Abdomen 2023

Nutrition, Metabolic Diseases and the
Gastrointestinal Tract (NMDG 2081)

ANATOMY OF THE ABDOMEN
BY: SOLOMON TIBEBU (BSc, MD, MSc)
AAU, CHS, SOM
By : Dr. Solomon Tibebu (AAU, CHS)

Introduction
• The abdomen is the part of the trunk between
the thorax and the pelvis.
• It is a flexible, dynamic container, housing most
of the organs of the digestive system and part
of the urogenital system.
• Boundaries of the abdominopelvic cavity–
1) Musculoaponeurotic walls anterolaterally,
2) The diaphragm superiorly, and
3) The muscles of the pelvis inferiorly,
Suspended between and supported by two bony
rings the inferior margin of the thoracic skeleton
superiorly and pelvic girdle inferiorly) linked by a
semirigid lumbar vertebral column in the posterior
abdominal wall.
4Fs - FAT, FEACES, FLATUS, FLUID

FUNCTIONS
• Houses and protects major
viscera
• One of the most important
roles of the abdominal wall is
to assist in breathing
• Increased intra-abdominal
pressure assists in voiding the
contents of the bladder and
rectum and in giving birth.
Upper extent - Nipple, tip of
scapula
Abdominal Regions
(Reference Planes , and Quadrants)
• Clinicians refer to nine regions of the
abdominal cavity to describe the location
of abdominal organs, pains, or
pathologies.
• The nine regions are delineated by four
planes:
1) Two sagittal (vertical)- mid clavicular -
midinguinal point or semilunar
2) Two transverse (horizontal) planes.
 Subcostal plane(most commonly used),
passing through the inferior border of the
10th costal cartilage on each side or
transpyloric plane.
 The trans-tubercular plane, passing
through the iliac tubercles or interspinous
plane(passing through ASIS)

The 9 regions

Abdominal quadrants

Anterolateral Abdominal Wall
• Although the abdominal wall is
continuous, it is subdivided into the
anterior wall, right and left lateral walls
(flanks), and posterior wall for
descriptive purposes
• The abdominal wall consists partly of
bone but mainly of muscle.
• The skeletal elements of the wall are:
1) The five lumbar vertebrae and their intervening
intervertebral discs
2) The superior expanded parts of the pelvic bones
3) Bony components of the inferior thoracic wall including
the costal margin, rib XII, the end of rib XI and the
xiphoid process

Anterolateral Abdominal Wall…cont
• Muscles make up the rest of the
abdominal wall:
1) lateral to the vertebral column, the
quadratus lumborum, psoas major,
and iliacus muscles reinforce the
posterior aspect of the
2) lateral parts of the abdominal wall are
predominantly formed by three layers
of muscles(transversus abdominis,
internal oblique, and external
oblique;
3) anteriorly, a segmented muscle (the
rectus abdominis) on each side spans
the distance between the inferior
thoracic wall and the pelvis.

Structure of the Anterior/anterolateral Abdominal Wall
• The anterior abdominal wall is made up of skin, superficial fascia,

deep fascia, muscles, extraperitoneal fascia, and parietal
peritoneum.
1) Skin
The skin is loosely attached to the underlying structures except at the umbilicus
The natural lines of cleavage in the skin are constant and run downward and forward almost
horizontally around the trunk.
If possible, all surgical incisions should be made in the lines of cleavage where the bundles of
collagen fibers in the dermis run in parallel rows. An incision along a cleavage line will heal as a
narrow scar, whereas one that crosses the lines will heal as wide or heaped-up scars.
Nerve supply – ventral rami of T7-T11 + Subcostal nerve + L1

2) Superficial Fascia
• The superficial fascia is divided
into:
1) A superficial fatty layer (fascia
of Camper) and
2) A deep membranous layer
(Scarpa's fascia).
The fatty layer is continuous with
the superficial fat over the rest of
the body and may be extremely
thick (8 cm or more in obese
patients).
The membranous layer is thin and
fades out laterally and above
 The membranous layer continues
inferiorly into the perineal region as the
superficial perineal fascia (Colles fascia),
but not into the thighs.

Membranous Layer of Superficial Fascia and the Extravasation of
Urine
• The membranous layer of the superficial
fascia is important clinically because
beneath it is a potential closed space that
does not open into the thigh but is
continuous with the superficial perineal
pouch via the penis and scrotum.
• Rupture of the penile urethra may be
followed by extravasation of urine into
the scrotum, perineum, and penis and
then up into the lower part of the
anterior abdominal wall deep to the
membranous layer of fascia.
• The urine is excluded from the thigh
because of the attachment of the fascia
to the fascia lata
Arrows indicate paths taken by urine in

cases of ruptured urethra.

• When closing abdominal wounds it is usual for a surgeon to put in a
continuous suture uniting the divided membranous layer of
superficial fascia. This strengthens the healing wound, prevents
stretching of the skin scar, and makes for a more cosmetically
acceptable result.
3) Deep Fascia
• The deep fascia in the anterior abdominal wall is merely a thin layer
of connective tissue covering the muscles; it lies immediately deep to
the membranous layer of superficial fascia.

