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I. D.Intro to GI Tract III. Large Intestine

II. Small Intestine A. Ileocecal junction
A. Layers of Small B. Cecum
Intestine C. Colon
B. Duodenum D. Rectum
C. Jejunum & Ileum E. Anal Canal
D. Mesentery IV. Arterial Blood Supply
V. Venous Drainage
VI. Nervous Supply
VIII. References
IX. Appendix
LEGENDS Figure 1​. The Gastrointestinal System
-books Divisions of GI Tract: Based on Blood Supply
-mentioned by the lecturer but was not in the ppt/lecture notes 1) Foregut = Celiac Trunk
- from old transes 2) Midgut = Superior Mesenteric Artery
3) Hindgut = Inferior Mesenteric Artery
-take note for exam
Foregut:​ Begins at oral cavity and ends at portion of gut ​where
liver bud arises
● Demonstrate knowledge of the alimentary tract, especially: → ​at first half of 2nd part of duodenum
➝Small intestines → also ​where the duodenal papilla is (Ampulla of Vater)
■ Segments/location ● Does not end at the stomach!
■ Duodenum - divisions, positions, relations
■ Duodenal fossae Midgut​: Begins distal to the Ampulla of Vater and ends at distal
■ Openings of the biliary system 1/3 of transverse colon
■ Jejunum & Ileum
■ Mesentery - roots, contents, function Hindgut: ​Begins at distal 1/3 of transverse colon and ends above
■ Differentiate the 3 segments the pectinate line of the anal canal
■ Meckel’s Diverticulum
○ Large intestines II. SMALL INTESTINE
■ Segments/location
■ Coverings, attachments A. LAYERS OF THE SMALL INTESTINE
■ Differentiate it from the small bowel 1) Serosa
■ Ileocecal valve, folds, fossae → outermost
■ Appendix → underneath the peritoneum
○ Rectum 2) Subserosa
○ Anal Canal, External & Internal Anal Sphincters → location of blood vessels & nerves
○ Blood Supply, Venous Drainage, Innervation, Lymphatics 3) Muscularis Externa
of small & large intestines → Layers:
a) Outer longitudinal muscle
b) Myenteric/Auerbach’s Plexus
● Oropharynx c) Inner circular muscle
● Esophagus 4) Submucosa
● Stomach a) Meissner’s Plexus
● Small Intestine (Duodenum, Jejunum, Ileum) 5) Mucosa
● Large Intestine / Colon → innermost
● Rectum a) Muscularis mucosae
● Anal Canal b) Lamina Propria
c) Epithelium

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Figure 2​. Layers of the Small Intestine

Myenteric / Auerbach’s Plexus Figure 3​. Parts of the Small Intestine

→ between the ​ICOL​ (inner circular & outer longitudinal muscle) 1st Part (Superior Part)
→ function: motility
● Immediately after the pyloric ring
- innervates the smooth muscle of the enteric tract
➝ Highest acidity of duodenal content, ulcers occur here
Parasympathetic = relaxation (pre-relaxes a segment) ● Length: 5 cm
Sympathetic = contraction (causes motility in a previous segment ➝ 1st 2-3 cm = free with mesentery (mobile portion)
to push food forward) ■ Ampulla (Duodenal Cap) ​- covered entirely by
Without parasympathetic innervations, the succeeding enteric peritoneum
segments cannot receive the bolus of food ➝ Distal 3 cm = no mesentery, immobile
● Only part of duodenum seen intra-abdominally
Meissner’s Plexus
➝ 2nd-4th part of duodenum = ​retroperitoneal​
→ Function: innervate epithelial cells and smooth muscle cells of
● Inferior surface: contributes to greater omentum
the muscularis mucosa (Yale School of Medicine)
● Superior surface: contributes to lesser omentum (​gastrohepatic
Congenital Megacolon ligament​)
→ aka Hirschsprung’s Disease or Aganglionic Megacolon ● Most distal part of lesser omentum is ​hepatoduodenal
→ due to mutation in the RET gene (tyrosine kinase receptor ligament
involved in crest cell migration) ➝ Importance: ​Portal Triad
→ leads to absence of parasympathetic ganglia in the bowel ■ Portal vein
- failure of relaxation leading to functional obstruction ■ Common bile duct
■ Hepatic artery
Irritable Bowel Syndrome ​(Berne & Levy) Case: Vehicular crash causing compression of abdomen.
→ ​Collective term for disorders with “complaints of diarrhea, Findings present stellate fracture and profuse bleeding from liver
constipation, alternating patterns of both, often with accompanying due to injury. What to do?
pain and distention” → ​Pringle Maneuver​: ​Hook finger underneath ​Epiploic
→ Etiology unknown, but may involve ​visceral hypersensitivity​, at Foramen or Foramen of Winslow (​border of
the level of either the enteric NS, CNS or both hepatoduodenal ligament), pull without avulsing it. This will
compress the portal vein and hepatic artery, which comprise
B. DUODENUM entire blood supply of the liver.
● Duodenum
2nd Part (Descending Part)
→ First part of the small intestine
● Length: 7-10 cm
→ Shortest (25 cm), widest, most fixed part
● Location:
→ C-shaped organ around the head of the pancreas
- Curves around head of pancreas
→ Begins at pylorus on R side, ends at duodenojejunal flexure
- Parallel and right of the IVC
at L side
● Retroperitoneal
→ Partially retroperitoneal (mostly fixed by peritoneum to
● The anterior peritoneum here (its middle ⅓) reflects to give
structures on the posterior abdominal wall)
rise to the double layered mesentery of the transverse
● Duodenojejunal flexure / junction
colon = ​Transverse Mesocolon
→ ~ L2 vertebral level, 2-3 cm from midline
● Brunner’s Glands (Duodenal Glands)
● Site of influx of digestive juices
→ ​only in the duodenum
➝ AKA where bile ducts and pancreatic ducts
→ Secretion: Bicarbonate
▪ to neutralize the acidic chyme coming from the stomach
- The duodenum doesn’t have the same epithelial
lining resistant to acid or enough mucus secreting
cells as in the stomach, that’s why we need
Brunner’s glands
● 4 parts:
→ 1st Part / Superior Part : L1 vertebral level
→ 2nd Part / Descending Part : L1-L3
→ 3rd Part / Horizontal Part / Inferior Part: L3
→ 4th Part / Ascending Part: L3-L2

