and obstruction
-post operative pain control

-pgthology of esophageal disease increase risk of aspiration

-Excessive perioperative I V FLUD especially crystalloid lead to increase complication
-esophageal perforation may induce by NG .

MCQ
1-THE esophagus is also known as ;
A-wind pipe
B-stomach
C-voice box
D-food pipe

2-the esophagus is -------to the trachea

A-anterior
B-posterior
C-lateral
D- medial
 MCQ
3-MOST common site for FB impaction ;
A stomach
B-esophagus
C-intestine
D-rectum

4-Length of esophagus is
A-20 cm
B-30 cm
C-40 cm
D-25 cm

MCQ
5-GERD due to following abnormalities ;
A-compression of the esophagus from aortic arch
B-cricopharyngeal incoordination
C-denervation of esophageal muscle
D-lower esophageal sphincter incompetence

6- Barrets esophagus is commonly associated with ;

A-adenocarcinoma
B-sequmous cell carcinoma
C-fibroma
D-leiomyoma
MCQ
7-WHICH of these cause heartburn
A-obesity
B-lying down soon after eating a large meal;
C-Eating high fat food
D-all of above
8- the cervical esophagus
A-commences at level of thyroid cartilage
B-lies anterior to thyroid gland
D-lies anterior to trachea
D-has striated muscle in its wall

MCQ
9-The narrowest site of esophagus ;
A;at cross aortic arch
B-at cross bronchial steam
C-at enter diaphragm
D at crico pharangeal junction

10-esophageal varicese cause by

A- chagase disease
B-GERD
C-Acalassia
D liver cirrosis
 LIVER

DR MUSHTAQ CH ABUALHAIL
MBCHB DGS CABS FRCS F MAS D
MAS
CONSULTANT SURGEON

INTRODUCTION
OBJECTIVE OF LECTURE
. Explain the location of liver and simple information
.Explain the anatomical features of liver
.explain function of liver
.describe liver disease .
.relation of liver with anasthesia
 INTRODUCTION
-Liver is largest organ of body after skin .
-weight 1.5 Kg .
-located in upper quadrant of abdominal cavity under cover of 7-11 ribs on right side.
-Except fat it obsorbed all nutrient from GIT BY PORTAL system
-liver has dual blood supply portal vein 75% and hepatic artery 25%

FACTORS AFFECTING HEPATI BLOOD FLOW

-INCREASE HEPATIC BLOOD FLOW BY ;
.Hypercarpia
;acute hepatits
.supine posture
.food intake
.drugs ,phenobaritone
-Decrease hepatic blood flow
-hypoxia
-cirrhosis
-hypocarbia
-drugs halothane ,anasthesia
ANATOMICAL FEATURE OF LIVER
SURFACES;
-Diaphragmatic surfaces ;dome shaped ,smooth in outline separates liver from pleura ,pericardium and lungs
-Visceral surfaces is related to
.RT side to gastric and pyloric areas
.lesser omentum and gall bladder and RT colon
LOBES OF LIVER
.MAJOR lobes RT and LT
.Accessory lobes caudate and Quadrate lobe
LIGAMENT OF LIVER
-Falciform ligament ,coronary ligament ,round ligament
-hepatogastric and duodenogastric ligament

FUNCTION OF LIVER

-Metabolic

-storage
-Excretory

-protective
-circulatory
-coagulation
METABOLIC FUNCTION
Carbohydrate metabolism
-Gluconeogenesis (synthesis of glucose from AA )
-Glycogenolysis (breakdown glycogen to glucose )
-synthesis of fatty acids ,lipoproteins and cholesterol
-synthesis of plasma protein (albumin ,globulin,fibrinogen )
-Urea synthesis

STORAGE FUNCTION

-Glycogen.
-Vitamins A,D ,E K (fat soluable )

-iron
-copper
EXCRETORY FUNCTION

-Bile
.water
.cholesterol
.bile pigments
.bile acid
.phospholipid
.bicarbonate and other ions
;fatty acid

PROTECTIVE FUNCTION
-
-purification
-transformation
-clearance
Kupffer cell ingeste bacteria and other foreign material from blood
CIRCULATORY AND COAGULATION FUNCTION

-the liver receives blood throught two vascular system portal and hepatic .
-production and secretion of coagulation factors
-.fibrinogen 1
-.prothrombin 2
-.factors 2.7 ,9 , 10 ,11
-.protein c
-.protein s
-antithrombin

