VI.

ANATOMY AND PHYSIOLOGY

Peritoneum
The peritoneum is the serous membrane that lines the abdominal cavity. It lies
directly beneath the abdominal musculature (rectus abdominis and transverse abdominis).
It is a type of loose connective tissue and is covered by mesothelium. Extensions of the
peritoneum form the mesenteries, omenta and ligaments that support the abdominal
contents. The peritoneum produces fluid to lubricate abdominal viscera. The peritoneum
also enhances immune responses and walls off infection in the abdomen to
prevent peritonitis.
In the early embryo, the primitive gut tube is suspended by the dorsal and ventral
mesogastria. The mesogastria divide the embryo into two cavities, called the left and right
coelomic cavities. The ventral mesogastrium atrophies caudal to the pylorus of
the stomach and cranial to the rectum. This gives the entire small intestine and most of
the large intestine large scope for expansion and rotation. It also allows the left and right
coelomic cavities to coalesce forming one cavity; the peritoneal cavity. Peritoneal
structures develop from the dorsal and ventral mesogastria. Lining the abdomen is a thin
layer of loose connective tissue covered by a single layer of mesothelial cells. The layer of
mesothelial cells is referred to as the peritoneum. Collectively, the connective tissue and
peritoneum are referred to as the serosa. Mesothelial cells are simple squamous and of
mesodermal origin, they have microvilli on their surface and are very fragile but
regenerate very quickly. A small amount of fibroelastic tissue is present within the
connective tissue layer to provide support. There are two layers of peritoneum lining the
37 | Anatomy and Physiology

abdomen. Lining the abdominal wall is the parietal layer, lining the abdominal viscera is
the visceral layer.
The small space within these two layers is called the peritoneal cavity. In reality
there are no viscera located in the peritoneal cavity. However the cavity created by
the serosa is also confusingly referred to as the peritoneal cavity, and contains most
abdominal contents.
A small evagination extends into the thorax along the right side of the oesophagus.
The peritoneum also evaginates to extend into the inguinal canals. Fat is often stored
beneath the peritoneum. Many species have lymphoid tissue aggregates and fixed
phagocytes in the omentum that are not covered by mesothelial cells. The peritoneum is
smooth and clear in the healthy animal.
Peritoneal Fluid
A small quantity of peritoneal fluid is produced by mesothelial cells. It fills the
potential space formed by the two layers of peritoneum and allows the two layers to slide
over each other freely. Peritoneal fluid is also produced as a transudate which coats the
serosal surface of viscera to facilitate frictionless movement e.g. during peristalsis. It is in
equilibrium with plasma but doesn't contain high molecular weight molecules like
fibrinogen. The fluid is constantly being produced and resorbed through the large surface
area of the peritoneum, for this reason drugs are sometimes administered by
intraperitoneal injection. Bacterial toxins are also absorbed readily and can cause
inflammation of the peritoneum; peritonitis.

38 | Anatomy and Physiology

Peritoneum secretes a small volume of clear fluid for lubrication. It provides a

route for entry of blood and nerve and lymphatics. There is high fibrinolytic activity to
protect against the formation of adhesions. Inflammed portions of the peritoneum adhere
to each other and may become organised and permanent. This may help to wall of
infections and bring leuckocytes to the site of
infection. This trait is taken advantage of in
surgery when serosal surfaces are often turned
in when closing an incision.
Small Intestine
Most digestion and absorption of food
occurs in the small intestine. The small intestine is a narrow, twisting tube that occupies
most of the lower abdomen between the stomach and the beginning of the large intestine.
It extends about 20 feet in length. The small intestine consists of three parts: the
duodenum (the C-shaped part), the jejunum (the coiled midsection), and the ileum (the last
section).
The small intestine has two important functions.
1. The digestive process is completed here by enzymes and other substances made by
intestinal cells, the pancreas, and the liver. Glands in the intestine walls secrete enzymes
that breakdown starches and sugars. The pancreas secretes enzymes into the small
intestine that help breakdown carbohydrates, fats, and proteins. The liver produces bile,
which is stored in the gallbladder. Bile helps to make fat molecules (which otherwise are
not soluble in water) soluble, so they can be absorbed by the body.
39 | Anatomy and Physiology

2. The small intestine absorbs the nutrients from the digestive process. The inner wall of
the small intestine is covered by millions of tiny fingerlike projections called villi. The
villi are covered with even tinier projections called microvilli. The combination of villi
and microvilli increase the surface area of
the small intestine greatly, allowing
absorption

of

nutrients

to

occur.