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4th Part (Ascending Part)
● Runs superiorly and left of the aorta, to reach the inferior
border of the body of the pancreas
● Curves anteriorly to join jejunum at the ​duodenojejunal
flexure​ / junction
● Supported by the​ Ligament of Treitz
➝ aka Suspensory Muscle of the Duodenum
➝ Composed of skeletal muscle from the ​R crus of the
diaphragm and a fibromuscular band of smooth
muscle from the 3rd and 4th part of duodenum
➝ Contraction of muscle widens the angle of the
duodenojejunal flexure, thus facilitating movements of
the intestinal contents

Figure 4​. Magnified image of Ampulla of Vater Table 1. Jejunum vs. Ileum

Embryology​: JEJUNUM ILEUM

● Major Duodenal Papilla
→ ​Common Bile Duct + Major Pancreatic Duct = Location Starts at Ends at ileocecal
Hepatopancreatic Ampulla or Ampulla of Vater duodenojejunal junction
- Ampulla is regulated by: ​Hepatopancreatic junction
Sphincter of Oddi
- Opening to an eminence called the Length Shorter; 2/5 length Longer; 3/5 length
Major Duodenal Papilla
● Minor Duodenal Papilla Occupancy LUQ RLQ
- Minor Pancreatic Duct / ​Duct of Santorini
Thickness Thicker Thinner
“Embryologically, the liver and pancreas develop separately.
Diameter Wider and larger Narrower
During rotation of gut, there is migration of the pancreas and it will
pull the bile ducts with it. Eventually, the common bile duct and the
Color Deeper red Paler pink
main pancreatic duct of Wirsung will combine and enter into the
2nd part of the duodenum as the major duodenal papilla through
Vasculature Less arcades, loops More arcades, loops
the Ampulla of Vater. It is the major pancreatic duct, the ​Duct of
Vasa Recta Longer Shorter, more numerous
“Normally, the pancreas will eventually migrate. Originally, the
pancreas drains through the minor pancreatic duct only. As the Arcades Few large loops Many short arcades
main pancreatic duct combines with the common bile duct, the
original minor pancreatic duct usually closes and disappears. But Mesenteric Fat Less More
in 25-30% of individuals, there is a persistence of minor pancreatic
duct called the ​Duct of Santorini. ​The ampulla there is unnamed” Absorption Less More

Exposure to High More than jejunum


Lymph Nodes N/A Present, due to high

(Peyer’s amount of absorption;
Patches) / thus more prone to
MALT infection (at distal ⅓)

Figure 5​. (A) Pancreas at 6th week of dev’t. Ventral and dorsal pancreatic duct in Plicae Present, more Thins out, disappears
close contact. (B) Fusion of pancreatic duct --- main pancreatic duct + bile duct Circulares distinct, tall, closely
enters duodenum at the major papilla. The accessory pancreatic duct (when packed
present) enters duodenum at the minor papilla (Langman’s Embryology)

3rd Part (Horizontal / Inferior Part) Plicae Circulares

● Runs transversely to the left - Function: to slow down food for prolonged exposure to
● Passes over IVC, aorta digestive enzymes (like speed bumps on the road)
● Superior border​: Superior Mesenteric Artery, Root of - Not for absorption or increasing surface area
Mesentery, Head & Uncinate of Pancreas
● Posterior border: R Psoas major, R gonadal vessels, IVC, - Duodenum is the area where digestive enzymes
aorta enter the gut, but food doesn't stay long enough for
complete digestion. Upon reaching the jejunum, where
there are plicae circulares, larger particles are slowed
down for adequate digestion. At the ileum, they should
already be digested enough to be absorbed.

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→ Contents​: Superior Mesenteric arteries and veins,
- Presence of plicae circulares explains why the jejunum is lymphatics
thicker and wider (in order to receive large bulks of food) → Lymphatics​:
▪ Lacteals within the villi absorb fats into plexuses
Peyer’s Patches in the walls
- High density of MALT in the GIT ▪ Course: Lacteals → Juxta-intestinal →
- Function: filters bacteria and toxins in the lymph Mesenteric and Superior Central Nodes → Aorta
- Found at the distal 1/3 of ileum (terminal ileum), where
the greatest amount of absorption occurs ● Root of mesentery
→ Length: 15 cm
Increased absorption in ileum → Need for greater blood → Oblique from duodenojejunal junction (L of L2) to
supply → more arcades, shorter vasa recta ileocolic junction (R of sacroiliac joint)

● Mesentery vs Omentum
→ Mesentery = suspends organ from the posterior
abdominal wall
→ Omentum​ (aka ligaments) = organ to organ connection
▪ Greater omentum
- ​gastrocolic ligament
▪ Lesser omentum
- gastrohepatic ligament
- hepatoduodenal ligament

Figure 6​. Lower Left: Mucosa of the Ileum; Upper Right: Mucosa of the Jejunum

Figure 8​. Mesentery Proper and Mesocolon

● Mesentery Proper
→ inferior to the duodenum, suspending the small intestine
or bowel loops
● Transverse Mesocolon
→ has a mesentery, crosses the 2nd part of duodenum
Figure 7​. Jejunum vs Ileum
As a general rule, draw an imaginary line across the R costal
angle and L ASIS.
Everything​ Above: Jejunum
Everything ​Below: Ileum

● Mesentery
→ Fan shaped fold of peritoneum
→ Function​: tethers the entire gut from the posterior
abdominal wall

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Mesentery of the Small Intestine Embryology​:​ (Source: GIT Embryology 2021B, Langman’s Embryology, Dr. Zorba
Bautista’s PPT on GIT Embryology, and this lecture)

Figure 11.​ (Modified image) Primitive dorsal and ventral mesenteries (encircled:
liver bud)

3rd Week: Appearance of Liver Primordium

● Liver
➔ Septum transversum
■ where primordial liver parenchyma will
develop, under the leaves of the diaphragm

Figure 9.​ Cross Section of Omental Bursa

➔ Arises out of the ventral foregut endoderm
adjacent to the septum transversum ​(Duke Medicine)
➔ As the liver enlarges within the folds of the
septum transversum, the ventral mesentery of the
foregut is obliterated
■ Ventral mesentery of the liver becomes the
falciform ligament ​(Duke Medicine)