LIVER DISEASE
ACUTE LIVER DISEASE
-Viral hepatits
-Drugs
-idiopathic
-Autoimmune
Chronic liver diease
-alcohol liver disease
-viral hepatitis
-Autoimmune
Cholectatic
SYMPTOMS OF LIVER DISEASE
1- RT upper abdominal pain
2- jaundice
3-change color of stool and urine
4-fatigue
5-nausea and vomiting
6-confusion
7-weight loss

EXTRA –HEPATIC MANIFFESTATIONS OF LIVER

DISEAE
. GIT
.CVS
.RESPIRATORY
.RENAL.
. METABOLIC
.CNS
GIT EFFECT
-PORTAL hypertention
.pressure more than 10 mmHg
-splenomegaly
-Ascitis
-GIT bleeding due to esophageal varices
-delay gastric emptying

CARDIOVASCULA CVS

-ARTERAL hypertention
RESPIRATORY ;
.Pleural effusion
.reduce FRC due to ascites
.hepatopulmonary syndrum

COAGULATION

Bleeding risk ; -decrease synthesis of coagulation factors and fibrinogen and Vit k
-Hypercoarulation ;decreases synthesis of protein c and s, decrease plasminogen
RENAL EFFECT
-hepatorenal syndrum
.hypoperfuion of kidney lead to renal failure
METABOLIC EFFECT
;
HYPOGLYCEMIA ,HYPOALBUINMIA ,MALNURTETION,HYPONATREMIA
RESPIRATORY ALKALOSIS AND METABOLIC ACIDOSIS
C NS
CONFUSION

PRE OPERATIVE EVALUTION IL LIVER DISEASE

1-History ;dyspnea ,esophageal varices ,confusion
2-physical ex ;orientation ,pleural effusion,pulse ,blood pressure ,ascites,malnutreition
3- investigation
-blood count(anemia,infection )
-coagulation (bleeding time ,pt, ptt ,fibrinogen )
-renal function test (blood urea and creatinine )
-Liver function test(bilirubin ,liver enzyme and albumin)
-ECG
-Chest-Xray
EFFECT OF ANESTHETIC DRUGS IN LIVER DISEASE
1-Sedatives
.propofol ..safe
.Ketamine –safe
.thiopental –dose reduction
.benzodiazepines –should avoided
2-Opioids
-remifentanil –safe
-fentanyl –dose deduction
-morphine -avoide

EFFECT OF ANASTETIC DRUGE IN LIVER DISEASE

3-Neuromuscular blocking agent
-atracurium – safe
-succinylcholine –dose reduction
-vecuronium –avoid
4-volatile anesthesia
-isoflurane –safe
-halothane –avoide cause halothal heptitis
INTRA OPERATIVE CONSIDERATION
-Monitoring
. ECG ,Pulse oximetry ,end-tidal co2 ,tepmpreture ,urie out put
-large-bore iv set
-cvc
Risk of complication due to severe liver disease ;
1-aspiration (ascites ,gastric emptying )
2-hypoxia (pleural effusion ,HRS )
3-hypotention (hypovolemia )
4-bleeding (esophageal varices and coagulopathy
5-oliguria (hepatorenal faluire )

POST OPERATIVE PAIN CONTROL IN LIVER DISEAS

-I V analgesia with fentanyl is well tolerated in patient with compensated liver disease
-regional analgesia very useful in reduce systemic analgesia but attention to
coagulopathy is essential .
-use of TAP blocks is recommended .

-parecetmol is not containducated but use if liver function test normal

 DR MUSHTAQ CH ABUALHAIL
GALL BLADDER AND BILE DUCT CONSULTANT SURGEON
MBCHB CABS DGS F FRCS F
MAS D MAS

TITLE ; GALL BLADDER AND BILE DUCT

Objectives ;to
1-Identify anatomy of gall bladder and biliary system .

2-outline disease of gall bladder

3- outline disease of bile duct

4- anesthetic significant
ANATOMY OF GALL BLADDER
-the gall bladder;
-pear shaped sac
-30 – 50 ml capacity
-located in visceral surface of liver fossa
-it has 4 parts fundus , body .,infunduplem ,and neck .
-blood supply cystic artery
-function concentrated bile .