4) Muscles of the Anterior Abdominal Wall
• The muscles of the anterior abdominal wall consist of three broad thin
sheets that are aponeurotic in front; from exterior to interior they are
the:
1) External oblique,
2) Internal oblique, and
3) Transversus.
On either side of the midline anteriorly is, in addition, a wide vertical
muscle, the rectus abdominis

External oblique
• A broad, thin, muscular sheet that arises from the
outer surfaces of the lower eight ribs and fans out to
be inserted into the xiphoid process, the linea alba, the
pubic crest, the pubic tubercle, and the anterior half of
the iliac crest.
• A triangular-shaped defect in the external oblique
aponeurosis lies immediately above and medial to the
pubic tubercle. This is known as the superficial
inguinal ring

External oblique aponeurosis and
associated ligaments
• The lower border of the external oblique
aponeurosis forms the inguinal ligament on each
side.
• This thickened reinforced free edge of the external
oblique aponeurosis passes between the anterior
superior iliac spine laterally and the pubic
tubercle medially.
• Between the anterior superior iliac spine and the
pubic tubercle, the lower border of the
aponeurosis is folded backward on itself, forming
the inguinal ligament and a canal .
• From the medial end of the ligament, the lacunar
ligament extends backward and upward to the
pectineal line on the superior ramus of the pubis.
Its sharp, free crescentic edge forms the medial
margin of the femoral ring

• The lateral part of the posterior edge
of the inguinal ligament gives origin
to part of the internal oblique and
transversus abdominis muscles.
• To the inferior rounded border of the
inguinal ligament is attached the deep
fascia of the thigh, the fascia lata

Internal Oblique
• A broad, thin, muscular sheet that lies
deep to the external oblique; most of
its fibers run at right angles to those of
the external oblique.
• It arises from the lumbar fascia, the
anterior two thirds of the iliac crest,
and the lateral two thirds of the
inguinal ligament
• The muscle fibers radiate as they pass upward and
forward. The muscle is inserted into the lower
borders of the lower three ribs and their costal
cartilages, the xiphoid process, the linea alba, and
the symphysis pubis

Internal oblique… cont
• The internal oblique has a lower free border that
arches over the spermatic cord (or round ligament
of the uterus) and then descends behind it to be
attached to the pubic crest and the pectineal line.
• Near their insertion, the lowest tendinous fibers

are joined by similar fibers from the transversus
abdominis to form the conjoint tendon.
• The conjoint tendon is attached medially to the

linea alba, but it has a lateral free border.
• As the spermatic cord (or round ligament of the uterus)
passes under the lower border of the internal oblique,
it carries with it some of the muscle fibers that are
called the cremaster muscle.

Transversus abdominis
• A thin sheet of muscle that lies deep to
the internal oblique, and its fibers run
horizontally forward.
• It arises from the deep surface of the
lower six costal cartilages (interdigitating
with the diaphragm), the lumbar fascia,
the anterior two thirds of the iliac crest,
and the lateral third of the inguinal
ligament.
• It is inserted into the xiphoid process, the
linea alba, and the symphysis pubis.
• The lowest tendinous fibers join similar
fibers from the internal oblique to form
the conjoint tendon, which is fixed to the
pubic crest and the pectineal line

Rectus Abdominis
• a long strap muscle that extends along the whole length of
the anterior abdominal wall. It is broader above and lies
close to the midline, being separated from its fellow by the
linea alba.
• Origin - arises by two heads, from the front of the
symphysis pubis and from the pubic crest.
• Insertion - It is inserted into the fifth, sixth, and seventh
costal cartilages and the xiphoid process.
• When it contracts, its lateral margin forms a curved ridge
that can be palpated and often seen and is termed the
linea semilunaris(extends from the tip of the ninth costal
cartilage to the pubic tubercle)
Pyramidalis
• The pyramidalis muscle is often absent. It arises by its base
from the anterior surface of the pubis and is inserted into
the linea alba.
• It lies in front of the lower part of the rectus abdominis.

Rectus Sheath
• The rectus sheath is a long fibrous sheath that encloses the rectus
abdominis muscle and pyramidalis muscle (if present) and contains
the anterior rami of the lower six thoracic nerves and the superior
and inferior epigastric vessels and lymph vessels. It is formed mainly
by the aponeuroses of the three lateral abdominal muscles

Rectus sheath …Cont
• For ease of description the rectus sheath is considered at three
levels.
A) Above the costal margin, the anterior wall is formed by the
aponeurosis of the external oblique. The posterior wall is
formed by the thoracic wall that is, the fifth, sixth, and
seventh costal cartilages and the intercostal spaces.
B) Between the costal margin and the level of the anterior
superior iliac spine, the aponeurosis of the internal oblique
splits to enclose the rectus muscle; the external oblique
aponeurosis is directed in front of the muscle, and the
transversus aponeurosis is directed behind the muscle.
C) Between the level of the anterosuperior iliac spine and the
pubis, the aponeuroses of all three muscles form the
anterior wall. The posterior wall is absent, and the rectus
muscle lies in contact with the fascia transversalis.
• It should be noted that where the aponeuroses forming the
posterior wall pass in front of the rectus at the level of the
anterior superior iliac spine, the posterior wall has a free, curved
lower border called the arcuate line. At this site, the inferior
epigastric vessels enter the rectus sheath and pass upward to
anastomose with the superior epigastric vessels

Nerve Supply of Anterior Abdominal Wall Muscles

Hematoma of the Rectus Sheath

Function of the Anterior Abdominal Wall Muscles
• The oblique muscles laterally flex and rotate the trunk.

• The rectus abdominis flexes the trunk and stabilizes the pelvis, and
the pyramidalis keeps the linea alba taut during the process.
• The muscles of the anterior and lateral abdominal walls assist the
diaphragm during inspiration by relaxing as the diaphragm descends
so that the abdominal viscera can be accommodated.
• The muscles assist in the act of forced expiration that occurs during
coughing and sneezing by pulling down the ribs and sternum.

5) Fascia Transversalis
• The fascia transversalis is a thin layer of fascia that lines the
transversus abdominis muscle and is continuous with a similar layer
lining the diaphragm and the iliacus muscle.
• The femoral sheath for the femoral vessels in the lower limbs is
formed from the fascia transversalis and the fascia iliaca that covers
the iliacus muscle

6) Extraperitoneal Fat
• The extraperitoneal fat is a thin layer of connective tissue that

contains a variable amount of fat and lies between the fascia
transversalis and the parietal peritoneum

7) Parietal Peritoneum
• The walls of the abdomen are lined with parietal peritoneum (Fig. 4-
10). This is a thin serous membrane and is continuous below with the
parietal peritoneum lining the pelvis

Nerves of the Anterior Abdominal Wall

Inguinal Canal
• The inguinal canal is an oblique passage through the
lower part of the anterior abdominal wall.
• The canal is about 4 cm long in the adult and extends
from the deep inguinal ring, a hole in the fascia
transversalis, downward and medially to the
superficial inguinal ring, a hole in the aponeurosis of
the external oblique muscle.
• It lies parallel to and immediately above the inguinal
ligament.
• The deep inguinal ring, an oval opening in the fascia
transversalis, lies about 1.3 cm above the inguinal
ligament midway between the anterior superior iliac
spine and the symphysis pubis.
• The superficial inguinal ring is a triangular-shaped
defect in the aponeurosis of the external oblique
muscle and lies immediately above and medial to the
pubic tubercle.

