Anatomy of digestive system

Introduction:
The intestine which is the longest part of the digestive system is divided into
long less distensible- small intestine and more distensible- large intestine.

Embryology:
The proximal one and a half parts of duodenum including the liver, gallbladder
and pancreas develop from foregut. The distal two and a half parts of
duodenum, jejunum, ileum, caecum, appendix, ascending colon and right 2/3
of transverse colon develop from midgut. Lastly, the left 1/3 of transverse
colon, descending colon, pelvic colon and proximal part of rectum develop
from hind gut.
 SMALL INTESTINE

It extends from the pylorus to the ileocaecal junction, it is about 6 meters long.
It is divided into the following parts-
1. Duodenum
2. Jejunum
3. Ileum
The structure of the small intestine is better adapted for digestion and
absorption because of its great length and the presence of circular folds of
mucous membrane, villi and microvilli.
Circular folds of mucous membrane or plicae circularis or valves of kerkring
form complete or incomplete circles which are permanent. They begin in the
second part of the duodenum and continue up to the proximal half of jejunum.
These folds facilitate absorption.
Intestinal villi are finger like projections of mucous membrane just visible to
the naked eye, which give the surface a velvety appearance. They are large and
numerous in the duodenum but are smaller and fewer in the ileum. They
increase the surface area of small intestine about eight times.
Each villus is covered by a layer of absorptive columnar cells. The surface of
these cells has a striated border which is seen under the electron microscope
to be made of microvilli.
Intestinal glands or crypts of Lieberkühn are simple tubular glands distributed
over the entire mucous membrane of jejunum and ileum. They open by small
circular apertures on the surface of the mucous membrane between the villi.
They secrete digestive enzymes and mucus.
Duodenal glands or Brunner’s glands lie in the submucosa which are small and
secrete mucus. Lymphatic follicles are of 2 types, solitary and aggregated
[ peyer’s]. Peyer’s patches are the largest and most numerous in the ileum and
are smaller and fewer in the jejunum.
Each villus has a central lymph vessel called a lacteal lymph from the lacteal
drains into the plexuses in the walls of the gut and from there to regional
lymph nodes.

Arterial supply-
It is derived from jejunal and ileal branches of superior mesenteric artery. The
vasa recta are distributed alternately to the opposite surfaces of the gut. They
run between the serous and muscular coats and give off numerous branches
which supply and pierce the muscular coat and form a plexus in the
submucosa. From this plexus minute branches pass to the glands and villi.

Lymphatics-
The lymphatics or lacteals, have a circular course in the walls of the intestine.
Large lymphatics formed at the mesenteric border pass to the mesenteric
lymph nodes.

Nerve supply-
The nerve supply of the small intestine is sympathetic [T9 to T11] as well as
parasympathetic [vagus] both of which pass through the coeliac and superior
mesenteric plexuses. The nerves form the myenteric plexus of Auerbach
containing parasympathetic ganglia between circular and longitudinal muscle
coats. Fibres from this plexus form the sub mucous plexus of Meissner which
also contains parasympathetic ganglia.
Sympathetic nerves are motor to the sphincters and to the muscularis
mucosae and inhibitory for peristaltic movements. The parasympathetic nerves
stimulate peristalsis but inhibit the sphincters.
 DUODENUM

The term duodenum is a Latin corruption of the Greek word,

‘‘dudekadactulos’’, meaning twelve fingers long.
It is c-shaped, 25 cm long, shortest, widest and most fixed part of the small
intestine. Most of the duodenum is retroperitoneal except 2-3 cms which is
covered by peritoneum.
Upper border of this initial segment gives attachment to right free margin of
lesser omentum [hepatoduodenal ligament] which contains portal vein,
hepatic artery and common bile duct.
Lower border gives attachment to the greater omentum. Lesser sac lies behind
it and epiploic foramen [ of Winslow] lies above it. So peritoneal relations of
this initial segment is similar to stomach.
Duodenum begins at pyloroduodenal junction which lies 1.25 cm to the right of
the midline on the transpyloric plane [ lower border of L1 vertebra]
It ends at the duodenojejunal flexure which lies 2.5 cm to the left of the
midline and 1 cm below the transpyloric plane. Lies at L2 vertebral level.

