2016-01-10

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지라, 이자(Spleen, Pancreas)

지라 (Spleen)림프기관중가장큰장기 (길이 12 cm, 너비 7 cm)

지라문(splenic hilum)제외한 부분 : 복막에싸여있음

무게 : 75-130 g

위치 : 왼갈비아래부위 (Lt. hypochondriac region)

표면 : 가로막면 & 내장면

위의큰굽이(greater curvature)와연결

왼콩팥과연결

이자(pancreas)꼬리와접함Omental bursa의왼쪽경계

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태어나기전에는혈액세포를만들어내는조혈기관(hematopoietic organ)

태어난후에는 RBC, platele을 인식하고파괴하여철과글로빈을재활용

혈액필터기능

많은양의혈액보유

출혈에대응하여혈액삼출하여자가수혈기능(self-transfusion)

피막과잔기둥안에민무늬근육의작용에의해서

제법크면서많은유용한기능이있지만생명과직결되는필수장기는아님

지라동맥 (Splenic a.)

1) 복강동맥 (Celiac trunk)의가장큰가지

2) 지라콩팥인대(Splenic lig.)앞에서 5개이상으로나뉘어지라로!!

혈관들은서로연결되어있지않아구역 (segment)를형성부분절제

종말동맥 (end artery): 지라경색증 (splenic infarction)

지라정맥(Splenic v.)

1) 지라문(Hilum of spleen)을빠져나온정맥이모여서!!

2) 아래창자간막정맥(Inf. Mesenteric v)과합류 → 이자목뒤에서위창자간막정맥

(Sup. Mesenteric v)과 → 간문맥(Hepatic portal v.)형성

림프절 : 이자지라림프절 (Pancreaticosplenic nodes)

신경 : 복강신경얼기 (Celiac plexus)

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- Usually a purplish color, the spleen is located intraperitoneally in the left upper

abdominal quandrant. The spleen is entirely surrounded by peritoneum except at the

hilum, where the splenic branches of the splenic artery and vein enter and leave.

- The spleen normally contains a large quantity of blood that is expelled periodically into

the circulation by the action of the smooth muscle in its capsule and trabeculae.

Spleen

지라

* 복막내장기이며, 지라를덮는복막은잘벗겨지지만그속의섬유피막capsule은 trabeculae와연속된구조물로잘벗겨지지않는다.

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- Although well protected by the 9th through 12th ribs, the spleen is the most frequently

injured organ in the abdomen when severe blows on the left side fracture one or more of

the 9th through 12th ribs. Blunt trauma to other regions of the abdomen that cause a

sudden, marked increase in intra-abdominal pressure (e.g., by impalement on a steering

wheel of a car or the handlebars of a bicycle) can also rupture the spleen. If ruptured, the

spleen bleeds profusely because its capsule is thin and its parenchyma is soft and

pulpy. Rupture of the spleen causes severe intraperitoneal hemorrhage and shock.

Rupture of the spleen (지라파열, 갈비뼈골절, 교통사고, 폭행)

지라

** splenomegaly (지라비대): 정상보다 3배이상커지면왼갈비뼈모서리에서지라의아래끝이만져짐

; 과립백혈구성백혈병시; 적혈구가파괴되는용혈성빈혈 (hemolytic anemia)나백혈구가파괴되는과립백혈구성빈혈 (granulocytic anemia)시동반

지라절제술 (splenectomy): 부분, 온절제술• 덧지라 (accessory spleen): 10% 정도사람에게서관찰, 지라절제술을시행해도

증상이사라지지않는경우덧지라의유무확인

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이자 (Pancreas)위치 : L1, 2 높이의복막뒤에위치

이자머리, 목, 몸통, 꼬리로구분

갈고리돌기 : 이자머리아래에서왼쪽으로위창자간막

동맥(SMA)뒤로나있는갈고리모양의돌기

후복막장기(retroperitoneal organ) vs. spleen

외분비기능 : 꽈리세포(acinar cell) → 이자액

(pancreatic juice) → 이자관(pancreatic duct) or

덧이자관(accessory pancreatic duct) → 샘창자(duodenum)

내분비기능 : 이자섬 (pancreatic islet) →

글루카곤, 인슐린 → 혈액

*SMA와위치관계

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혈관분포

1) 이자샘창자동맥(Pancreaticoduodenal a.)