Walls of the Inguinal Canal
Anterior wall:
• Formed along its entire length by the
aponeurosis of the external oblique muscle.
• It is also reinforced laterally by the medial
fibers of the internal oblique muscle because
the lower fibers of the internal oblique
originate from the lateral two-thirds of the
inguinal ligament.
• Furthermore, as the internal oblique muscle covers
the deep inguinal ring, it also contributes a layer
(the cremasteric fascia containing the cremasteric
muscle) to the coverings of the structures
traversing the inguinal canal.

Posterior wall:
• Formed along its entire
length by the transversalis
fascia. It is reinforced
along its medial one-third
by the conjoint tendon
(inguinal falx).
• This tendon is the
combined insertion of the
transversus abdominis
and internal oblique
muscles into the pubic
crest and pectineal line.

• Roof or superior wall: Arching lowest fibers of the internal oblique
and transversus abdominis muscles
• Floor or inferior wall: Upturned lower edge of the inguinal ligament
and, at its medial end, the lacunar ligament.

Contents
• The contents of the inguinal
canal are:
1) The spermatic cord in men;
2) The round ligament of the uterus and
genital branch of the genitofemoral nerve
in women

Coverings and contents of the spermatic cord
• The coverings of the spermatic cord include
the following:
1) Internal spermatic fascia: derived from the
transversalis fascia.
2) Cremasteric fascia: derived from the fascia
of both the superficial and the deep
surfaces of the internal oblique muscle.
3) External spermatic fascia: derived from the
external oblique aponeurosis and its
investing fascia.

Contents of the
spermatic cord
• The structures in the spermatic cord include:
1) the ductus deferens;
2) the artery to ductus deferens (from the inferior
vesical artery);
3) the testicular artery (from the abdominal aorta);
4) the pampiniform plexus of veins (testicular veins);
5) the cremasteric artery and vein (small vessels
associated with the cremasteric fascia);
6) the genital branch of the genitofemoral nerve
(innervation to the cremasteric muscle);
7) sympathetic and visceral afferent nerve fibers;
8) lymphatics;
9) remnants of the processus vaginalis.

Inguinal Hernias
• An inguinal hernia is a protrusion of parietal peritoneum and viscera, such
as the small intestine, through a normal or abnormal opening from the
cavity in which they belong.
• Most hernias are reducible, meaning that they can be returned to their
normal place in the peritoneal cavity by appropriate manipulation.
• Between 80% and 90% of abdominal hernias are in the inguinal region; the
two main types are direct and indirect inguinal hernias.
• Indirect inguinal hernia is formed by the persisting processus vaginalis. If
the entire stalk of the processus vaginalis persists, the hernia extends into
the scrotum superior to the testis, forming a complete indirect inguinal
hernia

Indirect Inguinal Hernia
• The indirect inguinal hernia is the most common

form of hernia and is believed to be congenital in
origin.
• The hernial sac is the remains of the processus
vaginalis (an outpouching of peritoneum
• It follows that the sac enters the inguinal canal
through the deep inguinal ring lateral to the inferior
epigastric vessels.
• It may extend part of the way along the canal or the
full length, as far as the superficial inguinal ring.
• If the processus vaginalis has undergone no
obliteration, then the hernia is complete and
extends through the superficial inguinal ring down
into the scrotum or labium majus. Under these
circumstances the neck of the hernial sac lies at the
deep inguinal ring lateral to the inferior epigastric
vessels, and the body of the sac resides in the
inguinal canal and scrotum (or base of labium
majus).

The indirect inguinal hernia can be summarized as follows:
• It is the remains of the processus vaginalis and therefore is congenital
in origin.
• It is more common than a direct inguinal hernia.
• It is much more common in males than females.
• It is more common on the right side.
• It is most common in children and young adults.

Direct Inguinal Hernia
• The direct inguinal hernia makes up about 15% of all
inguinal hernias.
• The sac of a direct hernia bulges directly anteriorly through
the posterior wall of the inguinal canal medial to the
inferior epigastric vessels.
• Because of the presence of the strong conjoint tendon, this
hernia is usually nothing more than a generalized bulge;
therefore, the neck of the hernial sac is wide.
• Direct inguinal hernias are rare in women and most are
bilateral. It is a disease of old men with weak abdominal
muscles.
• A direct inguinal hernia can be summarized as follows:
 It is common in old men with weak abdominal muscles and is rare in
women.
 The hernial sac bulges forward through the posterior wall of the
inguinal canal medial to the inferior epigastric vessels.
 The neck of the hernial sac is wide.
 An inguinal hernia can be distinguished from a femoral hernia by the
fact that the sac, as it emerges through the superficial inguinal ring,
lies above and medial to the pubic tubercle, whereas that of a femoral
hernia lies below and lateral to the tubercle

Testis, scrotum, acute scrotum, scrotal
swellings

Peritoneum and Peritoneal Cavity

Peritoneum
• The peritoneum is a continuous, glistening and
slippery transparent serous membrane. It lines the
abdominopelvic cavity and invests the viscera.
• The peritoneum consists of two continuous layers:
1) the parietal peritoneum, which lines the internal
surface of the abdominopelvic wall, and
2) the visceral peritoneum, which invests viscera
such as the stomach and intestines.
Both layers of peritoneum consist of mesothelium, a
layer of simple squamous epithelial cells.
Abdominal viscera are either suspended in the
peritoneal cavity by folds of peritoneum (mesenteries)
or are outside the peritoneal cavity.
Organs suspended in the cavity are referred to as

intraperitoneal; organs outside the peritoneal cavity,
with only one surface or part of one surface covered
by peritoneum, are retroperitoneal