Undigested material travels next to the

large intestine
Colon
The colon is also called the large intestine.
The ileum (last part of the small intestine) connects to the cecum (first part of the colon) in
the lower right abdomen. The rest of the colon is divided into four parts: The ascending
colon travels up the right side of the abdomen, the transverse colon runs across the
abdomen, the descending colon travels down the left abdomen and the sigmoid colon is a
short curving of the colon, just before the rectum.
The colon removes water, salt, and some nutrients forming stool. Muscles line the colon's
walls, squeezing its contents along. Billions of bacteria coat the colon and its contents,
living in a healthy balance with the body.
The large intestine is the final section of the gastrointestinal tract that performs the
vital task of absorbing water and vitamins while converting digested food into feces.
Although shorter than the small intestine in length, the large intestine is considerably
thicker in diameter, thus giving it its name. The large intestine is about 5 feet (1.5 m) in
40 | Anatomy and Physiology

length and 2.5 inches (6-7 cm) in diameter in the living body, but becomes much larger
postmortem as the smooth muscle tissue of the intestinal wall relaxes.
The large intestine wraps around the border of the abdominal body cavity from the right
side of the body, across the top of the abdomen, and finally down the left side.
Beginning on the right side of the abdomen, the large intestine is connected to the ilium
of the small intestine via the ileocecal sphincter. From the ileocecal sphincter, the large
intestine forms a sideways T, extending both superiorly and inferiorly. The inferior
region of the large intestine forms a short dead-end segment known as the cecum that
terminates in the vermiform appendix. The superior region forms a hollow tube known as
the ascending colon that climbs along the right side of the abdomen. Just inferior to the
diaphragm, the ascending colon turns about 90 degrees toward the middle of the body at
the hepatic flexure and continues across the abdomen as the transverse colon. At the left
side of the abdomen, the transverse colon turns about 90 degrees at the splenic flexure and
runs down the left side of the abdomen as the descending colon. At the end of the
descending colon, the large intestine bends slightly medially at the sigmoid flexure to
form the S-shaped sigmoid colon before straightening into the rectum. The rectum is the
enlarged final segment of the large intestine that terminates at the anus.
Like the rest of the gastrointestinal canal, the large intestine is made of four tissue layers:

The innermost layer, known as the mucosa, is made of simple columnar epithelial tissue.
The mucosa of the large intestine is smooth, lacking the villi found in the small intestine.
Many mucous glands secrete mucus into the hollow lumen of the large intestine to
lubricate its surface and protect it from rough food particles.
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Surrounding the mucosa is a layer of blood vessels, nerves and connective tissue known as
the submucosa, which supports the other layers of the large intestine.

The muscularis layer surrounds the submucosa and contains many layers of visceral
muscle cells that contract and move the large intestine. Continuous contraction of smooth
muscle bands in the muscularis produces lumpy, pouch-like structures known
as haustra in the large intestine.

Finally, the serosa forms the outermost layer. The serosa is a thin layer of simple
squamous epithelial tissue that secretes watery serous fluid to lubricate the surface of the
large intestine, protecting it from friction between abdominal organs and the surrounding
muscles and bones of the lower torso.
The large intestine performs the vital functions of converting food into feces, absorbing
essential vitamins produced by gut bacteria, and reclaiming water from feces. A slurry of
digested food, known as chyme, enters the large intestine from the small intestine via the
ileocecal sphincter. Chyme passes through the cecum where it is mixed with beneficial
bacteria that have colonized the large intestine throughout a persons lifetime. The chyme
is then slowly moved from one haustra to the next through the four regions of the colon.
Most of the movement of chyme is achieved by slow waves of peristalsis over a period of
several hours, but the colon can also be emptied quickly by stronger waves of mass
peristalsis following a large meal. While chyme moves through the large intestine,
bacteria digest substances in the chyme that are not digestible by the human digestive
system.