Figure 10​. Sagittal section

● Lesser Sac = formed by falciform ligament, transverse

mesocolon, greater omentum and lesser omentum
Figure 12​. Ventral Mesentery
→ Falciform Ligament ​= connects the liver to the
anterior abdominal wall
● The entire gut from top to bottom below the diaphragm
→ Foramen of Winslow / Epiploic Foramen ​= ​only
will have a mesentery embryologically
interconnection between greater and lesser sac​; on
● Foregut​ = only one that will have a ventral mesentery,
lateral border of hepatoduodenal ligament
● Greater Sac​ = everything outside the lesser sac which is derived from the septum transversum
​Gastric ulcers
4th Week: Rotation of the Stomach
● usually perforate on the posterior wall
- 1-2 AM: highest secretion of gastric acid
● There will be a configuration where stomach is upright
- Most people are asleep or lying down.
and facing forward. In its complete form, the stomach is
● To operate: open lesser sac, flip stomach up, close sac
looking to the side and lying down.
● Pus usually comes out of epiploic ligament into the lesser

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- The small bowel grows faster than the colonic
- Because it's growing faster, it will now flip over and
the small bowel segment will drop

● At the same time, underneath the septum transversum,

the ​liver is enlarging​ and will occupy the RUQ.
● The ​stomach flips over and faces down, due to the
growing liver in front that is pushing it backwards.
● The stomach is trapped by the septum transversum in a
tight space. The stomach grows to the right because the
spleen is developing on the left. The portion connected to
the duodenum goes up to create a C-shaped loop and
rotates to the right.
● Small bowel loops elongate

6th Week: Herniation of Intestinal Loops

● Abdominal wall is not yet closed
Figure 13.​ Rotation of the Stomach
● Vitelline duct and yolk sac still present
● Lateral walls are not yet closed
5th Week - 10th Week: Rotation of the Gut ● Midgut or the intestinal loops will herniate ​(meaning it
will exit the baby’s body, due to the rapid expansion of
the liver) and enter the extraembryonic cavity
● Appearance of the cecal bud

Figure 14​. Midgut

● Jejunal segment (blue), Proximal part of ileum (fuschia)
● Vitelline duct
- source of nutrition, going to the yolk sac Figure 15​. Physiological Umbilical Herniation (6th Week)
- Should be completely obliterated at birth
- If it persists, it’s called Meckel's diverticulum. 10th Week: Retraction of Herniated Loops

● Meckel's Diverticulum ● The small intestine or midgut develops outside for about
- Abnormal lining of gastric epithelium producing three weeks, and is set to return, due to the abdominal
acidic secretions (instead of the normal intestinal wall growing and eventually closing in the midline.
epithelium), ● Proximal portion of Jejunum
- First sign of Meckel’s Diverticulum = - First part to reenter the abdominal cavity
Unexplainable hemorrhage from lower GIT - Its mesentery is not long enough for it to go straight
➔ Location​: 20-30 cm proximal from ileocecal down to the pelvis at the right side.
junction, where there are no Brunner’s glands - It cannot go to RUQ because the liver is there.
➔ Prone to bleeding and ulceration - Only space available is the ​LUQ​, and pulls the rest
➔ Massive hemorrhage coming out the anus as of the contents there
melena (black tarry stools) or hematochezia
(fresh bloody red stools)
➔ Outpouching is difficult to see on x-ray and
➔ Cause of disorder is unknown

Rotation of the Midgut

● Midgut is the longest segment of the gut
- In the 5 week period, all the components are
developing simultaneously. The midgut is much
longer, and grows more rapidly than the foregut
and hindgut. At a certain point in time, the segment
will be longer than the remaining segments. Figure 16.​ Retraction of Herniated Loops (10th Week)

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● Hindgut
-Composed of: rectum, sigmoid colon, descending
colon, part of transverse colon
- Intra abdominal and doesn't go out
➔ When the jejunum returns, it goes to the left and
drags in everything until the terminal ileum
➔ Cecum
- connects terminal ileum to ascending colon
- cecal bud is the​ last to re-enter
- Will end up in the ​RLQ because the jejunum
pushed the colon to the L
- The jejunum fills LUQ and the descending
colon is forced to go to the left
➔ Rectum stays in the midline because it’s attached
to the sacrum
- The ileum can no longer occupy both the LUQ
due to the jejunum and the LLQ because of
the sigmoid colon
Mesenteries of Intestinal Loops
● Dorsal mesenteries or posterior mesenteries : found in Figure 17​. Anterior view of the large intestine
all structures
● Ventral mesentery​ : found only in the foregut A. ILEOCECAL JUNCTION
● The mesenteries of the duodenum (the distal part) Ileocecal Valve
attaches to the posterior wall, such that the duodenum is
● Main purpose is to prevent the fecal material of going
now retroperitoneal
back to the small bowel/intestine
● The jejunum which was first to re-enter will retain its
dorsal mesentery all the way until the ileocecal junction. ● It is not actually a sphincter, but rather multiple rings
That’s why it’s called ​mesentery proper​. of muscle particularly three. Comprised of the following:
● The dorsal mesentery of the ascending colon is pushed ➔ Inner circular muscle of the ileum
to the right gutter and fuses with the posterior wall. Such ➔ Circular muscle of the colon
that the​ ascending colon is now partially retroperitoneal ➔ Longitudinal muscle of the tenia coli
● The transverse mesocolon now lies anterior to the
duodenum. The gap in the 2nd part of the duodenum is
where the ​transverse mesocolon​ is.
● The mesocolon of the ​descending colon gets pushed to
the gutter and fuses posteriorly to become ​retroperitoneal
● Sigmoid colon, lower end of cecum and the appendix
remain as free mesenteries
● Pancreas becomes retroperitoneal

