2 ANATOMY OF THE ABDOMINAL VISCERA (FOREGUT AND DERIVATES)

Objectives:
1. Describe the four layers of the gastrointestinal tract.
2. Describe the difference between parietal vs. visceral peritoneum, peritoneal vs. retroperitoneal organs, and greater vs. lesser
sacs of the peritoneal cavity.
3. Define the term mesentery and name its functional significance.
4. Name the important factors that affect the position of the abdominal viscera.
5. Describe the parts, functions and relationships of the stomach and greater and lesser omenta.
6. Describe the parts, functions and relationships of the duodenum.
7. Discuss the clinical significance of the above relationships.
8. Describe the functions and relationships of the liver. Understand the difference between the anatomical and functional lobes of
the liver.
9. Describe the parts and functions of the gallbladder and the pattern of joining of the extrahepatic bile ducts.
10. Name some causes and consequences of obstruction of the bile ducts.
11. Describe the parts, functions and relationships of the pancreas (and its ducts) and the spleen.

Four Layers of the GI Tract:

 The GI tract consists of four layers:
1. Serosa (=visceral peritoneum):
a. Thin, outermost layer.
2. Tunica muscularis:
a. Consists of two layers of smooth muscle
i. An outer longitudinal coat and an inner circular coat.
3. Submucosa:
a. Layer of connective tissue that contains many vessels (note
arteries branching in this layer).
4. Mucosa:
a. Composed of delicate connective tissue with an epithelial surface.
b. Contains various glands (digestive enzymes & mucus). In small
intestine, mucosa is highly modified to form villi (numerous, tiny, finger-like processes that give mucosa a velvety
texture, and greatly increase the absorptive surface of small intestine; stomach and large intestine lack villi).
 Nerve innervation of GI tract:
o The rhythmic contraction of the smooth muscle of the GI tract to propel contents is termed peristalsis.
o Peristalsis is under the influence of the ANS.
o In fact, two nerve plexuses lie in the wall of the GI tract: the myenteric (Auerbach’s) plexus between the outer
longitudinal and inner circular muscle layers, and the submucous (Meissner’s) plexus.

Parietal Vs. Visceral Peritoneum & Peritoneal Vs. Retroperitoneal Organs:

1. The peritoneum is a serous membrane that lines the abdominal and pelvic
cavities.
a. Explain that a serous membrane secretes a watery (serous) fluid to
keep the surfaces of the viscera moist.
2. Parietal peritoneum lines the body walls, including the organs that lie on
these walls (eg, the urinary bladder).
a. These organs are referred to as retroperitoneal.
3. Visceral peritoneum completely surrounds the organs (eg, most of small
intestine).
a. These organs are referred to as peritoneal.
b. Peritoneal organs are attached to the body wall by folds of
peritoneum termed mesenteries. The mesenteries, etc. provide a
means by which vessels and nerves can pass to and from the viscera
(eg., point out the branches of the SMA passing to the small intestine in its mesentery.
4. Peritoneal organs are more mobile than retroperitoneal organs.

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Mesentery is a double layer of visceral peritoneum containing fat and blood
vessels. It anchors, protects and nourishes the intestines.

Most Dorsal Parts of Peritoneal Cavity:

 The hepatorenal pouch (of Morrison), between the liver (hepar) anteriorly and the R
kidney (renal) posteriorly, is of clinical importance.
 It lies at the lowest point of the peritoneal cavity when the subject is recumbent.
 Another low point in the peritoneal cavity is the rectovesical pouch (male) or
rectouterine pouch (female).
 Pathological fluids (blood, pus, etc.) may accumulate in these pouches, and be
transported from one pouch to the other depending on the positon of the patient.

Organs of the Abdomen:

 For descriptive purposes the abdomen can be divided into FOUR QUADRANTS by two perpendicular lines
intersecting at the umbilicus.
 The quadrants are designated Right Upper Quadrant (RUQ), Right Lower Quadrant (RLQ) etc.

Factors Affecting Position of Viscera:

 The POSITION OF THE ABDOMINAL VISCERA IS SOMEWHAT VARIABLE.
 Factors affecting the position of the viscera include
o 1) body habitus (as shown here)
o 2) phase of respiration
o 3) position of the body
o 4) degree of distention of hollow organs
o 5) age
o 6) embryological anomalies (eg., the cecum and appendix lying in the RUQ because they fail to descend during
development
7) pathological conditions (eg., tumors) that displace organs.
 Also, recall that peritoneal organs are more mobile than retroperitoneal organs.