Duodenum is divided into 4 parts showing 2 flexures:

1. First part or superior part – 2-inch long
2. Second part or descending part – 3-inch long
3. Third part or horizontal part – 4-inch-long, extends across the midline
crossing L3 vertebra.
4. Fourth part or ascending part- 1-inch-long lying to the left of L2 vertebra.
It is just above umbilicus level.
There are 2 flexures- superior and inferior duodenal flexures.
Superior flexure lies at the junction of first and second part and to the right
side of L1 vertebra. Inferior flexure lies at the junction of second and third
part of duodenum and to the right side of L3 vertebra.

First part-
The first part begins at the pylorus and passes backwards, upwards and to
the right to meet the second part at the superior duodenal flexure. Its
relations are as follows:

Peritoneal relations-
The proximal 2.5 cm is movable. It is attached to the lesser omentum above
and to the greater omentum below. The distal 2.5 cm is fixed,
retroperitoneal and is covered with peritoneum only on its posterior aspect.

Visceral relations-
 Anteriorly: quadrate lobe of liver, gallbladder.
 Posteriorly: gastroduodenal artery, bile duct, portal vein.
 Superiorly: epiploic foramen.
 Inferiorly: head and neck of pancreas.
 Relations of first and second part of duodenum.

Second part-
Course: this part is about 7.5 cm long. It begins at the duodenal flexure
passes down the lower border of the 3rd lumbar vertebra, where it curves
towards the left at the inferior duodenal flexure, to become continuous
with the third part.

Its relations are as follows:

Peritoneal relations: it is retroperitoneal and fixed. Its anterior surface is
covered with peritoneum, except near the middle, where it is directly
related to the colon.
Visceral relations-
Anteriorly-
 right lobe of the liver
 transverse colon
 root of the transverse mesocolon
 small intestine

Posteriorly-
 anterior surface of the right kidney near the medial border
 right renal vessels
 right edge of the inferior vena cava
  right psoas major

Medially-
 head of the pancreas
 the bile duct

Laterally-
 Right colic flexure
The interior of the second part of the duodenum shows the following features:
 The major duodenal papilla- it is an elevation, at its summit
hepatopancreatic ampulla opens.
 The minor duodenal papilla- distal to the pylorus and presents the
opening of the accessory pancreatic duct.
Below the major duodenal papilla, a longitudinal fold called plica
longitudinalis is present.

Third part-
Course: this part is about 10 cm long. It begins at the inferior duodenal
flexure on the right side of the lower border of the 3rd lumbar vertebra. It
passes almost horizontally and slightly upwards in front of the inferior vena
cava, and ends by the joining the fourth part in front of the abdominal
aorta. Its relations are as follows:

Peritoneal relations-
It is retroperitoneal and is fixed. Its anterior surface is covered with
peritoneum except in the median plane, where it is crossed by the superior
mesenteric vessels and by the root of the mesentery.
Visceral relations-
Anteriorly-
 Superior mesenteric vessels
 Root of mesentery

Posteriorly-
 Right ureter
 Right psoas
 Right testicular or ovarian vessels
 Inferior vena cava
 Abdominal aorta with origin of inferior mesenteric artery

Superiorly-
 Head of the pancreas with uncinate process

Inferiorly-
 Coils of jejunum

Fourth part-
Course: This part is 2.5 cm long. It runs upwards on or immediately to the
left of the aorta, up to the upper border of the second lumbar vertebra,
where it turns forwards to become continuous with the jejunum at the
duodenojejunal flexure. Its relations are as follows.
Peritoneal relations:
It is mostly retroperitoneal, and covered with peritoneum only anteriorly.
The terminal part is suspended by the most upper part of the mesentery
and is mobile.

Visceral relations:
Anteriorly:
 Transverse colon
 Transverse mesocolon
 Lesser sac and
 Stomach

Posteriorly:
 Left sympathetic chain
 Left renal artery
 Left gonadal artery
 Inferior mesenteric vein
To the right: attachment of the upper part of the root of the mesentery
To the left: left kidney and left ureter.
Superiorly: body of pancreas.
Suspensory muscle of duodenum or ligament of treitz is a fibromuscular
band which suspends and supports duodenal flexure.

Arterial supply:
Superior and inferior pancreaticoduodenal artery.

Venous drainage:
The veins of the duodenum drain into the splenic, superior mesenteric and
portal veins.