10th-11th Week​: Abdomen should have closed​. SMALL INTES

● Consists of Cecum, Appendix, Ascending,Transverse,
Descending, and Sigmoid Colon; Rectum, and Anal
● Distinguishable characteristics of the large intestine
compared to small intestine are:
➔ Greater internal diameter
➔ Haustra: sacculations of the wall of the colon
between the tenia Figure 18. Ileocecal Junction
➔ Omental appendices: small, fatty, omentum-like
projections B. APPENDIX
➔ Teniae coli: are three distinct longitudinal bands ● Also called as Vermiform appendix, “vermi” being
which are thickened bands of smooth muscle worm-like
● These tenia coli are named whether if there is something ● Approximately 3.5inches in length
attached to it ● It is a true diverticulum of the large intestine that has
➔ Mesocolic tenia - where transverse and sigmoid lymphoid tissue
mesocolon attaches ● It has a mesentery, mesoappendix, which attaches it to
➔ Omental tenia - where the omental appendices the cecum
attach ● Commonly situated ​retrocecal​, but due to its attachment
○ Free tenia - no attachment with the ceum, it can varies
● Arterial supply: appendicular branch ​of​ I​ leocolic artery
● Venous drainage​: Ileocolic vein
● Lymphatic drainage: passes through the lymph nodes of
the mesoappendix and to the ileocolic lymph nodes.

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Efferent lymphatic vessels pass to the superior ● Nerve supply​: superior mesenteric plexus
mesenteric lymph nodes ● Lymphatic drainage:
● Only segment of the colon that will have a complete ➔ Epicolic and paracolic lymph nodes → ileocolic and
covering of longitudinal muscle. Taenia coli will converge intermediate right colic lymph nodes → superior
at the base and completely envelop by the longitudinal mesenteric lymph nodes
muscle Transverse Colon
Appendicitis ● Description:
● inflammation of the appendix ➔ Third part of the large intestine
● caused by obstruction to the appendiceal orifice of the ➔ Most mobile, since it is not attached to the posterior
small lumen of the appendix commonly by a fecal matter abdominal wall, and longest part of the large
if the patient is highly constipated. Bacteria will proliferate intestines
and its fluid secretion that leads to swelling of the well ➔ Crosses the abdomen from the right colic flexure to
and occluding the blood supply. the left colic flexure
➔ Left colic flexure is also called as splenic flexure; It
C. COLON is usually more superior, more acute but less
● Encircles the small intestine; the ascending colon lies mobile than the right colic flexure
to the right, transverse colon superior and/or anterior, ➔ It has a mesentery called transverse mesocolon,
descending colon to the left, and the sigmoid colon which fuses with the posterior wall of the omental
inferior to it. bursa
● Comprised of five different parts: ➔ The root of the mesentery lies along the border of
➔ Cecum the pancreas and posteriorly continuous with the
➔ Ascending colon parietal peritoneum
➔ Transverse colon ● Arterial supply:​ Mainly middle colic artery, branch of
➔ Descending colon the SMA, also may receive from the right and left colic
➔ Sigmoid colon arteries via anastomoses. Its anastomoses collectively
● Plicae circulares becomes semilunar folds form the marginal artery (of Drummond, juxtacolic artery)
● Generally 800 cm only ● Venous drainage​: Superior mesenteric artery
Cecum ● Lymphatic drainage​: middle colic artery → superior
● Description: mesenteric lymph nodes
➔ First part of the large intestine ● Nerve supply​: superior mesenteric nerve plexus via
➔ It is the area where the fecal material enters from the periarterial plexuses of the right and middle colic
the small bowel arteries
➔ Lies in the right lower quadrant and the iliac fossa
Descending Colon
➔ Cecum has no mesentery, makes it prone to
displacement from the iliac fossa ● Description:
➔ Occupies a secondarily retroperitoneal position
● Arterial supply​: ileocolic artery, part of the superior
although has a short mesentery approximately 33%
mesenteric artery
of people
● Venous drainage​: ileocolic vein, tributary of the SMV ➔ The short mesentery is not enough to induce
● Lymphatic drainage: volvulus/twisting of the colon
➔ passes through the lymph nodes of the ➔ It has a paracolic gutter on its lateral aspect the
mesoappendix and to the ileocolic lymph nodes. same as with the ascending colon
➔ Efferent lymphatic vessels pass to the superior ➔ As it descend, it passes to the anterior border of the
mesenteric lymph nodes left kidney
● Nerve supply​: Sympathetic (lower thoracic part) and ● Arterial supply​: left colic and sigmoid arteries,
parasympathetic (vagus) nerves from the ​superior branches of the inferior mesenteric artery
mesenteric plexus ➔ It forms a part of the marginal artery via the
Ascending Colon anastomosis of the superior branch of the most
● Description: superior sigmoid artery and the descending branch
➔ Second part of the large intestine of the left colic artery
➔ Generally narrower than the cecum ● Venous drainage: ​IMV, to the splenic vein and to the
➔ Secondarily retroperitoneal along the right side of hepatic portal vein
the posterior abdominal wall ● Nerve supply:
➔ Forms the right paracolic gutter, ​deep vertical ➔ Sympathetic nerves: lumbar part of the sympathetic
groove lined with parietal peritoneum trunk via lumbar splanchnic nerves
➔ Parietal peritoneum covers the ascending colon ➔ Parasympathetic nerves: pelvic splanchnic nerves
anteriorly and its side via the inferior hypogastric/pelvic plexus and nerves
➔ Usually have no mesentery but 25% of people do
● Lymphatic drainage:​ epicolic and paracolic nodes →
have short mesentery
intermediate colic lymph nodes → inferior mesenteric
➔ Passes superiorly to the right lobe of the liver which
lymph nodes that lie around IMA
turns to left at the ​right colic flexure or hepatic
➔ Lymph from the left colic flexure may drain to the
superior mesenteric lymph nodes
● ​ ranch
Arterial supply: I​leocolic and right colic arteries​, b
of SMA
● Venous drainage:​ Ileocolic and right colic veins,
tributaries of SMV