Disposition of
Abdominal Viscera:
1. Abdominal
esophagus is a
very short
portion that joins the stomach just below the diaphragm.

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2. Stomach is continuous distally with the duodenum (1st part of small intestine).
3. Small intestine consists of three parts: duodenum, jejunum and ileum. Jejunum + ileum ~ 7meters long, and their coils lie in
both abdomen and pelvis.
4. Large intestine (remainder of GI tract) is only ~1.5 meters long (but is larger in caliber than small intestine).
5. Large intestine consists of cecum (w/appendix attached to it), ascending colon (R side of abdomen), R colic (hepatic) flexure,
transverse colon, L colic (splenic) flexure, descending colon (L side of abdomen), sigmoid colon (lower part of abdomen and
pelvis), rectum and anal canal.
6. Liver and gallbladder develop as outgrowths from the duodenum, and are connected to it by a duct system.
7. Pancreas is also an outgrowth of duodenum, and is connected to it by a duct system.
8. The organs which are retroperitoneal include most of the duodenum, ascending and descending colon, rectum, and the
pancreas. All of the other organs are peritoneal.
 Today I will discuss in detail the organs derived from the embryonic foregut; namely the stomach, duodenum, liver and
gallbladder, pancreas, and the spleen (which is NOT part of the GI tract and is not derived from the foregut).

Parts and Anterior Relationships of Stomach:

 The stomach is the most distensible organ in the body (it can hold 2 -3 liters of food). (A newborn’s stomach, ~ the size of a
lemon, can hold up to 30 mL of milk).
 The stomach has two surfaces (anterior (shown here) and posterior), two curvatures (greater, convex & to the left; lesser,
concave & to the right), and two notches (cardiac notch, where esophagus meets greater curvature; angular notch, ~ two-thirds
of the distance along lesser curvature).
 The stomach has three parts:
1. Fundus: rounded upper end of stomach, above horizontal line running from cardiac notch to gr. curvature. Gas tends to collect
here.
2. Body: Main part of stomach.
3. Pyloric part:
A. Pyloric antrum: proximal, expanded part.
B. Pyloric canal: distal, narrowed part.
 Lesser omentum:
o Sheet of peritoneum attached to lesser curvature (and 1 st part of
duodenum).
o Divided into two parts: hepatogastric lig. & hepatoduodenal lig.
o Epiploic f. is posterior to free edge of hepatoduodenal lig.
 Greater omentum:
o Sheet of peritoneum which hangs down from greater curvature.
 Anterior relationships of stomach: (stomach lies mainly in LUQ).
o L lobe of liver, diaphragm, anterior abdominal wall

Posterior Relationships of Stomach:

Orient (greater omentum cut and stomach has been reflected superiorly).
1. Posterior relationships of stomach (the following organs constitute the
“stomach bed”):
a. Diaphragm, spleen, L suprarenal gland and L kidney, pancreas,
transverse mesocolon, L colic flexure

Function of Stomach:
1. The FUNCTION OF THE STOMACH is the mechanical and chemical breakdown of
food.
a. Mechanical breakdown is by peristalsis (contraction of the smooth
muscle in its wall).
b. Chemical breakdown is accomplished by the secretion of HCL and the
enzyme pepsin (a protein-splitting enzyme).

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 c. CHYME is the name given to the liquid food material resulting from the stomach's digestive processes.
2. The stomach has TWO ORIFICES.
a. The CARDIAC ORIFICE (near the heart) receives food from the esophagus.
i. A functional sphincter is present in the region of the cardiac orifice; its important function is to prevent reflux
of food material and gastric juices into the esophagus.
b. The esophageal mucosa is vulnerable to gastric juices. (The sharp change between the esophageal /gastric mucosa is
marked by a zigzag (Z) line (visible surgically and endoscopically)).
c. The PYLORIC ORIFICE leads into the duodenum.
i. This opening is surrounded by the PYLORUS
3. PYLORIC SPHINCTER, a thickening of the circular muscle layer of the stomach.
a. Most of the time the pyloric orifice is closed when the stomach is digesting food, but the sphincter relaxes
intermittently to allow chyme to pass into the duodenum.
b. Irritation of the sphincter by a nearby ulcer may cause it to spasm, resulting in gastric retention and distension.
(Surgical division of the sphincter may be required, or a surgical anastomosis of the stomach with the jejunum can be
performed (thus by-passing the sphincter)).
c. The mucosa of the stomach is thrown into folds or RUGAE. (The rugae partially disappear as the stomach becomes
distended. (RTW)).