위샘창자동맥와 SMA의가지에의해활꼴동맥고리 (arcade)을 형성

2) 큰이자동맥(Major pancreatic a.) (지라동맥의가지)

3) 이자꼬리동맥(Caudal pancreatic a.) (지라동맥의가지)

4) 뒤이자동맥(Dorsal pancreatic a.) (지라동맥의가지)

이자머리에 혈액공급

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내시경역행쓸개이자조영술 (endoscopic retrograde cholangiopancreatography)

; ERCP: 이자와쓸개관질병을진단하는표준시술 greater duodenal papilla로삽입관을넣어조영제투입

정맥 : 동맥과같은이름의정맥들이문맥계통으로들어감

림프절 :

이자지라림프절(Pancreaticosplenic nodes) & 날문림프절(Pyloric lymph nodes)

신경 : 미주신경(vagus n.) & 가슴내장신경 (thoracic splanchnic n.)

임상적중요성 :

1) 이자머리에이자암 (pancreatic cancer); 쓸개관이간밖에서막히는가장흔한경우

샘창자의내강이좁아지고아래대정맥(IVC)과 오른쪽콩팥정맥이

눌려서복수(ascites)가생기고다리가부음(edema of extremities).

온쓸개관이눌려서쓸개의팽창과황달(jaundice)이생김 , 극심한통증유발

이자는멀리있는림프절까지광범위하게연결되므로, 초기에문맥을따라

간으로전이되는일이흔하므로이자암을수술로제거하는것은무의미

2) 지라절제술(splenectomy) 때지라혈관을묶을경우부주의로이자꼬리를같이

묶는경우가있음

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- The uncinate process, a projection from the inferior part of the head, extends medially to the

left, posterior to the SMA.

- The main pancreatic duct begins in the tail of the pancreas and runs through the parenchyma

of the gland to the head, where it turns inferiorly and is closely related to the bile duct. The

main pancreatic duct and the bile duct unite to form a short, dilated hepatopancreatic ampulla,

which opens into the descending part of the duodenum at the summit of the major duodenal

papilla. The sphincter of the pancreatic duct (around the terminal part of the pancreatic duct),

the sphincter of the bile duct (around the termination of the bile duct), and the

hepatopancreatic sphincter (sphincter of Oddi) - around the hepatopancreatic ampulla - are

smooth muscle sphincters that control the flow of bile and pancreatic juice into the duodenum.

Pancreas

이자

위내분비세포(enteroendocrine cells)

소장전체에걸쳐다양하게존재

여러가지펩티트호르몬을분비

생산부위 분비자극 표적세포 효과

CCK 샘창자 I cell 아미노산, 지방산

샘꽈리세포(acnar cells)

이자효소

Secretin 샘창자 S cell 위산(H+) 샘꽈리중심세포(centroacinar cells)

NaHCO3(알칼리성액)

• CCK (cholecystokinin) Chole + cyst + kinin

(쓸개 + 주머니 + 운동 or 수축)쓸개의운동측면

• CCK = PZ (pancreozyme)이자효소의작용

** 기능적측면에서이름이다르지만동일한물질

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1. Enteroendocrine cell

2. Centroacinar cells vs. acinar cells

3. 쓸개관수축 & 이자효소분비

십이지장,뒤배벽(duodenum, Post. abdominal wall)

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Small intestine

소장

소장

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- The first and shortest part of the small intestine - is also the widest and most fixed part.

- Most of the duodenum is fixed by peritoneum to structures on the posterior abdominal

wall and is considered partially retroperitoneal.