ANATOMY OF BILE DUCT

Biliary tree divided to;
-intrahepatic ducts
-Extrahepatic ducts
intrahepatic ducts
. These comprise hepatocyte and ductile that connected to RT and LT hepatic duct
Extrahepatic ducts
RT and LT hepatic duct join to give common hepatic duct
-common hepatic duct with cystic duct give common bile duct
-common hepatic duct drain to 2nd part of duodenum at ampulla of vater
DISEASE OF GALL BLADDER (GALL STONE)
Gall stone (cholelithiasis );
-Two type of gall stones;
-80% are cholesterol stone
-20% are pigment stones
risk factors
-cholesterol stones are ;
1- female 2- fatty 3- fertile 4- 50 year old 5-rapid weight reduction
-Pigment stones ; hemolytic disease ,and biliary infection

CLINICAL FEATURE
-70 -80 % Asymptomatic
-other have symtoms
,.RT upper abdominal pain
. Vometing
.abdominal distention
;heatburn
.shoulder pain
COMPLICAION OF GALLSTONES
A-Gallbadder complication
-acute cholecystits
-chronic chole cystitis
-empyema (gallbladder full with pus)
-emphesma (gallbladder full with gas )
-perforation
B-Bile duct complication
-cholangitis
-obstructive jaundice
C-PNCREASE complication
gall stone pncreatitis

CHOLECYSTITIS
-Acute calculus cholecystitis
-due to obstruction of cystic duct by stone
-acute a calculus cholecystitis
due to
.1- postoperative state
2-sever trauma
3-sever burn
4-sepsis
INVESTIGATION
A- Blood test ;
-total serum bilirubin direct and indirect
-LFT
-Serum hepatitis A , B ,C

B- Radiological ;
-plain radiograph
-ultrasound
-CT scan
-MRCP

TREAMENT
-acute state
1- null by mouth
2- iv fluid
3-iv antibiotic
4- iv analgesia
Chronic state
-open cholecystectomy
- Lap cholecysectomy
BILE DUCT DISEASE(CHOLEDOCHOLITHIASIS )
-common bile duct stones
Primary or secondary
Clinical feature ;
-silent ,biliary colic,cholangitis , gallstones pancreatitis or obstructive jaundice
DX ; by ULTRASOUND and MRCP
-TREAMENT
-ERCP followed by lap chole

JAUNDUICE
-Its yellowish discoloration of skin , mucous membranes and sclera due excess plasma bilirubin .
-signs and symptoms ;
-skin ,and mucous membranes ----yellow
-stool---clay coloured
-urine---dark
-Itching
-abdominal pain
-fatigue
-ascitis
TYPES AND CAUSES OF JAUNDUICE
1- pre hepatic cause by
-hemolytic disease like thalesemia , sickle cell anemia ,drugs

2-intra hepatic
-liver cirrhosis and hepatitis

3-post hepatic
-CBD stones ,and carcinoma of pancrease

LABORATORY DX OF JAUNDICE
Serum bilirubin levels
. Normal 0.2 to o.8 mg/dl
.unconjugated (free indirect bilirubin) o.2 to 0.7 mg/dl
.conjugated (direct ) 0.1 to 0.4 mg/dl .
.latent jaundice above 1mg/dl
.clinical jaundice above 2mg/dl
PRE –HEPATIC
-serum –increase unconjugated
-urine bilirubin absent
urobilinogen increase
-stool –urobilinogen increase
HEPTOCELLULAR (INTRHEPATIC )
-Serum increase conjugated and uncogugated
-urine-bilirubin present
-stool urobilinogen decrease
-liver enzyme increase
-serum albumin level decrease

POST HEPATIC
-serum bilirubin conjugated direct increase
-urine bilirubin –present
uroblilinogen –absent
-stool stercobilinogen absent
-liver enzyme
1-AST ,ALT –slight increase
2-ALT - highly increase
ANASTHETIC SIGNIFICANT OF LAPAROSCOPIC
CHOLECYSTECTOMY
-physiological effect of pneumoperitoneum
The co2 was affected by increase intrabdominal pressure above venous pressure lead to
hypercarbia which activates sympathetic system cause brady cardia and arrhythmia ,
increase heart rate and BP.
-RESPIRATORY effect
Reduction in lung volume,decrease pulmonary compliance andincrease peak airway pressure
this lead to ventelation/perfusion mismatch
-Cardiovascular effect
Hemodynamic change include alteration of arterial blood pressure and cardic arrest
-renal effect
Renal impairment due to pneumperitonum

ANESTHETIST ROLE IN LAPAROSCOPY

-the role of anashesia in laprscopy is vital,surgery never done without experience in
anaesthesia .tht following monitoring
-ECG
-Air way pressure
-pulse oximeter
-End-tidal co2
-body tempreture
Balanced anaesthesia using muscle relaxant ,iv narcotic
Prophylactic heparin should be used-
Co2 embolism managment
PANCREAS AND SPLEEN