Peritoneal folds
(Omenta, mesenteries, and ligaments)
The peritoneal ligaments, omenta, and
mesenteries permit blood, lymph
vessels, and nerves to reach the viscera
1) Omenta – lesser omentum, greater

omentum.
The lesser omentum connects the lesser

curvature of the stomach and the proximal
part of the duodenum to the liver;
A portal triads free edge of the lesser
omentum

Omentum … cont
The greater omentum-
 A prominent peritoneal fold that hangs
down like an apron from the greater
curvature of the stomach and the
proximal part of the duodenum.
 After descending, it folds back and
attaches to the anterior surface of the
transverse colon and its mesentery.

A peritoneal ligaments
• Peritoneal ligaments are two-layered
folds of peritoneum that connect solid
viscera to the abdominal walls. The
liver, for example, is connected to the
diaphragm by the falciform ligament,
the coronary ligament, and the right
and left triangular ligaments.
1) Falciform ligament
2) Hepatogastric ligament
3) Hepatoduodenal ligament
4) Gastrophrenic ligament
5) Gastrosplenic ligament
6) Gastrocolic ligament
7) Coronary ligaments

Mesenteries
• Mesenteries are two-layered folds of peritoneum connecting parts of
the intestines to the posterior abdominal wall, for example,
1) The mesentery of the small intestine (mesentery proper),
2) Mesentery of the transverse colon (the transverse mesocolon), and
3) Sigmoid colon - the sigmoid mesocolon.
4) Mesentey of the appendix – mesoappendix
• The peritoneal ligaments, omenta, and mesenteries permit blood, lymph vessels,
and nerves to reach the viscera.
• The extent of the peritoneum and the peritoneal cavity should be studied in the
transverse and sagittal sections of the abdomen seen

Subdivisions of the Peritoneal Cavity
• The peritoneal cavity is
divided into the greater
and lesser peritoneal sacs.
• The greater sac is the main
and larger part of the
peritoneal cavity. A surgical
incision through the
anterolateral abdominal
wall enters the greater sac.
• The omental bursa (lesser
sac) lies posterior to the
stomach and lesser
omentum.

Lesser sac
• The left margin of the sac is
formed by the spleen and the
gastrosplenic omentum and
splenicorenal ligament.
• The right margin opens into the

greater sac (the main part of the
peritoneal cavity) through
epiploic foramen

• The greater omentum is often
referred to by the surgeons as the
abdominal policeman.
• The lower and the right and left

margins are free, and it moves
about the peritoneal cavity in
response to the peristaltic
movements of the neighboring
gut.

Boundaries of the epiploic foramen
• The opening into the lesser sac (epiploic

foramen) has the following boundaries:
1) Anteriorly: Free border of the lesser
omentum, the bile duct, the hepatic artery,
and the portal vein
2) Posteriorly: Inferior vena cava
3) Superiorly: Caudate process of the
caudate lobe of the liver
4) Inferiorly: First part of the duodenum

Recesses, Spaces, and
Gutters
• Duodenal Recesses
• Cecal Recesses
• Subphrenic Spaces
 The right and left anterior subphrenic spaces
 The right posterior subphrenic space
• Free communication occurs between the
supracolic and the infracolic compartments
through the paracolic gutters, the grooves
between the lateral aspect of the ascending or
descending colon and the posterolateral
abdominal wall.

Movement of Peritoneal Fluid
• The paracolic gutters are of
considerable clinical importance because
they provide pathways for the flow of
ascitic fluid and the spread of
intraperitoneal infections.
• Purulent material (consisting of or
containing pus) in the abdomen can be
transported along the paracolic gutters
into the pelvis, especially when the person
is upright.
• Thus, to facilitate the flow of exudate into
the pelvic cavity where absorption of
toxins is slow, patients with peritonitis are
often placed in the sitting position (at least
a 45° angle).
• Similarly, the paracolic gutters provide
pathways for the spread of tumor cells
that have sloughed from the ulcerated
surface of a tumor and entered the
peritoneal cavity(intraperitoneal
metastasis) ex ovarian ca. By : Dr. Solomon Tibebu (AAU, CHS)
Subphrenic abscess => empyema
• Collection of infected peritoneal fluid in one of the subphrenic spaces
is often accompanied by infection of the pleural cavity.
• It is common to find a localized empyema in a patient with a
subphrenic abscess.
• It is believed that the infection spreads from the peritoneum to the
pleura via the diaphragmatic lymph vessels.

Nerve Supply of the Peritoneum
1) The parietal peritoneum
• The parietal peritoneum is sensitive to pain, temperature, touch, and
pressure.
The parietal peritoneum lining the anterior abdominal wall is supplied by
the lower six thoracic and first lumbar nerves that is, the same nerves that
innervate the overlying muscles and skin.
The central part of the diaphragmatic peritoneum is supplied by the
phrenic nerves;
Peripherally, the diaphragmatic peritoneum is supplied by the lower six
thoracic nerves.
The parietal peritoneum in the pelvis is mainly supplied by the obturator
nerve, a branch of the lumbar plexus.
Abdominal pain originating from the parietal peritoneum is therefore of
the somatic type and can be precisely localized.
An inflamed parietal peritoneum is extremely sensitive to stretching
• An inflamed parietal peritoneum is extremely sensitive to stretching.
This fact is made use of clinically in diagnosing peritonitis.
How? Pressure is applied to the abdominal wall with a single finger over the site of the
inflammation. The pressure is then removed by suddenly withdrawing the finger. The
abdominal wall rebounds, resulting in extreme local pain, which is known as rebound
tenderness.
• It should always be remembered that the parietal peritoneum in the
pelvis is innervated by the obturator nerve and can be palpated by
means of a rectal or vaginal examination.
• An inflamed appendix may hang down into the pelvis and irritate the
parietal peritoneum. A pelvic examination can detect extreme
tenderness of the parietal peritoneum on the right side
Nerve Supply of the Peritoneum
1) The Visceral peritoneum
• The visceral peritoneum is sensitive only to stretch and tearing and is
not sensitive to touch, pressure, or temperature.
• It is supplied by autonomic afferent nerves that supply the viscera or
are traveling in the mesenteries.
• Overdistention of a viscus leads to the sensation of pain.
• The mesenteries of the small and large intestines are sensitive to
mechanical stretching.
• Pain arising from an abdominal viscus is dull and poorly localized