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Sigmoid Colon ➔ Parasympathetic nerves: S2-S4 spinal cord level
● Description: via the pelvic splanchnic nerves and left and right
➔ Usually has a long mesentery, the sigmoid inferior hypogastric plexuses to the pelvic plexus
➔ Omental appendices are long and disappears when
the sigmoid mesentery terminates
➔ Once the distal colon tinea starts fanning out and
become one whole entire wall or loop of
longitudinal smooth muscle,externally, marks the
demarcation of the rectum and the rectosigmoid
● Its arterial supply, venous drainage, lymphatic drainage,
and nerve supply are the same with the descending
● Usually the first one to expands compared to
transverse colon
● Description
➔ Follows the curvature of the sacral and coccyx
forming the sacral flexure of the rectum
➔ Ends antero-inferior to the tip of the coccyx,
immediately before a sharp posterior-inferior angle,
the anorectal flexure
➔ Retroperitoneal and subperitoneal part of the large
➔ Complete layer of muscularis externa
➔ Tenia coli already fanned out leading to no division
into three sections
➔ Has ​transverse rectal folds or valves of
Houston ​to slow down peristaltic rush
■ Two on the left - Superior and Inferior
■ One on the right - Middle
➔ Ampulla of the rectum
Figure 19.​ Anterior and Internal view of the rectum and anal canal
■ Receives and holds the fecal matter until it is
Anal Canal
■ It has the ability to dilate for it to
● Terminal part of the large intestine and of the entire
accommodate the fecal matter that is
digestive canal
essential for maintaining fecal continence
● Begins at the point where the rectal ampulla narrows at
➔ Peritoneum covers the ​anterior and lateral
the level of the U-shaped sling formed by the
surfaces of the superior third of the rectum​, only
the ​anterior of the middle third​, and ​none on the
inferior​ third due to its nature being subperitoneal
● 2.5-3.5cm long
➔ Peritoneal reflections form the floor of the pouches:
● Ends at the Anal Verge
■ For males: Rectovesical pouch
Anatomical Anal Canal
■ For females: Anterior to the uterus,
● Extends from the dentate or pectinate line to the anal
Vesicouterine pouch, while posterior to the
uterus, rectouterine pouch or Pouch of
Surgical Anal Canal
● Begins at the anorectal junction
● Arterial supply: ● Terminates at the anal verge
➔ Proximal part: Superior rectal artery, IMA
➔ Middle and Inferior: Right and left middle rectal Other Parts
arteries, anterior division of the internal iliac arteries Anus
➔ Anorectal junction and anal canal: Inferior rectal ● Is the external outlet of alimentary tract
arteries, from the internal pudendal arteries in the ● Descends posteroinferiorly between anococcygeal
perineum ligament and perineal body
● Surrounded by internal and external anal sphincters
● Venous drainage: Superior, middle, and inferior
Internal Sphincter
rectal veins
● Involuntary sphincter surrounding superior 2/3 of the anal
➔ Superior drains to portal venous system
➔ Middle and inferior drains to the systemic system
● Thickening of the circular muscle layer
● Nerve supply: ● Contraction (tonus) - stimulated and maintained by
➔ Sympathetic nerves: lumbar spinal cord, conveyed sympathetic fibers from the superior rectal (peri-arterial
via lumbar splanchnic nerves and the and hypogastric plexuses; inhibited by parasympathetic
hypogastric/pelvic plexuses, and through the fiber stimulation, both intrinsically in relation to peristalsis
periarterial plexus of the inferior mesenteric and and extrinsically by fibers conveyed by the pelvic
superior rectal arteries splanchnic nerves

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● Tonically contracted most of the time to prevent leakage Anorectal Sphincter Tone​ can be assessed during digital rectal
of fluid and flatus exam (DRE) when the patient is asked to squeeze the examining
External Sphincter finger.
● Large voluntary sphincter that forms a broad band on
each side of the inferior 2/3 of the anal canal Embryology​: (end of 7th week)
● Supplied mainly by S4 through the inferior rectal nerve Upper ⅔ of the Anal Canal:
● With subcutaneous, superficial, and deep parts; these ● is derived from the endoderm of the hindgut
are zones rather than muscle bellies and are often ● It is lined by simple columnar epithelium
indistinct. ● Supplied by the superior rectal artery ( branches from the
Anorectal Junction inferior mesenteric artery)
● Where the rectum joins the anal canal Lower ⅓ of the Anal Canal:
● Where the rectal ampulla narrows abruptly as it traverses ● Derived from the ectoderm around the proctodeum
pelvic diaphragm ● Supplied by inferior rectal arteries ( branches from the
● Indicated by superior ends of anal columns internal pudendal arteries)
Anal Columns of Morgagni​ ● Lined by stratified squamous epithelium
● infolding of the mucosa
● Acts as cushion upon defecation
● Series of longitudinal ridges found at the superior half of IV.ARTERIAL BLOOD SUPPLY
the mucous membrane NOTE: All underlined arteries are the ones that Dr. Bautista actually
● Contains terminal branches of superior rectal artery and mentioned in class; the others weren’t, but for the sake of completeness,
we also put it here.
● Contains vascular structures of hemorrhoidal vessels Table 12.​ Summary
Anal valves
Origin Arterial Supply Part it supplies
● Found at the inferior ends of the column
● Join the inferior ends of anal columns
Anal crypts DUODENUM
● Depressions superior to anal valves
● Secretions of the perianal glands are emptied Celiac 1. gastroduodenal a., and its part proximal to the
Anal sinuses trunk branch, entry of the bile duct
● Exude mucus upon compression that aids in defecation 2. superior into the descending
● Small recess superior to – valves pancreaticoduodenal a. part of the duodenum
Anorectal Ring
● Marks the junction between rectum and anal canal SMA inferior pancreaticoduodenal part distal to the entry
● Formed by joining of puborectalis muscle, Deep external a. of the bile duct (2nd,
sphincter, Conjoined longitudinal muscle, highest part of
the internal sphincter 3rd, and 4th parts)
Perianal glands
● Provide lubrication Pancreaticoduodenal arteries —> supply both the duodenum
● Oil secretion during defecation and pancreas
Perianal abscess
● Formed when there is inflammation of perianal glands JEJUNUM ​and​ ILEUM
Levator Ani Muscle
● Start of surgical anal canal SMA 1. Jejunal a. jejunum and ileum,
● 5 cm from the anal verge 2. Ileal a. respectively
● A part of the pelvic diaphragm
Puborectalis These arteries unite to form loops or arches called a ​ rterial
● U - shaped, medial most located levator ani Muscle
arcades,​ which gives rise to straight arteries called the ​vasa
● Pulls anorectal junction anteriorly, forming the anorectal
angle recta.


SMA 1. ileocolic a., and its 1. Cecum

branch, 2. appendix
2. appendicular a.