DR MUSHTAQ CH ABU ALHAIL

CONSULTANT SURGEON
MBCHB DGS
FRCS CABS F MAS D MAS

INTRODUCTION
 LOCATION

SHAPE AND SIZE

PARTS OF PANCREAS

ACUTE PANCREATITS
ETIOLOGY

ROLLE OF GALL STONE IN PANCREATITIS

D DX OF ACUTE PANCREATITIS

COMPLICATION OF ACUTE PANCREATITIS

SYSTEMIC COMPLICATION

COMPLICATION OF ACUTE PANCREATITIS

DX OF PANCREATITIS

DIAGNOSIS OF PANCREATITS
RANSON CRITERIA

RANSON CRITERIA
RANSON CRIRERIA

TREATMENT OF ACUTE PANCREATITIS

SPLEEN

LIGAMENT OF SPLEEN
ANATOMICAL RELATION OF SPLEEN

FUNCTION OF SPLEEN
FUNCTION OF SPLEEN

SPLEENIC TRAUMA
TREATMENT OF SPENIC TRAUMA

POST SPLENECTOMY INFECTION

 ANASTHETIC SIGNIFICANT

.Epidural anesthesia improves pancreatic perfusion and decreases the severity of

acute pancreatitis .

.propofol may induce pancreatitis ,so any patient presenting with abdominal pain
after propofol infusion should evaluated for acute pancreatits and treated to avoid
fatal complication .

.for splenectomy in patient with trauma or massive splenomegaly ,-appropriate IV

ACCESS and perioperative monitoring ,with blood preparation and antiboitocs and
vaccine present .

DR MUSHTAQ CH ABU ALHAIL

STOMACH AND DUODENUM MBCHB DGS CABS FRCS FMAS

D MAS
CONSULTANT SURGEON
INTRODUCTION

-Muscular sac located in upper part of abdominal cavity under diaphragm .

-J-Shaped
-capacity of stomach 50 ml within empty
-1—1.5l after meal
-4liters in extremely full
-play major role in digestive system—
-the gastric juice start from cephalic phase , gastric ,and intestinal phase
-the food stay within stomach 4-6 hrs
-the migratory complex start from fundus of stomach

STOMCH
ANATOMICAL DESCRIPTION OF STOMACH
-THE STOMACH HAS;
. Two opening ,the cardiac one connected to esophagus
pyloric one connected to duodenum
.Two curvatures ;greater omentum connected to spleen and trasverse colon
lesser omentum connected to liver
.Two surface Anterior –left lobe of liver and abdominal wall
posterior-aorta , pancreas and left kidney

PARTS OF STOMACH
1- Fundus ;dome shape projected upward to cardiac orifice, full with gas
2- Body ;extended from cardiac orifice to incisura angularis
3- antrum ; extended from incisura to pyloric sphincter.
4-pylorus ;most tubular part of stomach ,thick wall end to first part of duodenum
STOMACH WALL
. Mucosa contain gastric gland

.Sub mucosa

.muscularis

.Serosa

FUNCTION OF STOMACH
-Mechanical digestion
-Chemical digestion –pepsin break proteins
-Temporary storage allowing time for the digestion enzyme
-limited absorption
-non specific defence against microbes .
-preparation for iron absorption
-secretion of intrinsic factor for absorption of Vit B12.
-Regulation of passage of gastric content to duodenumm
GASTRIC JUICE
-PROPERRITIES OF GASTRIC JUICE
.Volume 1-1.5 liters
Natures acidic PH 0.7 to 4

-Composition
1- water 99% .
2-HCL -secreted by parietal cell
3- Digestive enzyme ;
-pepsin –for protein
-lipase fat
-rennin- milk
4-mucus from goblet cell to prevent autodigestion
5- Electrolyte mainly H ,Na,cl ,ca and mg

GASTRIC JUICE
-Main cell of gastric juice
1- chief cell produce pepsinogen

2-parietal cell (oxyulitic ) produce HCL

AND INTERNCIC FACTOR

3-Goblet cell mucus secretion

4-Enterochromatin cell produce histamine

5- G cell produce gastrin
DUODENUM

DUODENUM
-Is the shortest ,widest and most fixed part of small intestine
-located ;at umbilical region ,L1-L3 VERTEBRA
-IS C-shape structure-
-25 cm long
-Lacks mesentery and attached toto posterior abdominal wall
-Has 4 parts ;
1st part superior part 5cm long
2nd descending part 7.5 cm long
3rd horizontal part 10 cm
4th ascending part 2.5 cm
FUNCTION OF DUODENUM
-Receiving the mixed food from stomach
-Neutralizing the acidity of chime
-Advancing the digestive process with bile from liver and digestive enzyme from
pancreas
-Absorbing of iron and vitamin D
-Hormonal secretion ;
--secretin for fat and protein and fat digestion
--cholecystokinin aid in digestion of fat and protein

