지라, 이자 (Spleen, Pancreas)

지라, 이자 (Spleen, Pancreas) 지라 (Spleen) 림프기관중가장큰장기 ( 길이 12 cm, 너비 7 cm) 지라문 (splenic hilum) 제외한부분 : 복막에싸여있음 무게 : 75-130 g 위치 : 왼갈비아래부위 (Lt. hypochondriac region) 표면 : 가로막면 & 내장면 위의큰굽이 (greater curvature) 와연결 이자 (pancreas) 꼬리와접함 Omental bursa 의왼쪽경계 왼콩팥과연결 1

태어나기전에는혈액세포를만들어내는조혈기관 (hematopoietic organ) 태어난후에는 RBC, platele을인식하고파괴하여철과글로빈을재활용 혈액필터기능 많은양의혈액보유 출혈에대응하여혈액삼출하여자가수혈기능 (self-transfusion) 피막과잔기둥안에민무늬근육의작용에의해서 제법크면서많은유용한기능이있지만생명과직결되는필수장기는아님 지라동맥 (Splenic a.) 1) 복강동맥 (Celiac trunk) 의가장큰가지 2) 지라콩팥인대 (Splenic lig.) 앞에서 5개이상으로나뉘어지라로!! 혈관들은서로연결되어있지않아구역 (segment) 를형성 부분절제 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) 2

Spleen * 복막내장기이며, 지라를덮는복막은잘벗겨지지만그속의섬유피막 capsule 은 trabeculae 와연속된구조물로잘벗겨지지않는다. - 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. 지라 3

Rupture of the spleen ( 지라파열, 갈비뼈골절, 교통사고, 폭행 ) - 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. 지라 ** splenomegaly ( 지라비대 ): 정상보다 3 배이상커지면왼갈비뼈모서리에서지라의아래끝이만져짐 ; 과립백혈구성백혈병시 ; 적혈구가파괴되는용혈성빈혈 (hemolytic anemia) 나백혈구가파괴되는과립백혈구성빈혈 (granulocytic anemia) 시동반 지라절제술 (splenectomy): 부분, 온절제술 덧지라 (accessory spleen): 10% 정도사람에게서관찰, 지라절제술을시행해도증상이사라지지않는경우덧지라의유무확인 4

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 *SMA 와위치관계 5

혈관분포 1) 이자샘창자동맥 (Pancreaticoduodenal a.) 위샘창자동맥와 SMA의가지에의해활꼴동맥고리 (arcade) 을형성 2) 큰이자동맥 (Major pancreatic a.) ( 지라동맥의가지 ) 3) 이자꼬리동맥 (Caudal pancreatic a.) ( 지라동맥의가지 ) 4) 뒤이자동맥 (Dorsal pancreatic a.) ( 지라동맥의가지 ) 이자머리에혈액공급 6

내시경역행쓸개이자조영술 (endoscopic retrograde cholangiopancreatography) ; ERCP: 이자와쓸개관질병을진단하는표준시술 greater duodenal papilla 로삽입관을넣어조영제투입 정맥 : 동맥과같은이름의정맥들이문맥계통으로들어감 림프절 : 이자지라림프절 (Pancreaticosplenic nodes) & 날문림프절 (Pyloric lymph nodes) 신경 : 미주신경 (vagus n.) & 가슴내장신경 (thoracic splanchnic n.) 임상적중요성 : 1) 이자머리에이자암 (pancreatic cancer); 쓸개관이간밖에서막히는가장흔한경우샘창자의내강이좁아지고아래대정맥 (IVC) 과오른쪽콩팥정맥이눌려서복수 (ascites) 가생기고다리가부음 (edema of extremities). 온쓸개관이눌려서쓸개의팽창과황달 (jaundice) 이생김, 극심한통증유발 이자는멀리있는림프절까지광범위하게연결되므로, 초기에문맥을따라간으로전이되는일이흔하므로이자암을수술로제거하는것은무의미 2) 지라절제술 (splenectomy) 때지라혈관을묶을경우부주의로이자꼬리를같이묶는경우가있음 7

Pancreas - 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. 이자 위내분비세포 (enteroendocrine cells) 소장전체에걸쳐다양하게존재 여러가지펩티트호르몬을분비생산부위분비자극표적세포효과 CCK 샘창자 I cell 아미노산, 지방 산 샘꽈리세포 (acnar cells) Secretin 샘창자 S cell 위산 (H+) 샘꽈리중심세포 (centroacinar cells) 이자효소 NaHCO3 ( 알칼리성액 ) CCK (cholecystokinin) Chole + cyst + kinin ( 쓸개 + 주머니 + 운동 or 수축 ) 쓸개의운동측면 CCK = PZ (pancreozyme) 이자효소의작용 ** 기능적측면에서이름이다르지만동일한물질 8

1. Enteroendocrine cell 2. Centroacinar cells vs. acinar cells 3. 쓸개관수축 & 이자효소분비 십이지장, 뒤배벽 (duodenum, Post. abdominal wall) 9

Small intestine 소장 소장 10

The duodenum - 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) 소장 11

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허리근고름집 (psoas abscess): 결핵으로인해허리부위에고름집이생기면척추에서허리근집 (psoas sheath) 로잘퍼지며, 허리근막이두꺼워져질긴스타킹모양의대롱과같이된다. 드물게일어나는감염성근육염, 임상증상과징후가비전형적이어서진단과치료가늦어지고따라서사망률이높다 13

허리근징후 (psoas sign): 검사자를아프지않은쪽으로눕힌다음, 넓적다리에저항을주면서구부릴때통증유발 엉덩아랫배신경 (iliohypogastric n., L1): McBurney point, 샅굴부위위쪽음부넙다리신경 (genitofemoral n., L1,2): 정삭, 음부가지 음낭의앞 ( 감각 ), 고환올림근 ( 운동 ) 엉덩샅굴신경 (ilioinguinal n., L1): 음낭의앞 ( 감각 ), 대음순, 아래샅굴부위, 인접한넙적다리안쪽피부 14

배대동맥류 (abdominal aortic aneurysm): 선청성이나후천성으로대배동맥벽이약해져대동맥이국소적으로커진경우 대동맥은앞으로튀어나온척주의앞쪽에위치하며, 마른사람의대동맥은예상외로앞배벽과아주가깝게위치한다. 교감 - 배골반내장신경 1. 아래가슴내장신경 (lower thoracic splanchnic n.) 1. 큰내장신경 2. 작은내장신경 3. 맨아래내장신경 2. 허리내장신경 (lumbar splanchnic n.) 부교감 - 앞뒤미주신경줄기 - 골반내장신경 (pelvic splanchnic n.) 15

Visceral referred pain - 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. 16

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 Inferior vena cava - hepatic v - right adrenal v - left & right renal vv - right gonadal v - inferior phrenic v - lumbar vv - common iliac v 대정맥 17

Celiac a 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 동맥 SMA inferior pancreaticoduodenal aa (ant & post) jejunal a ileal a ileocolic a right colic a middle colic a IMA left colic a sigmoid a superior rectal a 동맥 18

- 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 19

Portal venous system 문맥 문맥 20

- 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 21

문맥 Lymphatic drainage - Para-aortic LNs ----------- Cisterna chyli adrenal LNs renal LNs gonadal LNs common iliac LNs - Preaortic LNs ----------- Cisterna chyli celiac LNs superior mesenteric LNs inferior mesenteric LNs 림프절 22

림프절 림프절 23