Gastrointestinal Tract
(Abdominal Viscera)

• The principal viscera of the
abdomen are:
1) the terminal part of the
esophagus and
2) the stomach,
3) intestines,
4) spleen,
5) pancreas,
6) liver,
7) gallbladder,
8) kidneys, and
9) suprarenal (adrenal) glands
Esophagus (Abdominal Portion)
• The esophagus is a muscular, collapsible tube about 25 cm long that

joins the pharynx to the stomach.
• The greater part of the esophagus lies within the thorax.
• The esophagus enters the abdomen through an opening in the right
crus of the diaphragm.
• After a course of about 1.25 cm, it enters the stomach on its right
side.
• Has 3 constrictions – cervical, thoracic (arch of aorta), diaphragmatic
1) cervical - pharyngoesophageal junction(cricopharyngeus muscle)

Relations
• The esophagus is related anteriorly to the posterior surface of the left lobe of the
liver and posteriorly to the left crus of the diaphragm. The left and right vagi lie
on its anterior and posterior surfaces, respectively.
Blood Supply
• Arteries -The arteries are branches from the left gastric artery.
• Veins -The veins drain into the left gastric vein, a tributary of the portal vein
(portal-systemic anastomosis).
Lymph Drainage-The lymph vessels follow the arteries into the left gastric nodes.
Nerve Supply - The nerve supply is the anterior and posterior gastric nerves (vagi)
and sympathetic branches of the thoracic part of the sympathetic trunk.

Stomach
Location and Description
• The stomach is the dilated portion of the alimentary canal and has
three main functions:
1) It stores food (in the adult it has a capacity of about 1500 mL),
2) it mixes the food with gastric secretions to form a semifluid chyme,
and
3) it controls the rate of delivery of the chyme to the small intestine so
that efficient digestion and absorption can take place.

Location
• The stomach is situated in the upper part of
the abdomen, extending from beneath the
left costal margin region into the epigastric
and umbilical regions.
• Much of the stomach lies under cover of
the lower ribs.
• It is roughly J-shaped and has two openings,
the cardiac and pyloric orifices; two
curvatures, the greater and lesser
curvatures; and two surfaces, an anterior
and a posterior surface

• The stomach is divided into the following
parts:
1) Fundus: This is dome-shaped and
projects upward and to the left of the
cardiac orifice. It is usually full of gas.
2) Body: This extends from the level of
the cardiac orifice to the level of the
incisura angularis, a constant notch in
the lower part of the lesser curvature.
3) Pyloric antrum: This extends from the
incisura angularis to the pylorus
4) Pylorus: This is the most tubular part of
the stomach. The thick muscular wall is
called the pyloric sphincter, and the
cavity of the pylorus is the pyloric
canal.

Relations
• Anteriorly: The anterior abdominal wall,
the left costal margin, the left pleura and
lung, the diaphragm, and the left lobe of
the liver.
• Posteriorly: The lesser sac, the stomach
bed.
• The bed of the stomach, on which the
stomach rests in the supine position, is
formed by the structures forming the
posterior wall of the omental bursa.
• From superior to inferior, the stomach
bed is formed by the left dome of the
diaphragm, spleen, left kidney and
suprarenal gland, splenic artery,
pancreas, and transverse mesocolon and
colon
Blood Supply
1) Arteries
• The arteries are derived from the
branches of the celiac artery

Veins
• The veins drain into the portal
circulation.
• The left and right gastric veins
drain directly into the portal vein.
• The short gastric veins and the left
gastroepiploic veins join the
splenic vein.
• The right gastroepiploic vein joins
the superior mesenteric vein.

Lymph Drainage
• The lymph vessels follow the arteries into
the left and right gastric nodes, the left and
right gastroepiploic nodes, and the short
gastric nodes.
• All lymph from the stomach eventually
passes to the celiac nodes located around
the root of the celiac artery on the posterior
abdominal wall.
• Because the lymphatic vessels of the mucous
membrane and submucosa of the stomach are in
continuity, it is possible for cancer cells to travel to
different parts of the stomach, some distance away
from the primary site => total gastrectomy

Nerve Supply
The nerve supply includes
 Sympathetic fibers derived from
the celiac plexus, also carry pain
fibers
 Parasympathetic fibers from the
right(posterior trunk) and left
vagus(anterior trunk) nerves.
Gastric ulcer- occur in the alkaline-
producing mucosa of the
stomach(antrum and pyloric canal)
usually on or close to the lesser
curvature.
Chronic ulcer => vagotomy

Small Intestine
• The small intestine is the longest part of the alimentary canal,

consisting of the duodenum, jejunum, and ileum
• The primary site for absorption of nutrients from ingested materials,
and extends from the pylorus to the ileocecal junction where the
ileum joins the cecum (the first part of the large intestine).