DISORDER OF DUODENUM

. Duodenal ulcer

.Duodenal diverticulum

.Duodenal obstruction

.Duodenitis
COMMON DISEASE OF STOMACH AND
DUODENUM
PEPTIC ULCER ;
-Erosion of a mucous membrane of stomach ,pylorus ,duodenum or esophagus.
-Associated with infection of [Link] .
- cause by many risk factors
-Associated with complication
-need investigation for diagnosis
-need careful treatment

PEPTIC ULCER SITES

---DUODENUM
--STOMACH
--ESOPHAGUS
--MECHELS DIVERTICULUM
-98% LOCATED in 1st part of duodenum and stomach ratio 4;1
esophagus result from GERD
PEPTIC ULCER -AETIOLOGY

-Acid
Familial
Stress
NSAIDS drugs
Smoking
H .PYLOI
-As part of acute gastritis (chemical injury , drugs ,alcohol )
-As complication of stress ,burn (curling ulcer ) ,major trauma ,CVA (CUSHING Ulcer )
-As a result of hyperacidity (Zollinger –Ellison syndrome )

PEPTIC ULCER - INVESTIGATION

-Endoscopy
-Test of H .pylori
Serum and stool
-breath test
-serological test
PEPTIC ULCER -TREATMENT
-Medical treatment
(H2 antagonist and Proton pump inhipter )
-Eraducation treatment
-PPI e.g OMPRAZOLE
-Metronidazoll
-Amoxacyllin or clindamycin

PEPTIC ULCER COMPLICATION

-
--pyloric obstruction

-perforation

--bleeding
PYLORIC OBSTRUCTION
-patient present with vomiting and dehydration
-investigated by serum electrolyte and barium meal
-treated by 1- NG tube 2-I Vfluid 3-CORRECTE electrolyte 4-surgery
Perforation
-present with acute abdomen
-investigate by chest x-ray air under diaphragm
-perforation occur anterior to suface ,need emergency surgery
Bleeding
Occur posterior to surface
Need blood transfusion
-endoscopy and stop bleeding by clips or cautary

ACUTE GASTRIC DIULATATION

-
-upper abdominal distention due to gas and fluid in stomach
-causes ;
1- functional obstruction ;DM ,uremia ,post operative
2- Mechanical ;ulcer ,tumour ,Bezor ,polyp
Treated
1- NG
2-IV FLUID
3-treate the according to cause
ANASTHETIC SIGNIFICANT
-acute dilatation of stomach after GA NEED ATTENTION TO OVERCOME MORBIDIRY

-Peri-operative aspiration continues to be important to patient safety in anaesthetic practice

-Anesthetic management of patient with full stomach is important .air way related mortality associated with anesthesia are 1 -
respiratory failure 2-acute lung injury3- multiorgan [Link] aspiration of gastrin contents occur once every 2000
elective GA and associated with 20% of hospital mortality

--surgical patient stop solid food for 6 hrs befor induction GA and 2hrshold clear fluids
-peri operative gastric ultrasound need for
1-uncertain prandial status
2-obesity
3 –DM DELAY GASTRIC EMPTY
4-children

MCQ
1-What name of the part of stomach attached to esophagus
A-fundus
B pylorus
C-cardia
D-antrum

2-lesser omentum connects stomach to

A-spleen
B- transverse colon
C-diaphragm
D-liver
MCQ
3-Which of the following cell in stomach secrete HCL and intrinsic factor
A-parietal cell
B G cell
C-chief cell
D-goblet cell

4-which of the following cell produce pepsinogen

A-goblet cell
B-chief cell
C-parietal cell
D –G CELL

MCQ
5- Gastric juice contain
A-trypsin ,pepsin,lipase
B-pepsin ,lipase , rennin
C-pepsin ,amylase ,trypsin
D-trypsin ,pepsin ,rennin
6-part of stomach attached to duodenum is
A cardia
B-pylorus
C –antrum
D- body
MCQ
7- PATIENT stop solid food before GA
A- 1 HRS
B-3 HRS
C-6HRS
D-2HRS
8-COMMON site of peptic ;
A-stomach
B-duodenum
C-esophagus
D-stomach and duodenum

MCQ
9- PEPTIC ULCER releated to hyperacidity cause by
A- trauma
B-burn
[Link]
D-ZOLLINGER –Ellison syndrum
10 –cushing ulcer cause by
A-burn
B-truma
C- cerebrovascular accident CVA
D-DRUGS