Functions of Greater Omentum:

 The greater omentum can move within the peritoneal cavity to seal off
an inflamed area (eg., an inflamed appendix), thus helping to limit the
spread of infection. (Greater omentum has been termed the
“policeman of the abdomen”).
 Greater omentum also cushions organs against injury and provides
insulation to prevent loss of body heat.

Functions, Parts, and Relationships of Duodenum:

1. The small intestine consists of three parts: 1) duodenum 2) jejunum and 3) ileum.
a. The FUNCTIONS OF THE SMALL INTESTINE include the secretion of digestive enzymes and the absorption of most of the food.
2. Parts and relationships of duodenum: (Overall, the DUODENUM IS C-SHAPED. It is molded around the head of the pancreas.)
a. SUPERIOR (1ST) PART
Inferior: head of pancreas
Anterior: liver & gallbladder (not shown)
Posterior: common bile duct, hepatic portal v.
b. DESCENDING (2ND) PART
Medial: head of pancreas
Anterior: liver & gallbladder (not shown), transverse colon & mesocolon
Posterior: R kidney
c. HORIZONTAL (3RD) PART
Superior: head of pancreas
Anterior: root of mesentery, sup. mesenteric a. & v.
Posterior: R psoas major m., IVC, aorta
d. ASCENDING (4TH) PART
Anterior: root of mesentery
Posterior: L psoas major m.
(The 4th part passes superiorly to join the jejunum at the duodenojejunal (DJ) flexure (try repeating THAT 3X!))
3. All parts of the duodenum are retroperitoneal EXCEPT the 1st part (which is therefore the most mobile).
Relationship of Duodenum to Gallbladder:
 Clinical significance of the close relationship of the 1 st and 2nd parts of the
duodenum to the gallbladder (GB): If the GB becomes inflamed (b/c of impacted
gallstone), it can adhere to the adjacent parts of the GI tract (duodenum and
transverse colon).
 Tissue breaks down and a fistula develops.
 Large gallstone could then pass into the duodenum and become lodged at the
ileocecal valve, with consequent bowel obstruction.

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 Gas from GI tract could also pass into gallbladder via a fistula, providing a diagnostic radiographic sign.

“Nutcracker:”
Clinical significance of duodenal relationships.
 The sup. mesenteric vessels pass anterior to the 3rd part of the duodenum and may even compress it to the
degree that there is interference with the passage of its contents. This is termed sup. mesenteric a. syndrome
and may cause nausea and vomiting.
 LRV= left renal vein
 DUO= duodenum (3rd part)
 SI= small intestine

Mucosa of Duodenum:
 The INTERIOR OF THE DUODENUM shows CIRCULAR FOLDS in most of
its parts.
o These folds increase the surface area for the absorption of
foods.
 Inside the 2nd part of the duodenum is a projection termed the MAJOR
DUODENAL PAPILLA.
o This papilla marks the common opening of the common bile
duct and the main pancreatic duct.
o Slightly more superiorly there may be a MINOR DUODENAL
PAPILLA marking the opening of the accessory pancreatic duct.
 CA of pancreas (head) could obstruct duodenum because of close
anatomical relationship between the two organs.

Functions and Relationships of Liver:

1. The liver is the largest gland in the body (1/40th of total body weight in adult; RTW).
2. The liver is said to be the MOST VASCULAR ORGAN IN THE BODY. Because of its softness and vascularity injuries to the liver
result in severe bleeding.
3. The liver performs many important FUNCTIONS. These include:
1) secretion of bile (important for digestion of fats)
2) secretion of hormones
3) metabolism of products of digestion
4) metabolism of drugs and toxins
5) synthesis of serum proteins and lipids
6) elimination of old cells and particulate matter from blood
7) production of blood cells (during fetal life).
Needless to say, the liver is essential to life! Nevertheless, it has been
estimated that one-third of the liver is adequate to maintain normal
function.
RELATIONSHIPS:
4. The liver lies primarily in the RUQ. It has two surfaces which are
separated by a sharp inf. border. The fundus of the gallbladder
projects below the inferior border. The DIAPHRAGMATIC SURFACE is smooth and convex. Through the diaphragm the liver is
related to the bases of the R and L lungs (hepatic abscesses in the liver may perforate the diaphragm and enter the pleural
cavities and bases of the lungs). The diaphragmatic surface is separated into R and L lobes by the falciform lig. The falciform lig.
is a fold of peritoneum which connects the liver to the anterior abdominal wall and to the diaphragm. The free edge of the
falciform lig. contains the round lig. of the liver (obliterated umbilical v.). The coronary ligament is also a reflection of
peritoneum from the liver onto the diaphragm. At its right and left extremities, the coronary ligament ends as the R and L
triangular ligs.