Lymphatic drainage:
Lymph vessels end in the following nodes-
 Pancreaticoduodenal nodes
 Hepatic nodes
 Coeliac nodes
 Superior mesenteric nodes
Nerve supply:
Sympathetic nerves from the thoracic ninth and tenth spinal segments and
parasympathetic nerves from the vagus pass through the coeliac plexus
and reach the duodenum along its arteries.
 JEJUNUM AND ILEUM:

The jejunum and ileum are suspended from the posterior abdominal wall
by the mesentery and, therefore are mobile. The jejunum constitutes the
upper two-fifths of the mobile part of the small intestine, while the ileum
constitutes the lower three-fifths. The jejunum begins at the
duodenojejunal flexure. The ileum terminates at the ileocaecal junction.
JEJUNUM ILEUM
Wider, thicker, more vascular Narrower, thinner and less vascular
One or two arterial arcades formed Ileal arteries form more arterial
between adjacent jejunal braches. aracades hence vasa are shorter.
Vasa recta is longer.
Fat is less and confined to the root. Fat is more, hence translucent
Hence ‘translucent windows’ are windows are not seen.
easily seen between the adjacent
vasa recta.
Plica circularis or valves of kerkring Circular folds are smaller, fewer. In
are more numerous. terminal part of ileum folds are
absent.
Only solitary lymphatic follicles are Large number of peyer’s patches
present. are present.
Villi are larger, longer and more Villi are shorter, less numerous and
numerous. usually absent over the peyer’s
patches.

Vasa recta Vasa recta

Ant. aracades Ant. aracades

Blood is supplied from branches of superior mesenteric artery and drained

by corresponding veins.
Lymphatic drainage: lymph drains into plexus in the walls of the gut. The
lymph ultimately drains into the nodes in front of the aorta.
Nerve supply: sympathetic nerves is from T9-T11 segments and
parasympathetic is from vagus.
Meckel’s diverticulum: is it the persistent proximal part of vitellointestinal
duct which is present in the embryo. It disappears in the 6th week of
intrauterine life.

Large intestine

The large intestine is a 1 to 1.5-meter continuation of the ileum, extending

from the ileocecal junction to the anus. its mucosa is completely devoid of
villi and has a large number of goblet cells. The 4 major functions of the
large intestine are recovery of water and electrolytes, formation and
storage of faeces and fermentation of some of the indigestible food matter
by bacteria. The ileocaecal valve controls the entry of material from the
last part of the small intestine called the ileum.
Most of the large intestine is located inside the abdominal cavity, with the
last portion residing within the pelvic cavity. Some parts of it are
intraperitoneal while others are retroperitoneal.
The large intestine has several distinct anatomical characteristics; the
omental appendices, teniae coli and haustra. Omental or epiploic
appendages are fat filled pouches of peritoneum that are attached
externally to the walls of the large intestine. Teniae coli are three
longitudinal bands of smooth muscle located underneath the peritoneum
that extend along certain sections of the large intestine. Their contractions
facilitate the peristaltic action of the large intestine, propelling the fecal
matter and forming the haustra. Haustra are sacculations that occur along
the large intestine, providing it with its characteristic ‘baggy’ aspect. They
are created by semilunar folds on the internal surface of the large
intestine.
 L.intestine
There is a very simple way to remember these features specific to the large
intestine. The mnemonic ' Eva Has Ten Socks' stands for:
 Epiploic appendages
 Haustra (Sacculation)
 Tenia coli
 Semilunar folds
The large intestine consists of eight parts; the cecum, appendix, ascending
colon, transverse colon, descending colon, sigmoid colon, rectum, and anal
canal. The middle four sections (ascending to sigmoid parts) form the
colon.

Blood supply:
 Midgut: superior mesenteric artery [SMA]
 Hindgut: inferior mesenteric artery [IMA]
 Flow between these two systems communicates via the marginal
artery of the colon that runs parallel to the colon for its entire
length. Historically, a structure variously identified as the arc of
Riolan or meandering mesenteric artery (of Moskowitz) was thought
to connect the proximal SMA to the proximal IMA.
 Venous drainage usually mirrors colonic arterial supply, with the
inferior mesenteric vein draining into the splenic vein, and the
superior mesenteric vein joining the splenic vein to form the hepatic
portal vein that then enters the liver.
Nervous supply:
Enteric nervous system: Meissner and Auerbach plexuses
Sympathetic & parasympathetic: aortic, celiac, superior mesenteric, inferior
mesenteric, hypogastric nervous plexuses

Lymphatic drainage:
Lymphatic drainage from the ascending colon and proximal two-thirds of
the transverse colon is to the colic lymph nodes and the superior
mesenteric lymph nodes, which drain into the cisterna chyli. The lymph
from the distal one-third of the transverse colon, the descending colon, the
sigmoid colon, and the upper rectum drain into the inferior mesenteric and
colic lymph nodes. The lower rectum to the anal canal above the pectinate
line drain to the internal iliac nodes. The anal canal below the pectinate line
drains into the superficial inguinal nodes.