Bacterial

fermentation

converts

the

chyme

into

feces

and

releases vitamins including vitamins K, B1, B2, B6, B12, and biotin. Vitamin K is almost
exclusively produced by the gut bacteria and is essential in the proper clotting of blood.
42 | Anatomy and Physiology

Gases such as carbon dioxide and methane are also produced as a byproduct of bacterial
fermentation and lead to flatulence, or gas passed through the anus.
The absorption of water by the large intestine not only helps to condense and
solidify feces, but also allows the body to retain water to be used in other metabolic
processes. Ions and nutrients released by gut bacteria and dissolved in water are also
absorbed in the large intestine and used by the body for metabolism. The dried, condensed
fecal matter is finally stored in the rectum and sigmoid colon until it can be eliminated
from the body through the process of defecation.

Appendix
The appendix sits at the junction of the small intestine
and large intestine. Its a thin tube about four inches
long. Normally, the appendix sits in the lower right
abdomen.
The function of the appendix is unknown. One theory is that the appendix acts as a
storehouse for good bacteria, rebooting the digestive system after diarrheal illnesses.
Other experts believe the appendix is just a useless remnant from our evolutionary past.
Surgical removal of the appendix causes no observable health problems.
Appendix, formally vermiform appendix, in anatomy, a vestigial hollow tube
that is closed at one end and is attached at the other end to the cecum, a pouchlike
beginning of the large intestine into which the small intestine empties its contents. It is not
clear whether the appendix serves any useful purpose in humans. Suspected functions
include housing and cultivating beneficial gut flora that can repopulate the digestive
43 | Anatomy and Physiology

system following an illness that wipes out normal populations of these flora; providing a
site for the production of endocrine cells in the fetus that produce molecules important in
regulating homeostasis; and serving a possible role in immune function during the first
three decades of life by exposing leukocytes (white blood cells) to antigens in the
gastrointestinal tract, thereby stimulating antibody production that may help modulate
immune reactions in the gut. While the specific functions of the human appendix remain
unclear, there is general agreement among scientists that the appendix is gradually
disappearing from the human species over evolutionary time. Blockage of the appendix
can lead to appendicitis, a painful and potentially dangerous inflammation.
The appendix is usually 8 to 10 cm (3 to 4 inches) long and less than 1.3 cm (0.5
inch) wide. The cavity of the appendix is much narrower where it joins the cecum than it
is at its closed end. The appendix has muscular walls that are ordinarily capable of
expelling into the cecum the mucous secretions of the appendiceal walls or any of the
intestinal contents that have worked their way into the structure. If anything blocks the
opening of the appendix or prevents it from expelling its contents into the
cecum, appendicitis may occur. The most common obstruction in the opening is a fecalith,
a hardened piece of fecal matter. Swelling of the lining of the appendiceal walls
themselves can also block the opening. When the appendix is prevented from emptying
itself, a series of events occurs. Fluids and its own mucous secretions collect in the
appendix, leading to edema, swelling, and the distention of the organ. As the distention
increases, the blood vessels of the appendix become closed off, which causes the necrosis
(death) of appendiceal tissue. Meanwhile, the bacteria normally found in this part of
the intestine begin to propagate in the closed-off pocket, worsening the inflammation. The
44 | Anatomy and Physiology

appendix, weakened by necrosis and subject to increasing pressure from within by the
distention, may burst, spilling its contents into the abdominal cavity and infecting the
membranes that line the cavity and cover the abdominal organs (see peritonitis).
Fortunately, peritonitis is usually prevented by the protective mechanisms of the body.
The omentum, a sheet of fatty tissue, often wraps itself around the inflamed appendix, and
an exudate that normally develops in the areas of inflammation behaves like glue and seals
off the appendix from the surrounding peritoneal cavity.
A person experiencing an attack of appendicitis may feel pain all over the
abdomen, only in the upper abdomen, or about the navel. This pain is usually not very
severe. After one to six hours or more the pain may become localized to the right lower
abdomen. Nausea and vomiting may develop sometime after the onset of the pain. Fever is
usually present but is seldom high in the early phases of the attack. The
patients leukocytes (white blood cells) are usually increased from a normal count of
5,00010,000 in an adult to an abnormal count of 12,00020,000; this phenomenon can be
caused by many other acute inflammatory conditions that occur in the abdomen.
In a person with a normally sited appendix, the pain of appendicitis is situated at a point
between the navel and the front edge of the right hipbone. But many people have the
appendix lying in an abnormal position and may feel the pain of an appendicitis attack in a
different or misleading location, which makes their symptoms difficult to distinguish from
the abdominal pain caused by a variety of other diseases. Careful diagnostic examination
by a physician can usually determine if acute appendicitis is indeed causing a patients
abdominal pain. Ultrasound or computed tomography (CT) scanning may also be useful in
the diagnosis of appendicitis.
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The basic treatment of appendicitis is the surgical removal of the appendix in a