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Relationships of Liver:
Orient students
Relationships:
 The VISCERAL SURFACE of the liver shows impressions for the
organs related to it.
 The R lobe is related to the R kidney and suprarenal gl., the R
colic (hepatic) flexure and the duodenum.
 The L lobe is related to the abdominal part of the esophagus
and the stomach.
 The visceral surface also has caudate and quadrate lobes. The
quadrate lobe is four-sided.
o The caudate lobe is so named because it has a caudate
(tail-like) process.
 THE FOUR LOBES ON THE VISCERAL SURFACE ARE SEPARATED
BY A PATTERN OF FISSURES AND SULCI WHICH RESEMBLE THE
LETTER H.
o The fissures for the lig. venosum and lig. teres (round lig.) form one vertical bar of the letter H.
o The sulci (grooves) for the IVC and gallbladder form the other vertical bar.
o The cross bar of the H is termed the porta hepatis ("gate" of the liver).
 The porta hepatis is where the branches of the proper hepatic a., portal v. and common hepatic duct enter or
leave the liver.

Contents of the Hepatoduodenal Ligament:

1. The LESSER OMENTUM is a double-layered sheet of peritoneum.
1. It has TWO PARTS:
1) HEPATOGASTRIC LIG. (from liver to lesser
curvature of stomach)
2) HEPATODUODENAL LIG. (from liver to 1st part
of duodenum).
Posterior to the free edge of the hepatoduodenal lig. is the EPIPLOIC
FORAMEN (which connects the lesser and greater sacs of the
peritoneal cavity).
2. Embedded within the hepatoduodenal lig. (ie., between its two
layers) can be seen the common bile duct, portal v. and proper
hepatic a. as they course toward the porta hepatis.
3. The relationships of the structures w/in hepatoduodenal
ligament:
1. Common bile duct (on right)
2. Hepatic artery (on left)
3. Hepatic portal vein (posterior)

Functional Lobes of Liver:

 In addition to the anatomical lobes of the liver, R & L FUNCTIONAL LOBES can be
recognized. Each functional lobe is further subdivided into lateral and medial
divisions, which in turn are divided into segments (I-VIII). The division of the liver into
functional lobes, etc. is based on the branching and distribution of the hepatic ducts,
hepatic arteries and portal vein.
 Since each of the 8 hepatic segments (I – VIII) has its own blood supply
and biliary drainage, it is possible to surgically resect an individual
segment damaged by injury or disease

Functions of Gallbladder:
1. BILE is produced by the liver, STORED & CONCENTRATED BY THE
GALLBLADDER, and released after a fatty meal.
2. The release of bile from the gallbladder is under the influence of a
hormone, CHOLECYSTOKININ.

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 a. This hormone is produced by the mucosa of the duodenum after gastric contents reach it.
3. In addition to causing contraction of the gallbladder the hormone relaxes the sphincters around the hepatopancreatic ampulla,
common bile duct and main pancreatic duct. Thus bile and pancreatic enzymes reach the duodenum.

Extrahepatic Bile Ducts and Part of Gallbladder:

Extrahepatic bile ducts:
 Bile leaves the liver via the R & L HEPATIC DUCTS which unite to form the
COMMON HEPATIC DUCT.
 The CYSTIC DUCT from the gallbladder joins the common hepatic duct to
form the COMMON BILE DUCT.
 The common bile duct in turn unites with the main pancreatic duct to form
the HEPATOPANCREATIC AMPULLA (OF VATER) which opens into the 2nd
part of the duodenum at the MAJOR DUODENAL PAPILLA.
Parts of gallbladder:
 The gallbladder is a pear-shaped organ of very variable size (capacity of ~
50mL).
 The GALLBLADDER consists of a FUNDUS (which projects below the inferior
margin of the liver), a BODY and a NECK.
 (The infundibulum (Hartmann’s pouch) is a diverticulum in the region of the
neck of the gallbladder and has been shown to be a pathologic feature. The
infundibulum is a common site for impaction of gallstones).
 The CYSTIC DUCT has a SPIRAL VALVE inside of it to keep the duct open and allow bile to flow in either direction.
 The mucosa of the gallbladder has a honey-comb appearance, which allows it to concentrate bile 6X – 10X (RTW).
 Sometimes GALLSTONES form in the gallbladder.
o A gallstone is a concretion composed chiefly of cholesterol crystals.
o Gallstones are much more common in females, and incidence increases w/age.
 (However, in ~ 50% of people, gallstones are “silent” (asymptomatic).
o One factor which is believed to contribute to gallstone formation is the sluggish flow of bile and the resultant
absorption of water from it).
o Gallstones may lodge anywhere along the biliary tree but most commonly do so at the ampulla.
 Blockage of the biliary tree causes JAUNDICE (bile in the blood, with yellowing of the skin and mucous membranes).
 Cancer of the head of the pancreas can also result in jaundice because the common bile duct is embedded in it.