Duodenum
• The duodenum is a C-shaped tube, about 25 cm
long.
• It receives the openings of the bile and pancreatic
ducts.
• Most of the duodenum is fixed by peritoneum to
structures on the posterior abdominal wall and is
considered partially retroperitoneal. The duodenum
is divisible into four parts:
1) Superior (first) part: short (approximately 5 cm) and
lies anterolateral to the body of the L1 vertebra.
2) Descending (second) part: longer (7-10 cm) and
descends along the right sides of the L1-L3 vertebrae.
3) Horizontal (third) part: 6-8 cm long and crosses the L3
vertebra.
4) Ascending (fourth) part: short (5 cm) and begins at the
left of the L3 vertebra and rises superiorly as far as the
superior border of the L2 vertebra.
The first 2 cm of the superior part of the duodenum, immediately
distal to the pylorus, has a mesentery and is mobile

First Part of the Duodenum
• The first part of the duodenum begins
at the pylorus and runs upward and
backward on the transpyloric plane at
the level of the first lumbar vertebra.
The relations of this part are as follows:
• Anteriorly: The quadrate lobe of the liver and the
gallbladder
• Posteriorly: The lesser sac (first inch only), the
gastroduodenal artery, the bile duct and portal vein,
and the inferior vena cava
• Superiorly: The entrance into the lesser sac (the
epiploic foramen)
• Inferiorly: The head of the pancreas

Second Part of the
Duodenum
• The second part of the duodenum runs
vertically downward in front of the
hilum of the right kidney on the right
side of the second and third lumbar
vertebrae.
The relations of this part are as follows:
• Anteriorly: The fundus of the gallbladder and the right
lobe of the liver, the transverse colon, and the coils of the
small intestine.
• Posteriorly: The hilum of the right kidney and the right
ureter
• Laterally: The ascending colon, the right colic flexure,

and the right lobe of the liver
• Medially: The head of the pancreas, the bile duct, and

the main pancreatic duct
Third Part of the Duodenum
• The third part of the duodenum runs
horizontally to the left on the subcostal
plane, passing in front of the vertebral
column and following the lower margin
of the head of the pancreas.
• The relations of this part are as
follows:
1) Anteriorly: The root of the mesentery of
the small intestine, the superior mesenteric
vessels contained within it, and coils of
jejunum.
2) Posteriorly: The right ureter, the right
psoas muscle, gonadal aa, the inferior vena
cava, and the aorta, inferior mesenteric aa
3) Superiorly: The head of the pancreas
4) Inferiorly: Coils of jejunum
Superior mesenteric aa
syndrome
• The superior mesenteric artery arises from the
anterior aspect of the aorta at the level of the L1
vertebral body. It is enveloped in fatty and lymphatic
tissue and extends in a caudal direction at an acute
angle into the mesentery.
• In the majority of patients, the normal angle between the
superior mesenteric artery and the aorta is between 38
and 65 degrees.

Fourth Part of the Duodenum
• The fourth part of the duodenum runs
upward and to the left to the
duodenojejunal flexure.
• The flexure is held in position by a
peritoneal fold, the ligament of Treitz,
which is attached to the right crus of the
diaphragm.
• The relations of this part are as follows:
• Anteriorly: The beginning of the root of the
mesentery and coils of jejunum
• Posteriorly: The left margin of the aorta and
the medial border of the left psoas muscle

Blood Supply
Arteries
• The upper half is supplied by the superior pancreaticoduodenal artery.
• The lower half is supplied by the inferior pancreaticoduodenal artery, a branch of the superior mesenteric
artery.
Veins
• The superior pancreaticoduodenal vein drains into the portal vein;
• the inferior vein joins the superior mesenteric vein (Fig. 5-22).
Lymph Drainage
• The lymph vessels follow the arteries and drain upward via pancreaticoduodenal nodes to the
gastroduodenal nodes and then to the celiac nodes and downward via pancreaticoduodenal nodes to the
superior mesenteric nodes around the origin of the superior mesenteric artery.
Nerve Supply
• The nerves are derived from sympathetic and parasympathetic (vagus) nerves from the celiac and superior
mesenteric plexuses.

Clinical Notes
1) Trauma to the Duodenum
• Apart from the first inch, the duodenum is rigidly fixed to the posterior
abdominal wall by peritoneum and therefore cannot move away from
crush injuries. In severe crush injuries to the anterior abdominal wall, the
third part of the duodenum may be severely crushed or torn against the
third lumbar vertebra.
2) Duodenal Ulcer
• An ulcer of the anterior wall of the first inch of the duodenum may
perforate into the upper part of the greater sac, above the transverse colon
=> chemical peritonitis.
• An ulcer of the posterior wall of the first part of the duodenum may
penetrate the wall and erode the relatively large gastroduodenal artery,
causing a severe hemorrhage.

Jejunum and Ileum
• The jejunum and ileum measure about 6 m long;
the upper two fifths of this length make up the
jejunum.
• The jejunum begins at the duodenojejunal
flexure, and the ileum ends at the ileocecal
junction.
• freely mobile and are attached to the posterior
abdominal wall by a fan-shaped fold of
peritoneum known as the mesentery of the small
intestine
• The root of the mesentery permits the entrance
and exit of the branches of the superior
mesenteric artery and vein, lymph vessels, and
nerves into the space between the two layers of
peritoneum forming the mesentery.

In the living, the jejunum can be distinguished from the ileum by the
following features:
• The jejunum lies coiled in the upper part of the peritoneal cavity
below the left side of the transverse mesocolon; the ileum is in the
lower part of the cavity and in the pelvis.
• The jejunum is wider bored, thicker walled, and redder than the
ileum. The jejunal wall feels thicker because the permanent infoldings
of the mucous membrane, the plicae circulares, are larger, more
numerous, and closely set in the jejunum, whereas in the upper part
of the ileum whereas in the upper part of the ileum they are smaller
and more widely separated and in the lower part they are absent