- Four parts

superior part - the first 2 cm out of 5 cm of this part has a mesentery and is mobile

descending part

hepatopancreatic ampulla

major duodenal papilla

horizontal part

ascending part

- Arteries

gastroduodenal artery (from the celiac trunk)

superior pancreaticoduodenal artery (from the gastroduodenal artery)

---- the entry of the bile duct ----

inferior pancreaticoduodenal artery (from the SMA)

The duodenum

소장

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허리근고름집 (psoas abscess): 결핵으로인해허리부위에고름집이생기면척추에서허리근집 (psoas sheath)로 잘퍼지며, 허리근막이두꺼워져질긴스타킹모양의대롱과같이된다. 드물게일어나는감염성근육염 ,임상증상과징후가비전형적이어서진단과치료가늦어지고따라서사망률이높다

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허리근징후 (psoas sign): 검사자를아프지않은쪽으로눕힌다음,넓적다리에저항을주면서구부릴때통증유발

엉덩아랫배신경 (iliohypogastric n., L1): McBurney point, 샅굴부위위쪽음부넙다리신경 (genitofemoral n., L1,2): 정삭, 음부가지음낭의앞(감각),

고환올림근(운동)엉덩샅굴신경 (ilioinguinal n., L1): 음낭의앞 (감각), 대음순, 아래샅굴부위,

인접한넙적다리안쪽피부

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배대동맥류 (abdominal aortic aneurysm): 선청성이나후천성으로대배동맥벽이약해져대동맥이국소적으로커진경우대동맥은앞으로튀어나온척주의앞쪽에위치하며, 마른사람의대동맥은예상외로앞배벽과아주가깝게위치한다.

교감

- 배골반내장신경1. 아래가슴내장신경

(lower thoracic splanchnic n.)1. 큰내장신경2. 작은내장신경3. 맨아래내장신경

2. 허리내장신경(lumbar splanchnic n.)

부교감- 앞뒤미주신경줄기- 골반내장신경

(pelvic splanchnic n.)

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- Organic pain arising from an organ such as the stomach varies from dull to severe; however, the pain

is poorly localized. It radiates to the dermatome level, which receives visceral afferent fibers from the

organ concerned. Visceral referred pain from a gastric ulcer, for example, is referred to the epigastric

region because the stomach is supplied by pain afferents that reach the T7 and T8 spinal sensory

ganglia and spinal cord segments through the greater splanchnic nerve. The pain is interpreted by the

brain as though the irritation occurred in the skin of the epigastric region, which is also supplied by the

same sensory ganglia and spinal cord segments.

Visceral referred pain

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Abdominal Aorta

Visceral branches

Celiac a

SMA

IMA

Suprarenal aa

Renal aa

Gonadal aa

Parietal branches

Inf phrenic aa

Lumbar aa (4 pairs)

Median sacral a

Common iliac a

대동맥

- hepatic v

- right adrenal v

- left & right renal vv

- right gonadal v

- inferior phrenic v

- lumbar vv

- common iliac v

Inferior vena cava

대정맥

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Left gastric a

esophageal br.

Splenic a

short gastric aa

left gastroepiploic a

splenic aa

Common hepatic a

right gastric a

gastroduodenal a

right gastroepiploic a

superior pancreaticoduodenal aa (ant & post)

proper hepatic a

right br.

cystic a

left br

Celiac a

동맥

left colic a

sigmoid a

superior rectal a

SMA

inferior pancreaticoduodenal aa (ant & post)

jejunal a

ileal a

ileocolic a

right colic a

middle colic a

IMA

동맥

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- The arterial supply to the digestive tract is from the abdominal aorta. The three major

branches of the aorta supplying the gut are the celiac trunk and the superior and

inferior mesenteric arteries. 동맥

동맥

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Portal venous system

문맥

문맥

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- The portal vein - formed by the union of the superior mesenteric and splenic veins - is

the main channel of the portal system of veins, which collects blood from the abdominal

part of the GI tract, pancreas, spleen, and most of the gallbladder and carries it to the

liver. 문맥

문맥

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문맥

Lymphatic drainage

- Preaortic LNs -----------→ Cisterna chyli

celiac LNs

superior mesenteric LNs

inferior mesenteric LNs

- Para-aortic LNs -----------→ Cisterna chyli

adrenal LNs

renal LNs

gonadal LNs

common iliac LNs

림프절

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림프절

림프절