Anatomy of

pharynx, Stomach , Duodenum

Stomach Pathology

faced
 Pharynx
•
Parts → Naso -
A. Base of skull to soft palate → Respiratory epithelium
↳r Oro is Soft palate to upper part of epiglottis Stratified squamous
-f*-
-

↳ Laryng -
→ upper part of epiglottis to cricoid CCG )

- • Wal deyers ring

= -
pharyngeal
is

Muscles → circular -
Sup constrictor →
oropharynx
[
.

Mid a →
Larynges
L
-
.

Inf U -
so u thyropheryngeus
I
-

C. rico pharynges

*
Longitudinal BStylo-B.CN 9 (Glossopharyngeal)
* Potato
*
Salpingo

Innervation -

Sensory -

Mainly → CN 9

[
( Vz
upper part Maxillary
[ lower
→

part → Vagus

Motor → All vcnaejous (except stylophayngeus CN 9)

BS -
A → External carotid
L V → Internal jugular

• 4 Gaps
364 SEC TION III GASTROINTESTINAL GASTROINTESTINAL—ANATOMY
` 

Gastrointestinal blood supply and innervation

EMBRYONIC PARASYMPATHETIC VERTEBRAL
GUT REGION ARTERY INNERVATION LEVEL STRUCTURES SUPPLIED
Foregut Celiac Vagus T12/L1 Pharynx (vagus nerve only) and lower esophagus
(celiac artery only) to proximal duodenum;
liver, gallbladder, pancreas, spleen (mesoderm)
Midgut SMA Vagus L1 Distal duodenum to proximal 2/3 of transverse
colon
Hindgut IMA Pelvic L3 Distal 1/3 of transverse colon to upper portion of
anal canal

Celiac trunk Branches of celiac trunk: common hepatic, splenic, and left gastric. These constitute the main
blood supply of the foregut.
Strong anastomoses exist between:
ƒ Left and right gastroepiploics
ƒ Left and right gastrics

Abdominal aorta
Celiac trunk Esophageal branches
Left hepatic
Left gastric
Short gastric

Right hepatic Splenic

Cystic
Left gastroepiploic

Proper hepatic

Common hepatic
“Anastamoses”
Gastroduodenal
Anterior superior pancreaticoduodenal Areas supplied by:
Posterior superior pancreaticoduodenal
Left gastric artery
Splenic artery
Right gastric
Right gastroepiploic Common hepatic artery
Celiac trunk * common hepatic Proper Hepatic
It'¥t :
-

plier
↳ ↳ ↳ send
Testpylorus Lesser
→
seams .ae
. -

&
curvature
.

T.IR/?Gastroepiploic
pancreatic duodenal head
(
o

of pancreas)

(Greater curvature)
*Lt .
Gastric ( Esophagus & lesser curvature)

(Fundus of stomach
•Splenic -

A short
gastric
→

- Same -
• Lt Gastro epiploic ( Gastro
.
-
o mental) → (Greater curvature )
B. pancreatic branches → Pancreas

Ulcer rupture * Lesser curvature -0 Left gastric

Bo Post
.
duodenum-76 Gastro duodenal

B- Post .
Stomach - *
Splenic artery
=
•

, T.ie
€
y-gj
uIg¥¥.SE#Somatostatin-moEgignihgibais'

;¥
.

# BE
Midst
 GASTROINTESTINAL GASTROINTESTINAL—EMBRYOLOGY
`  SEC TION III 359
Level of pylorus TALL
•

stomach
Tracheoesophageal

Vagotomy-Bqtruncalvagoto.my
• Esophageal atresia (EA) with distal tracheoesophageal fistula
= (TEF) is the most common (85%)
anomalies and often presents as polyhydramnios in utero (due to inability of fetus to swallow amniotic fluid).
Neonates drool, choke, and vomit with first feeding. TEFs allow air to enter stomach (visible on
CXR). Cyanosis is 2° to laryngospasm (to avoid reflux-related aspiration). Clinical test: failure to
pass nasogastric tube into stomach.
• Selective
In H-type, the vagotomy
fistula resembles the letter H. In pure EA, CXR shows gasless abdomen.

↳ Highly
Trachea

selective
Esophagus

vagotomy → we preserve
Tracheoesophageal
fistula

Latarjetne_ Esophageal
atresia

Parts ① Superior
:
→ no circular folds ( smooth) Duodenum
↳ Cap
Normal anatomy Pure EA
(atresia or stenosis)
-
-

Pure TEF
(H-type)
EA with distal TEF
(most common)

② Descending Gastric
-

papillaebubble
→ Minor → aces
song pancreatic
↳ major (Ampulla of Vater)
Normal Gasless stomach →
hepatic
Prominent
pancreatic
gastric bubble
duct
↳ transition from
Foregut to Midgut
③
Intestinal atresia Presents with bilious vomiting and abdominal distension within first 1–2 days of life.=
Tras verse
Duodenal Posterior
atresia—failureatoaorta
-
=

& IVCx-ray A shows “double bubble” (dilated

recanalize. Abdominal
-

A
(
stomach, proximal duodenum). Associated with Down syndrome.
Anterior one SMA
Jejunal and ileal atresia—disruption of& SMUvessels (typically SMA) Ž ischemic necrosis of
(
-

mesenteric
fetal intestine
SuperiorŽ segmental resorption: bowel becomes discontinuous. X-ray shows dilated loops of
-B Pancreas
small bowel with air-fluid levels.