SMA 1. ileocolic a. 1. part of ascending

2. right colic a. colon
2. ascending colon
and right colic flexure

Figure 2​.. Lateral view of puborectalis muscle
SMA 1. Middle colic a. 1. proximal ⅔

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2. Left colic a. 2. distal ⅓ Doc said to remember these three branches also because it’s
easy to ask in exams:
DESCENDING ​and ​SIGMOID COLON* ● Right & Left Inferior Phrenic Arteries​ – will go to the esophagus
● Superior Phrenic Arteries​ – will also supply the lower part of the
IMA 1. left colic a. both arteries supply esophagus
2. sigmoid a. the descending and
sigmoid colon

*The structures of the colon may also receive blood flow from
other arteries in the Marginal Artery of Drummond.


IMA superior rectal a. proximal part of


Internal right and left middle rectal a. middle and inferior

Iliac a. parts of the rectum,

Internal Inferior rectal a. anorectal junction and

Puden- anal canal
dal a.

Note: Anastomoses between the superior and inferior rectal

arteries may provide potential collateral circulation, but
anastomoses with the middle rectal arteries are sparse.

“I will not expect you to know all the names of the structures kasi,
it’s immaterial, even to us, surgeons; it’s not really that important.
You get the main structures, you’re fine.” – Dr. Baustista
● Supplies the abdominal part of the ​foregut ​(distal 1/3 of Figure 21​. Celiac Trunk and its branches
esophagus, stomach, 1​st & 2​nd parts of duodenum,
pancreas, spleen, liver, biliary system)
● Mainly supplies the ​midgut
● Arises from abdominal aorta (at level of aortic hiatus)
● Arises from abdominal aorta (at L1 level)
Major Branches - Found along the inferior border of the pancreas,
● Left gastric artery – supplies: lesser curvature of within the folds of the mesentery proper
stomach & distal (abdominal) esophagus Main Branches of SMA
→ ​Esophageal branch ● ​Ileocolic Artery​ – supplies: cecum, ileocecal junction,
● Splenic artery – supplies: spleen, greater curvature & and (to an extent) ascending colon
posterior body of stomach, pancreas → ​Terminal branch of SMA
→ ​Posterior gastric a. ​– supplies: posterior wall & → ​Anastomoses with right colic a.
fundus of stomach → ​Divides into ileal and colic branches
→ ​Left gastroepiploic (gastro-omental) a. ​– supplies: ● ​Right Colic Artery​ – supplies: ascending colon & right
left side of greater curvature of stomach colic flexure
→ ​Short gastric a. ​– supplies: fundus of stomach ● Middle Colic Artery​ – supplies: proximal 2/3 of
● Hepatic Artery transverse colon
→ ​Common Hepatic a​. → ​Last branch in terms of chronology
▪ ​Gastroduodenal a. ​– supplies: stomach, ● ​Inferior pancreaticoduodenal artery​ – supplies: 2​nd​,
pancreas, 1​st part of duodenum, distal part of 3​rd​, and 4​th​ parts of the duodenum (distal to entry of bile
bile duct duct)
− ​Superior pancreaticoduodenal a. – ● Jejunal & Ileal arteries​ – supplies jejunum and ileum
supplies: head of pancreas & proximal
− ​Right gastroepiploic a. – right side of
greater curvature of stomach
▪ ​Right gastric a. – supplies: right portion of
lesser curvature of stomach
→ ​Hepatic artery proper
▪ ​Right hepatic a.
▪ ​Left hepatic a.
▪ ​Cystic a.
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Figure 23​. Inferior Mesenteric Artery


● Arterial supply to the colon
● Anastomoses all the colonic branches​. It is the
anastomotic point between the superior and inferior
mesenteric arteries.
→ ​Ileocolic a. (from SMA)
→ ​Right colic a. (from SMA)
→ ​Left colic a. (from IMA)
→ ​Sigmoid a. (from IMA)
● Significant because even when one particular artery
supplying blood to the colon is injured, there will be other
arteries to provide blood flow to the colon.
→ ​ e.g. If the left colic artery is injured (stab wound - left
colic artery is transected so it’s ligated to save the
patient’s life), will the descending colon die because it
no longer has blood supply from the left colic artery?
—> No, because you still have your middle colic
artery and your sigmoid branches.

Figure 22.​ Superior Mesenteric Artery and its branches

● Note: It can be found in the cadavers. It’s very small and
does not look like a major vessel, but this is bigger in live
Main Branches of IMA
● Left Colic Artery​ – supplies: distal 1/3 of transverse
colon and descending colon, and (to an extent) sigmoid
colon (via anastomoses with the sigmoid artery and
superior rectal vessels)
→ ​Has ascending and descending branches
● Sigmoid Artery​ - supplies: descending and sigmoid
● Superior Rectal Artery​ - supplies: distal sigmoid colon
and proximal rectum
→ ​terminal branch of the inferior mesenteric a.
● Rectosigmoid artery​ – gives off part of rectal blood

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Figure 24.​ Inferior Mesenteric Artery and its branches

● Superior Rectal Artery​ (from IMA)
→ ​supplies are above the surgical anal canal
→ ​Supplies: area superior to pectinate line, superior
muscles, and perianal skin
● Middle Rectal Artery​ (direct branch of internal iliac
→ ​Has right and left branches
→ ​Supply the area above the levator ani muscle
→ ​Supplies: middle and inferior parts of rectum
● Inferior Rectal Artery​ (from internal pudendal artery, a
branch of the internal iliac artery)
→ ​Supply the area below the levator ani muscle
→ ​Supplies: anorectal junction and anal canal
→ ​Contributes to renal vasculature, making it a
contributor of hemorrhoids
● Occasionally, you will also find the ​Median Sacral Artery Figure 25.​ Arterial Supply, Rectum
(direct branch of Aorta)
→ ​Lies along the curvature of the sacrum just before the
bifurcation of the common iliac artery
→ ​It will send down an artery to the posterior part of the
“Does this mean walang mesentery ang rectum?”
● No. ​“Along the sacrum, the arteries, veins, and
lymphatics will all be encased in a mesentery-like
structure, which you can actually pull off from the
sacrum. There will be a potential plane that you can
actually separate in the live individuals. Madali siyang
tanggalin. You just have to know where. That’s why when
we do complete rectal incision because of a cancer, we
have to remove even that mesentery because all of the
lymphatics are there.”