Colic flexures:
There are two colic flexures, or curvatures in the transverse colon. The one
on the right, the right colic flexure is known as the hepatic flexure. The one
on the left, the left colic flexure is known as the splenic flexure.

Right colic flexure

The right colic flexure or hepatic flexure (as it is next to the liver) is the
sharp bend between the ascending colon and the transverse colon. The
hepatic flexure lies in the right upper quadrant of the human abdomen. It
receives blood supply from the superior mesenteric artery.

Left colic flexure

The left colic flexure or splenic flexure (as it is close to the spleen) is the
sharp bend between the transverse colon and the descending colon. The
splenic flexure is a watershed region as it receives dual blood supply from
the terminal branches of the superior mesenteric artery and the inferior
mesenteric artery.
 Caecum

The cecum is the first part of the large intestine, lying in the right iliac fossa
of the abdomen. The cecum is intraperitoneal with various folds and
pockets (retrocecal peritoneal recesses) surrounding it. It is 6cm long and
7.5 cm broad. The terminal ileum joins the cecum at the ileocolic junction.
The ileocecal orifice is marked by the ileal papilla, which consists of two
folds called ileocecal lips (superior, inferior). The folds fuse together around
the orifice, forming the frenula of the ileal orifice, which prevents reflux of
cecal contents into the ileum.

An ileocecal valve regulates the passage of intestinal contents from the

small into the large intestine. The functions of the cecum involve temporary
storage of chyme, and fluid and electrolyte reabsorption.

Relations:
Anterior:
coils of intestine and anterior abdominal wall.

Posterior:
 Muscles: right psoas and iliacus.
 Nerves: genitofemoral and lateral cutaneous nerve of thigh.
 Vessels: testicular or ovarian.
 Appendix in the retrocaecal recess.

Blood supply:
Arterial supply is from the ileocolic artery, a branch of the superior
mesenteric artery. It subsequently divides into anterior and posterior cecal
arteries, which directly supply the cecum.
 Venous drainage is provided by the corresponding ileocolic vein, and
empties into the superior mesenteric vein.

Lymphatic Drainage:
Lymph from the cecum drains into the ileocolic lymph nodes (which
surround the ileocolic artery).

Nerve supply:
Sympathetic and parasympathetic branches of the autonomic nervous
system innervate the cecum and appendix. This is achieved by the ileocolic
branch of the superior mesenteric plexus, which follows the same course as
the ileocolic artery and carries vagal and sympathetic nerve fibres.

ILEOCAECAL VALVE:
It is a sphincter muscle valve that separates the small intestine and the
large intestine. The ileocecal valve consists of two muscular layers of ileum,
an upper and lower lip, that are covered by mucosa and protrude into the
lumen of the caecum supported by mucosal folds called frenula.

Functions:
 It prevents reflux from caecum to ileum.
 It regulates the passage of ileal contents into the caecum and
prevents them from passing too quickly.

The portion of the large intestine located between the cecum and rectum is
termed the colon. It consists of four parts; ascending, transverse,
descending, and sigmoid. The main functions of the colon include fluid and
electrolyte reabsorption.
Ascending colon:
The ascending colon is the first of four main sections of the large intestine.
It travels through the right iliac fossa, right flank, and right hypochondriac
region. It ends at the right colic (hepatic) flexure. The ascending colon is
retroperitoneal and it is connected to the posterior abdominal wall by the
Toldt’s fascia. A deep vertical groove or recess (right paracolic gutter) lies
between the ascending colon and the lateral abdominal wall. The ascending
colon is heavily involved in fluid and electrolyte reabsorption, gradually
forming fecal matter. As the waste material exits the small intestine
through the ileocecal valve, it will move into the cecum and then to the
ascending colon where this process of extraction starts. The waste material
is pumped upwards toward the transverse colon by peristalsis.

Transverse colon:
The transverse colon is the second major part of the colon. It extends
between the right and left colic (splenic) flexures, spanning the right
hypochondriac, epigastric and left hypochondriac regions of the abdomen.
The greater curvature of the stomach and gastrocolic ligament are superior
to the transverse colon, while the greater omentum hangs over and
extends inferiorly to it.
The transverse colon is intraperitoneal. A peritoneal mesentery (transverse
mesocolon) attaches it to the posterior wall of the omental bursa. This
forms two abdominal compartments called supracolic and infracolic
compartments.