④ Ascending -
Ligament of Trefiz ( suspensory
lig of duodenum)
-

Hypertrophic pyloric Most common cause of gastric outlet obstruction in infants (1:600). Palpable olive-shaped mass in
Kane
Fogg
epigastric region, visible peristaltic waves, and nonbilious projectile vomiting at ∼ 2–6 weeks old.
-

stenosis
→

A
More common in firstborn males; associated with exposure to macrolides. (Erythromycin
* Results in hypokalemic hypochloremic metabolic alkalosis (2° to vomiting of gastric acid and
stomach
pyloric wall subsequent volume contraction).
Ultrasound shows thickened and lengthened pylorus A .
#

ic
lor el
Treatment: surgical incision of pyloric muscles (pyloromyotomy).
py ann
-

c h
 GASTROINTESTINAL GASTROINTESTINAL—PATHOLOGY
`  SEC TION III 379
µSEtweightGastric
inflammation of mucosa uodend

jErosion -8g injury of mucosa

UGLIER
✓
+ weight loss →

Gastritis Ulcer → U n u + Sub#a Ct beyond) ↳

Acute gastritis Erosions can be caused by: Especially common among alcoholics and
ƒ NSAIDs— PGE2 Ž  gastric mucosa patients taking daily NSAIDs (eg, patients with
↳ eutrophils
* -

protection
s o

rheumatoid arthritis)
& ƒ Burns (Curling ulcer)—hypovolemia
← -
Burned by the Curling iron
-

Ž mucosal-8 ischemia
intracranial hemorrhage
tumor
or

Lf ƒ Brain injury (Cushing ulcer)— vagal

t
Always Cushion the brain
stimulation Ž  ACh Ž  H+ production
f tog

Chronic gastritis Mucosal inflammation, often leading to atrophy

↳mphocytes (hypochlorhydria Ž hypergastrinemia) and
a -

intestinal metaplasia ( risk of gastric cancers) f.

Duodenal ulcer more

H pylori Most common.  risk of peptic ulcer disease, Affects antrum first and spreads to body of
T

Fete name MALT lymphoma • mucosal

-
associated lymphoid tissue stomach TtEastric ulcer

Autoimmune Autoantibodies to the H /K ATPase on parietal

+ +
T T
Affects body/fundus of stomach
to
cells and to intrinsic factor.  risk of pernicious
It
anemia
TtTfobTf¥BB⇐CMesdoblas
Ménétrier disease Hyperplasia of gastric mucosa Ž hypertrophied rugae (look like brain gyri A ). Causes excess
A mucus production with resultant protein loss and parietal cell atrophy with  acid production.
Precancerous.
Presents with Weight loss, Anorexia, Vomiting, Epigastric pain, Edema (due to protein loss)
Stomach (WAVEE). (•
protein losing gastro patty (low protein)

↳↳ &
f. production of mucus

Noff#portaIfoun
Pepsin -&b Digestion of
protein

Columnar
✓
Gastric cancer Most commonly gastric adenocarcinoma;
-
Virchow node—involvement of left
A
lymphoma, GI stromal tumor, carcinoid (rare). supraclavicular node by metastasis from
Early aggressive local spread with node/liver stomach.
metastases. Often presents late, with weight Krukenberg tumor—bilateral metastases to
loss, abdominal pain, early satiety, and in some ovaries. Abundant mucin-secreting, signet ring
• cases acanthosis nigricans or Leser-Trélat sign. cells.
Associated with blood type A. Sister Mary Joseph nodule—subcutaneous
a -
Is
ƒ Intestinal—associated with H pylori, dietary periumbilical metastasis.
It nitrosamines (smoked foods), tobacco Blumer shelf—palpable mass on digital rectal

÷÷÷÷÷÷÷iz
T I T TA F T

smoking, achlorhydria, chronic gastritis. exam suggesting metastasis to rectouterine t o

Commonly on lesser curvature; looks like pouch (pouch of Douglas).

T E
ulcer with raised margins.
ƒ Diffuse—not associated with H pylori; most
cases due to E-cadherin mutation; signet
ring cells (mucin-filled cells with peripheral
nuclei) A ; stomach wall grossly thickened
and leathery (linitis plastica).
Acanthosis Nigricans Virchow, node (
TEFFT sister Mary Joseph nodule

Kahlenberg tumor
f.
380 SEC TION III GASTROINTESTINAL GASTROINTESTINAL—PATHOLOGY
` 

Peptic ulcer disease

Gastric ulcer Duodenal ulcer
PAIN
ITT
Can be Greater with meals—weight loss Decreases with meals—weight gain
H PYLORI INFECTION ~ 70% ~ 90%
MECHANISM  mucosal protection against gastric acid  mucosal protection or  gastric acid secretion
OTHER CAUSES NSAIDs T
Zollinger-Ellison syndrome
RISK OF CARCINOMA

OTHER
⑧

Biopsy margins to rule out malignancy
Generally benign

Ulcer complications
Hemorrhage Gastric, duodenal (posterior > anterior). Most common complication.
-

Ruptured gastric ulcer on the lesser curvature of stomach Ž bleeding from left gastric artery.
An ulcer on the posterior wall of duodenum Ž bleeding from= gastroduodenal artery.
Obstruction Pyloric channel, duodenal.
I
Perforation Duodenal (anterior > posterior).
A
Anterior duodenal ulcers can perforate into the anterior abdominal cavity, potentially leading to
pneumoperitoneum.
May see free air under diaphragm (pneumoperitoneum) A with referred pain to the shoulder via
T d
irritation of phrenic nerve.

iii. jair
*

=
 -

-
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