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Figure 27​. Liver in Situ: Vascular System

Tributaries of the Superior Mesenteric Vein

● Drains jejunum, ileum and transverse colon
● Lies anterior and to the right of the SMA in the root of the
mesentery. Ends posterior to the neck of the pancreas
where it unites with the splenic vein to form the hepatic
portal vein.
➔ Inferior pancreaticoduodenal vein
➔ Right gastroepiploic vein
➔ Right colic vein- drains ascending colon
➔ Ileocolic vein- drains cecum and appendix and
ascending colon
Figure 26​. Venous Anatomy of the Abdomen ➔ Middle Colic
➔ Jejunal vein
● Blood from the GIT enters the liver via portal vein and ➔ Ileal vein
leaves the liver via hepatic veins to drain into the inferior
vena cava.
● The venous drainage of the midgut and foregut runs
parallel with its blood supply with the exception of the

Hepatic Portal Vein

● Formed by the superior mesenteric v. and splenic v.
● Collects blood with reduced oxygenation but rich in
nutrients from the abdominal part of the digestive system
● Ascends behind the pancreas (level of L2 vertebrae) and
courses superiorly into the hepatoduodenal ligament.
● 75-80% of the blood supply to the liver comes
through the portal vein and not the hepatic artery (only
25-20%). The blood comes from all those organs in the
abdomen that it drains.

Figure 28.​ Superior Mesenteric Vein

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Tributaries of the Splenic Vein Superior rectal vein
● Inferior mesenteric veins - drains left colic, sigmoid, ● drains into the portal circulation via inferior mesenteric
superior rectal and descending colon vein.
➔ Pancreatic vein Middle rectal vein
➔ Left gastroepiploic vein ● drains into the internal iliac vein (systemic drainage)
➔ Short gastric vein Inferior rectal vein
● drains into the internal pudendal vein then internal iliac
vein (systemic drainage)
Middle rectal vein and inferior rectal vein​ are exceptions
because it drains back to the systemic circulation instead of the
portal circulation.
The median sacral vein (or middle sacral veins)​ accompanies
the corresponding artery along the front of the sacrum, and
joins to form a single vein, which ends in the left common iliac
vein; sometimes in the angle of junction of the two iliac veins.

Rectal venous plexus:

● Internal venous plexus​ – found deep to the mucosa of
anorectal junction.
● External venous plexus ​– found in the external wall of
the rectum; subcutaneous
* these 2 plexuses bear the term rectal but they are primarily
“anal” in terms of location, function, and clinical significance.

The blood in the gut does not go directly into the IVC
because it has to go to the liver first.
rectum is another area where you have venous collaterals
meaning part of the GIT drain onto these vessels.
In cases of portal hypertension, the blood flow to the portal
Figure 29. Veins of the Stomach, Duodenum, Pancreas and
vein is not good, the blood that needs to return to the systemic
circulation drains into the rectal veins. This makes the unions
of the superior with the middle and inferior rectal veins
Veins Directly Draining into the Portal Vein
important portal- systemic anastomoses.
● Cystic vein – drains the gallbladder
● Superior pancreaticoduodenal
● Left and right gastric veins C. PORTOSYSTEMIC ANASTOMOSIS


Figure 31.​ Portosystemic Anastomosis

Figure 30​. Rectum and Anal Canal Venous Anastomosis

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● Portosystemic/ Portocaval anastomosis are accessory A. SMALL INTESTINE
drainages. ● Duodenum
● Done in order to reduce portal hypertension by diverting ➔ derive from the vagus and greater and lesser
blood from the portal venous system to the systemic (abdominopelvic) splanchnic nerves by way of the
venous system celiac and superior mesenteric plexuses.
● In the esophagus, there are venous plexuses that ➔ conveyed to the duodenum via peri-arterial plexuses
anastomose with the esophageal vessels that drains up extending to the pancreaticoduodenal arteries
your thorax into the hemiazygos system. ● Jejunum and Ileum
○ This is why in conditions that cause portal ➔ The SMA and its branches are surrounded by a
hypertension, you will find your esophageal varices periarterial nerve plexus through which the nerves are
or varicosities in your esophageal veins. conducted to the parts of the intestine supplied by this
➔ Sympathetic fibers originate in the T8–T10 segments of
the spinal cord, reach the superior mesenteric nerve
plexus through the sympathetic trunks and thoracic
abdominopelvic (greater, lesser, and least) splanchnic
➔ Presynaptic sympathetic fibers synapse on cell bodies
of postsynaptic sympathetic neurons in the celiac and
superior mesenteric (prevertebral) ganglia
➔ Parasympathetic fibers derived from the posterior vagal
trunks. The presynaptic parasympathetic fibers
synapse with postsynaptic parasympathetic neurons in
the myenteric and submucosal plexuses in the
intestinal wall
➔ Sympathetic stimulation reduces peristaltic and
secretory activity of the intestine and acts as a
vasoconstrictor, reducing or stopping digestion and
making blood (and energy) available for “fleeing or
➔ Parasympathetic stimulation increases peristaltic and
secretory activity of the intestine, restoring the digestion
process following a sympathetic reaction. The small
intestine also has sensory (visceral afferent) fibers. The
intestine is insensitive to most pain stimuli, including
cutting and burning; however, it is sensitive to
distension that is perceived as colic (spasmodic
abdominal pains or “intestinal cramps”).
● Cecum and Appendix
➔ derives from the sympathetic and parasympathetic
nerves from the superior mesenteric plexus
We only name the main ganglia which are located along the main ➔ Sympathetic nerve fibers originate in the lower thoracic
trunks, and the ones closer to the main trunks
part of the spinal cord, and the parasympathetic nerve
Figure 32. ​Nerves of Stomach and Duodenum with stomach reflected
fibers derive from the vagus nerves
➔ Afferent nerve fibers from the appendix accompany the
● Sympathetic stimulation comes from the sympathetic
sympathetic nerves to the T10 segment of the spinal
trunk and it causes: Decreased bowel motility, Decreased
bowel secretion, Vasoconstriction (to shunt blood to other
● Colon
parts of the body therefore inhibiting digestion)
➔ Ascending Colon
● Parasympathetic stimulation comes from the vagus nerve
- derived from Superior Mesenteric Plexus
and sacral plexus: Increased bowel motility, Increased bowel
➔ Transverse Colon
secretion, Vasodilation
- derived from Superior Mesenteric Plexus
● All nerves will end up at the main trunks. Major ganglionic
➔ Descending and Sigmoid Colon
areas found at the bases of arterial trunks are the ​celiac
- sympathetic supply- from the lumbar part of the
plexus, superior and inferior mesenteric plexus
sympathetic trunk via lumbar (abdominopelvic)
● Both the sympathetic and parasympathetic plexuses are
splanchnic nerves, the superior mesenteric
insensitive to pain due to lack of nociceptive receptors and
plexus, and the peri-arterial plexuses following
are sensitive to distention due to the stretch receptors
the inferior mesenteric artery and its branches
● Clinical Correlation: - parasympathetic nerve supply- from the pelvic
➔ Celiac plexus – if a patient has a pancreatic tumor that splanchnic nerves via the inferior hypogastric
is inoperable, the sensory innervations of the celiac (pelvic) plexus and nerves, which ascend
plexus will be ablated with ethyl alcohol instead to retroperitoneally from the plexus, independent of
reduce pain caused by the tumor. the arterial supply to this part of the
gastrointestinal tract