Parts and Relationships of Pancreas:

1. The PANCREAS is a RETROPERITONEAL ORGAN which lies obliquely across the
post. abdominal wall. Its deep position means that it is inaccessible to physical
examination.
2. The pancreas is a large, flat, finely lobulated organ. It consists of FOUR PARTS:
a. The HEAD, which lies to the right of the midline, is surrounded by the
duodenum. It has an uncinate process projecting to the left from its lower portion.
b. The NECK is a somewhat constricted portion.
c. The BODY is the middle part.
d. The TAIL is the left extremity of the pancreas; it reaches the hilus of the spleen.
3. Relationships:
Posterior:
Common bile duct, hepatic portal v. (formed by union of superior mesenteric v. &
splenic v. behind neck of pancreas), IVC, aorta, origin of SMA, L kidney.
Anterior:
Attachment of transverse mesocolon, stomach, lesser sac.
Superior:
The splenic a. runs along the sup. border of the pancreas

Exocrine Functions of Pancreas:

 The pancreas is BOTH AN EXOCRINE & AN ENDOCRINE GLAND.
 The EXOCRINE PART secretes digestive enzymes (protein-, carbohydrate-, and fat-splitting
enzymes).
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 These reach the duodenum via the main and accessory pancreatic ducts. (These ducts open into the 2nd part of the duodenum
at the major and minor duodenal papillae, as noted earlier).
 The main duct has a "herring bone" appearance since it receives obliquely oriented tributaries as it passes toward the
duodenum.

Endocrine Function of Pancreas:

 The ENDOCRINE PART secretes hormones (insulin and
glucagon) which are essential for the regulation of
carbohydrate metabolism.
 The cells which secrete these hormones are located in the
Islets of Langerhans. (The pancreas has a rich blood supply
in keeping with its endocrine function).
 (The acini are made of cells which secrete the digestive
enzymes).

Relationship of the Spleen:

 The SPLEEN is a PERITONEAL ORGAN which lies in the LUQ.
 It has TWO SURFACES.
1. The DIAPHRAGMATIC SURFACE is smooth and convex and is
related not only to the diaphragm but to the lower ribs (9-11)
on the left side. Fracture of these ribs could penetrate the
highly vascular spleen and cause severe hemorrhage.
2. The VISCERAL SURFACE shows impressions for the organs to
which it is related; namely, the stomach, L kidney, L colic
(splenic) flexure and the tail of the pancreas. The HILUS OF
THE SPLEEN is the area where the splenic a. and v. enter and
leave the spleen.
Optional:
 The spleen is normally about fist-sized. In such cases it is not palpable. An
enlarged spleen (SPLENOMEGALY) may be 10X the normal size! One cause
of this condition is liver disease such as alcoholic cirrhosis which causes the backup of blood in the splenic vein and enlargement
of the spleen. Enlarged spleens are palpable.
 Removal of the spleen (SPLENECTOMY) is done when bleeding cannot be stopped following severe trauma. The spleen is also
removed in certain blood disorders. In such cases accessory spleens (small nodules of splenic tissue near the hilus of the spleen),
if present, are also removed.

Structure and Functions of the Spleen:

 The spleen is surrounded by a fibrous capsule which is thin and easily
torn. (The spleen is the most frequently injured abdominal organ).
 Extending inward from the capsule are partitions or trabeculae which
carry blood vessels to and from the pulp of the spleen.
 Histologically the spleen is composed of WHITE PULP (lymphatic
tissue) and RED PULP (blood sinusoids).
o The white pulp produces lymphocytes and occurs as small
grayish islands of tissue scattered throughout the red pulp.
 The spleen is the largest lymphatic organ in the body.
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o The red pulp is composed of blood sinusoids (a type of blood vessel) and serves to filter the blood (removes dead and
dying red blood cells).
 The red pulp also stores and releases large quantities of blood into the circulation when necessary (eg.,
following hemorrhage in some other part of the body).
 It can do this because the capsule and trabeculae have smooth muscle in them which contracts under
sympathetic stimulation. (Prenatally, the spleen is a blood-forming organ).