• The jejunal mesentery is attached to the posterior abdominal wall above and to
the left of the aorta, whereas the ileal mesentery is attached below and to the
right of the aorta.
• The jejunal mesenteric vessels form only one or two arcades, with long and
infrequent branches passing to the intestinal wall. The ileum receives numerous
short terminal vessels that arise from a series of three or four or even more
arcades (Fig. 5-31).
• At the jejunal end of the mesentery, the fat is deposited near the root and is
scanty near the intestinal wall. At the ileal end of the mesentery the fat is
deposited throughout so that it extends from the root to the intestinal wall.
• Aggregations of lymphoid tissue (Peyer's patches) are present in the mucous
membrane of the lower ileum along the antimesenteric border. In the living these
may be visible through the wall of the ileum from the outside.
Neuro-vasculature
• Mid gut – 2nd part of duode, J & I,
Cecum, appendix, AC, 2/3 TC =
Superior mesenteric aa
Inferior pancreaticoduodenal aa
Ileal aa
Jejunal aa
Ilio-colic
Rt. Colic
Middle colic
Lymph Drainage
• The lymph vessels pass through several mesenteric
nodes and finally reach the superior mesenteric nodes.
Nerve Supply
• Branches from the sympathetic and parasympathetic
(vagus) nerves form the superior mesenteric plexus

Large intestine
The large intestine extends
from the ileocecal junction to
the anus. About 1.5m long.
• Cecum
• Appendix
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon
• Rectum

Ileocecal Valve
• A rudimentary structure, the ileocecal
valve consists of two horizontal folds of
mucous membrane that project around
the orifice of the ileum.
• The valve plays little or no part in the
prevention of reflux of cecal contents
into the ileum.
• The circular muscle of the lower end of
the ileum (called the ileocecal sphincter
by physiologists) serves as a sphincter
and controls the flow of contents from
the ileum into the colon.

Appendix
• The appendix is a narrow, muscular tube containing a large amount of
lymphoid tissue.
• It varies in length from 8 to 13 cm.
• The base is attached to the posteromedial surface of the cecum about
2.5 cm below the ileocecal junction.
• The remainder of the appendix is free.
• It has a complete peritoneal covering, which is attached to the
mesentery of the small intestine by a short mesentery of its own, the
mesoappendix. The mesoappendix contains the appendicular vessels
and nerves.

Vermiform appendix
Worm like diverticulum arising from the
posteromedial wall of the caecum
about 2cm below the ileocaecal orifice.
Positions of the appendix
1. Reterocaecal - behind the caecum –
commonest position – 65%
2. Preileal or post ileal – pass upwards to the
left. It points towards the spleen- 2 O’clock.
3. Pelvic -descending into the pelvis. The 2nd
common position.

• The relevant features of the large
intestine are as follows:
1. Wider in caliber than the small
intestine.
2. The greater part is fixed except for the
appendix, the TC, and the sigmoid
colon.
3. Taeniae coli – three ribbon like bands
thickened longitudinal muscle coat.
Converge at the base of the appendix.
4. The position of taeniae coli for
ascending, descending and caecum
- anterior (taeniae libera)
- posteromedial(taeniae mesocolica
- posterolateral (taeniae omentalis)
- Inferior, superior and posterior for TC
Rectum and Anal Canal
• The rectum is the fixed (primarily retroperitoneal and subperitoneal)
terminal part of the large intestine.
• It is continuous with the sigmoid colon at the level of S3 vertebra.

Accessory Organs of the Gastrointestinal Tract

THE LIVER
Surface Anatomy of the Liver
• The liver lies mainly in the right upper
quadrant of the abdomen where it is
hidden and protected by the thoracic
cage and diaphragm.
• The normal liver lies deep to ribs 7-11
on the right side and crosses the
midline toward the left nipple.
• Consequently, the liver occupies most
of the right hypochondrium, the upper
epigastrium, and extends into the left
hypochondrium.
Liver
• The liver is the largest gland in the body and has a wide variety of
functions.
• Three of its basic functions are:
1) production and secretion of bile,
2) involvement in many metabolic activities related to carbohydrate,
fat, and protein metabolism; and
3) filtration of the blood, removing bacteria and other foreign particles
that have gained entrance to the blood from the lumen of the
intestine.

• The liver may be divided into a large right lobe
and a small left lobe by the attachment of the
peritoneum of the falciform ligament.
• The right lobe is further divided into a quadrate
lobe and a caudate lobe by the presence of the
gallbladder, the fissure for the ligamentum teres,
the inferior vena cava, and the fissure for the
ligamentum venosum
• The liver has a convex diaphragmatic surface
(anterior, superior, and some posterior) and a
relatively flat or even concave visceral surface
(posteroinferior),
• The diaphragmatic surface of the liver is covered
with visceral peritoneum, except posteriorly in the
bare area of the liver where it lies in direct
contact with the diaphragm

• The visceral surface of the liver
is covered with peritoneum
except at the fossa for the
gallbladder and the porta
hepatis.
• In contrast to the smooth
diaphragmatic surface, the
visceral surface bears multiple
fissures and impressions from
contact with other organs

Blood Vessels of the Liver
• The liver, like the lungs, has a dual blood supply (afferent vessels):
1) Venous source (hepatic portal vein)
brings 75-80% of the blood to the liver,
containing about 40% more oxygen than blood returning to the heart from systemic
circuit
carries virtually all of the nutrients absorbed by the alimentary tract (except lipids
sustains the liver parenchyma (liver cells or hepatocytes
2) Arterial one –
Arterial blood from the hepatic artery,
accounting for only 20 - 25% of blood received by the liver,
is distributed initially to non-parenchymal structures, particularly the intrahepatic
bile ducts.

Portal circulation and
portocaval anastomosis
• Portal vein is formed anterior to the IVC
and posterior to the neck of the
pancreas (close to the level of the L1
vertebra and the transpyloric plane) by
the union of the superior mesenteric
and splenic veins.
• Portal Hypertension
• When scarring and fibrosis from cirrhosis
obstruct the portal vein in the liver,
pressure rises in the portal vein and its
tributaries, producing portal
hypertension.

Biliary Ducts and Gallbladder
• The biliary ducts convey bile from the liver to the
duodenum. Bile is produced continuously by the liver
and stored and concentrated in the gallbladder,
which releases it intermittently when fat enters the
duodenum. Bile emulsifies the fat, so that it can be
absorbed in the distal intestine.
• bile canaliculi => small interlobular biliary ducts =>
large collecting bile ducts of the intrahepatic portal
triad=> merges to form the right and left hepatic
ducts.
• The right and left hepatic ducts drain the right and
left (parts of the) liver, respectively.
• Shortly after leaving the porta hepatis, the right and
left hepatic ducts unite to form the common hepatic
duct, which is joined on the right side by the cystic
duct to form the bile duct (part of the extrahepatic
portal triad of the lesser omentum), which conveys
the bile to the duodenum.