Descending colon:
The descending colon extends between the left colic flexure and sigmoid
colon. It travels through the left hypochondriac region, left flank and left
iliac fossa. The left paracolic gutter is located between the descending colon
 and the lateral abdominal wall. This part of the colon is retroperitoneal.
Toldt’s fascia fixes the descending colon to the posterior abdominal wall.

Sigmoid colon:
The S-shaped sigmoid colon travels from the left iliac fossa until the third
sacral vertebra (rectosigmoid junction). This part of the colon is
intraperitoneal. It is connected to the pelvic wall by the sigmoid mesocolon.

Rectum:
The rectum stretches between the rectosigmoid junction and the anal
canal. The typical characteristics of the large intestine (taenia coli, haustra,
epiploic appendages) change or even terminate at the rectum. The roles of
the rectum include temporary storage of fecal matter and defecation.
The rectum has a characteristic S-shape marked by several bends or turns;
sacral, anorectal and lateral flexures. The latter correspond with three
infoldings called transverse rectal folds. The rectum ends at a dilated
ampulla.

Anal canal:
The anal canal forms the terminal part of the gastrointestinal tract. It
extends from the anorectal junction to the anus. The latter represents the
external orifice of the entire digestive system.
The mucosa of the superior half of the anal canal contains ridges called anal
columns. The inferior portions of these columns contain anal valves, which
are surrounded by anal sinuses. The latter are responsible for secreting
lubricating mucus during defection. The anal valves also form the pectinate
line which makes the distinction between the superior and inferior parts of
the anal canal.
 Vermiform Appendix

This is a worm-like diverticulum arising from the posteromedial wall of the

caecum, about 2 cm below the ileocaecal orifice.

Dimensions:
The length varies from 2 to 20 cm with an average of 9 cm. It is longer in
children than in adults. The diameter is about 5 mm. The lumen is quite narrow
and may be obliterated after mid-adult life.

Positions:
The appendix may pass upwards and to the right. This is a paracolic or
11o’clock position.
It may lie behind the caecum or colon, known as retrocaecal or 12 o’clock
position. This is the commonest position of the appendix, about 65%.
The appendix may pass upwards and to the left. It points towards the Spleen.
This is the splenic or 2 o’clock position. The appendix may lie in the front of the
ileum (preileal) or behind the ileum (postileal). The postileal type is most
dangerous type. It may pass horizontally to the left (as if pointing to the sacral
promontory called promontoric or 3 o’clock position.
It may descend into the pelvis called pelvic or 4 o’clock position. This is the
second most common position at about 30%.
It may lie below the caecum (subcaecal) and may point towards the inguinal
ligament called as midinguinal or 6 o’clock position.
Appendicular Orifice:
The appendicular orifice, situated on the posteromedial aspect of the caecum
2 cm below the ileocaecal orifice. The appendicular orifice is occasionally
guarded by an indistinct semilunar fold of the mucous membrane, known as
the valve of Gerlach.
The orifice is marked on the surface by a point situated 2 cm below the
junction of trans tubercular and right lateral planes.
Mcburney’s point is the site of maximum tenderness in appendicitis. The point
lies at the junction of lateral one-third and medial two-thirds of line joining the
right anterior superior iliac spine to umbilicus.

Lumen of Appendix:
It is quite small and may be partially or completely obliterated after mid-adult
life.

Peritoneal relations:
the appendix is suspended by a small, triangular fold peritoneum, called the
mesoappendix or appendicular mesentery. The fold passes upwards behind
the ileum, and is attached to the left layer of the mesentery.

Blood supply:
Arterial supply is from the appendicular artery (derived from the ileocolic
artery, a branch of the superior mesenteric artery) and venous drainage is via
the corresponding appendicular vein. Both are contained within the
mesoappendix.

Nerve supply:
The autonomic innervation of the appendix arises from the superior
mesenteric plexus. Afferent sensory fibers from the appendix are carried on
the sympathetic nerve fibers to enter the spinal cord at T10 which corresponds
to the umbilical dermatome.

Lymphatic drainage:
Lymphatics from the body and tail of the appendix run through the mesentery
to drain into the upper and lower ileocolic lymph nodes. The lymph from the
root of the appendix and the cecum drains into two groups: an anterior and a
posterior group.