minor operation called an appendectomy. The operation itself requires little more than a
half hour under anesthesia and produces relatively little postoperative discomfort. If a
diagnosis of acute appendicitis cannot immediately be made with reasonable certainty, it is
common to wait and observe the patients symptoms for a period from 10 to 24 hours so
that a definitive diagnosis can be made. This wait does slightly increase the risk that the
appendix will rupture and peritonitis set in, so the patient is kept under careful medical
surveillance at this time.

The Circulatory Pump

The heart is a four-chambered double pump, where each side (left and right)
operates as a separate pump. The left and right sides of the heart are separated by a
muscular wall of tissue known as the septum of the heart. The right side of the heart
receives deoxygenated blood from the systemic veins and pumps it to the lungs for
oxygenation. The left side of the heart receives oxygenated blood from the lungs and
pumps it through the systemic arteries to the tissues of the body. Each heartbeat results in
the simultaneous pumping of both sides of the heart, making the heart a very efficient
pump.
Hemostasis
Hemostasis, or the clotting of blood and formation of scabs, is managed by the
platelets of the blood. Platelets normally remain inactive in the blood until they reach
damaged tissue or leak out of the blood vessels through a wound. Once active, platelets
change into a spiny ball shape and become very sticky in order to latch on to damaged
46 | Anatomy and Physiology

tissues. Platelets next release chemical clotting factors and begin to produce the protein
fibrin to act as structure for the blood clot. Platelets also begin sticking together to form a
platelet plug. The platelet plug will serve as a temporary seal to keep blood in the vessel
and foreign material out of the vessel until the cells of the blood vessel can repair the
damage to the vessel wall.
Process of Wound Healing
Whether wounds are closed by primary intention, subject to delayed primary
closure or left to heal by secondary intention1, the wound healing process is a dynamic one
which can be divided into three phases. It is critical to remember that wound healing is not
linear and often wounds can progress both forwards and back through the phases
depending upon intrinsic and extrinsic forces at work within the patient.

The phases of wound healing are; Inflammatory phase, Proliferation phase, Maturation
phase
The inflammatory phase is the bodys natural response to injury. After initial
wounding, the blood vessels in the wound bed contract and a clot is formed.
Once haemostasis has been achieved, blood vessels then dilate to allow essential cells;
antibodies, white blood cells, growth factors, enzymes and nutrients to reach the wounded
area. This leads to a rise in exudate levels so the surrounding skin needs to be monitored
for signs of maceration. It is at this stage that the characteristic signs of inflammation can
be seen; erythema, heat, oedema, pain and functional disturbance. The predominant cells
at work here are the phagocytic cells; neutrophils and macrophages; mounting a host
response and autolysing any devitalised necrotic / sloughy tissue.
47 | Anatomy and Physiology

During proliferation, the wound is rebuilt with new granulation tissue which is
comprised of collagen andextracellular matrix and into which a new network of blood
vessels develop, a process known as angiogenesis. Healthy granulation tissue is
dependent upon the fibroblast receiving sufficient levels of oxygen and nutrients supplied
by the blood vessels. Healthy granulation tissue is granular and uneven in texture; it does
not bleed easily and is pink / red in colour. The colour and condition of the granulation
tissue is often an indicator of how the wound is healing. Dark granulation tissue can be
indicative of poor perfusion, ischaemia and / or infection. Epithelial cells finally resurface
the wound, a process known as epithelialisation.

Maturation is the final phase and occurs once the wound has closed. This phase
involves remodeling of collagen from type III to type I. Cellular activity reduces and the
number of blood vessels in the wounded area regress and decrease.

48 | Anatomy and Physiology