• The gallbladder (7-10 cm long) lies in the
fossa for the gallbladder on the visceral
surface of the liver.
• The gallbladder has three parts
the:
1) Fundus: the wide end of the organ, projects
from the inferior border of the liver and is
usually located at the tip of the right 9th
costal cartilage in the MCL
2) Body: contacts the visceral surface of the liver,
the transverse colon, and the superior part of the
duodenum.
3) Neck: narrow and tapered; directed toward the
porta hepatis; it makes an S-shaped bend and joins
the cystic duct.

• Understanding the variations in arteries
and bile duct formation is important for
surgeons when they ligate the cystic
duct during cholecystectomy, the
surgical removal of the gallbladder.
• When there is low union, the two ducts
may be joined by fibrous tissue, making
clamping the cystic duct difficult
without injuring the common hepatic
duct.

• Variation in origin and course of cystic
artery.
• A) The cystic artery usually arises from
the right hepatic artery in the
cystohepatic triangle (of Calot),
• Cystohepatic triangle (of Calot),
bounded by:
 the cystic duct,
common hepatic duct, and
visceral surface of the right liver.
B and C. Variations in the origin and
course of the cystic artery occur in
24.5% of people

• Biliary colic
• Acute cholecystitis (calculus, acalculous)
• Choledocholithiasis
• Cholicystoenteric fistula
• Cholecystectomy
• Biliary atresia, cyst
• Sphinicter odi dysfunction (SOD)

Cholecystectomy
• People with severe biliary colic usually have their gallbladders removed. The cystic artery
most commonly arises from the right hepatic artery in the cystohepatic triangle (Calot
triangle).
• Careful dissection of the cystohepatic triangle early during cholecystectomy safeguards
those important structures.
• Errors during gallbladder surgery commonly result from failure to appreciate the
common variations in the anatomy of the biliary system, especially its blood supply.
• Before dividing any structure and removing the gallbladder, surgeons identify all three
biliary ducts, as well as the cystic and hepatic arteries. It is usually the right hepatic
artery that is in danger during surgery and must be located before ligating the cystic
artery.
• Bile duct injury is a serious complication of cholecystectomy, which is estimated to occur
in 1 per 600 cases, and the risk appears to be modestly higher for laparoscopic
cholecystectomy (Sabiston and Lyerly, 1994).
cholecystenteric fistula
• A gallbladder that is dilated and inflamed owing to an impacted
gallstone in its duct may develop adhesions with adjacent
viscera.
• Continued inflammation may break down (ulcerate) the tissue
boundaries between the gallbladder and a part of the
alimentary tract adherent to it, resulting in a cholecystenteric
fistula.
• Because of their proximity to the gallbladder, the superior part
of the duodenum and the transverse colon are most likely to
develop a fistula of this type. The fistula would enable a large
gallstone, incapable of passing though the cystic duct, to enter
the alimentary tract.
• A large gallstone entering the small intestine in this way may
become trapped at the ileocecal valve, producing a bowel
obstruction (gallstone ileus).
• A cholecystenteric fistula also permits gas from the alimentary
tract to enter the gallbladder, providing a diagnostic
radiographic sign.

Pancreas

• elongated, accessory digestive gland, lies in the epigastrium and the left upper
quadrant
• lies retroperitoneally and transversely across the posterior abdominal wall,
posterior to the stomach between the duodenum on the right and the spleen on
the left.
• The transverse mesocolon attaches to its anterior margin.
• The pancreas produces
 An exocrine secretion (pancreatic juice from the acinar cells) that enters the duodenum through the main and accessory
pancreatic ducts.
 Endocrine secretions (glucagon and insulin from the pancreatic islets [of Langerhans]) that enter the blood (Fig. 2.46D).
• For descriptive purposes the pancreas is divided into four parts: head, neck, body,
and tail.
• The head -disc shaped and lies
within the concavity of the
duodenum.
• A part of the head extends to the
left behind the superior mesenteric
vessels and is called the uncinate
process

Main and accessory pancreatic duct

Vasculature

Spleen
• located in the left upper abdominal

quadrant or hypochondrium, where it
receives the protection of the lower
thoracic cage.
• As the largest of the lymphatic organs,
it participates in the body's defense
system as a site of lymphocyte (white
blood cell) proliferation and of
immune surveillance and response.
• It is oval shaped and has a notched
anterior border. It lies just beneath the
left half of the diaphragm close to the
9th, 10th, and 11th ribs. The long axis
lies along the shaft of the 10th rib,

The spleen is connected
• to the greater curvature of the stomach by the gastrosplenic ligament,
which contains the short gastric and gastro-omental vessels;
• to the left kidney by the splenorenal ligament which contains the
splenic vessels


Abdomen 2023

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Nutrition, Metabolic Diseases and the

Gastrointestinal Tract (NMDG 2081)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

• The anterior abdominal wall is made up of skin, superficial fascia,

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

Arrows indicate paths taken by urine in

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

• Near their insertion, the lowest tendinous fibers

• The conjoint tendon is attached medially to the

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

• The oblique muscles laterally flex and rotate the trunk.

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

• The extraperitoneal fat is a thin layer of connective tissue that

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

• The indirect inguinal hernia is the most common

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

Organs suspended in the cavity are referred to as

By : Dr. Solomon Tibebu (AAU, CHS)

1) Omenta – lesser omentum, greater

The lesser omentum connects the lesser

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

By : Dr. Solomon Tibebu (AAU, CHS)

• The right margin opens into the

By : Dr. Solomon Tibebu (AAU, CHS)

• The lower and the right and left

By : Dr. Solomon Tibebu (AAU, CHS)