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C, RECTUM ● Jejunum and Ileum
● Sympathetic supply is from the lumbar spinal cord, ➔ Lacteals​
conveyed via lumbar splanchnic nerves and the - specialized lymphatic vessels in the intestinal villi
hypogastric/pelvic plexuses, and through the peri-arterial (tiny projections of the mucous membrane) that
plexus of the inferior mesenteric and superior rectal arteries absorb fat; empty their milk-like fluid into the
● Parasympathetic supply is from the S2–S4 spinal cord lymphatic plexus in the walls of jejunum and ileum
level, passing via the pelvic splanchnic nerves and the left - lacteals drain in turn into lymphatic vessels
and right inferior hypogastric plexuses to the rectal (pelvic) between the layers of the mesentery
plexus. - within the mesentery, lymph passes sequentially
➔ Because the rectum is inferior (distal) to the pelvic through three groups of lymph nodes:
pain line, all visceral afferent fibers follow the ● Juxta-intestinal lymph nodes​: located close
parasympathetic fibers retrogradely to the S2–S4 to the intestinal wall
spinal sensory ganglia ● Mesenteric lymph nodes​: scattered among
the arterial arcades
● Superior central nodes​: located along the
proximal part of the SMA
➔ Efferent lymphatic vessels from the mesenteric lymph
nodes drain to the superior mesenteric lymph nodes;
Lymphatic vessels from the terminal ileum follow the
ileal branch of the ileocolic artery to the ileocolic lymph

Figure 33​. Innervation of Colon

● Bowel wall → intramural nodes → juxtaintestinal nodes
(along the border of the bowels) → mesenteric nodes →
superior mesenteric nodes → para-aortic area → lymphatic
trunk → thoracic duct Figure 34​. Mesenteric lymph nodes
● Lymphatic vessels follow the arterial vessels and drain into
the lymphatic node roots which include the superior and B. LARGE INTESTINE
inferior mesenteric nodes and celiac nodes forming the
● Cecum and Appendix
mesenteric trunk
➔ passes to lymph nodes in the meso-appendix and to
➔ Celiac Nodes​ – drain the gastric and duodenal nodes
the ileocolic lymph nodes
➔ Superior Mesenteric Nodes – drains the cecum,
➔ Efferent lymphatic vessels pass to the superior
appendix, ascending colon and middle colic lymph nodes
mesenteric lymph nodes
of transverse colon
➔ Inferior Mesenteric Nodes – drains the epicolic and ● Colon
paracolic nodes of transverse colon ➔ Ascending Colon
- passes first to epicolic and paracolic lymph nodes
→ ileocolic and intermediate right colic lymph
● Duodenum
nodes→ superior mesenteric lymph nodes
➔ lymphatic vessels follow the arteries.
➔ Transverse Colon
➔ Anterior lymphatic vessels→ pancreaticoduodenal lymph
- middle colic lymph nodes→ superior mesenteric
nodes→ pyloric lymph nodes
lymph nodes
➔ Posterior lymphatic vessels→ superior mesenteric lymph
➔ Descending Colon and Sigmoid Colon
- conducted through vessels passing to the epicolic
➔ both lymphatic vessels drain into Efferent lymphatic
and paracolic nodes→ intermediate colic lymph
vessels(from duodenal lymph nodes)→ celiac lymph
nodes along the → inferior mesenteric lymph
nodes. However, lymph from the left colic flexure

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may also drain to the superior mesenteric lymph
- Stomach - Appendix - Rectum
nodes - Liver - Ascending Colon - Upper anal canal
- Gallbladder & Bile - Proximal ⅔ of - Urogenital sinus
ducts transverse colon
- Pancreas
- Upper duodenum

Appendix B. Additional visual aid


Figure 35. Lymph nodes of the colon

● Rectum and Anal Canal
➔ Superior to the pectinate line​, the lymphatic
vessels→ internal iliac lymph nodes→ common iliac
and lumbar lymph nodes
➔ Inferior to the pectinate line​, the lymphatic vessels
superficially→ superficial inguinal lymph nodes, as
does most of the perineum


● Moore’s Clinically Oriented Anatomy 7th edition

● Berne & Levy Physiology 7th edition
● Netter’s Atlas of Human Anatomy 7th edition
● Snell’s Clinical Anatomy
● Junqueira’s Basic Histology 14th edition (Chapter 15)

● 2021B Trans: GIT Embryology

● 2021B Trans: Midgut & Hindgut
● GIT Embryology 2017 (Dr. Zorba Bnn Bautista’s PPT)
● GIT Midgut & Hindgut JAN 2019 (Dr. Zorba Bnn Bautista’s PPT)

● The gastrointestinal system. Retrieved from:




Appendix A. Derivatives of the Gut Regions (Duke University)


- Trachea, respiratory - Lower duodenum - Distal ⅓ of transverse

tract - Jejunum colon
- Lungs - Ileum - Descending colon
- Esophagus - Cecum - Sigmoid colon

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