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CONTENTS ADVANCED ANATOMY 2ND. ED.

Abdomen

Visceral Organs
THE KIDNEYS

Location and External Anatomy

The left and right kidneys lie in the retroperitoneal space on either side of
the spine in the superior lumbar region of the posterior abdominal wall. The
roughly fist sized organs are protected by the 11th and 12th ribs as well as
muscle and fat tissue. They lie in the T12-L3 region, with the right kidney
lying slightly lower due to displacement from the liver. The kidney’s unique
shape includes the convex lateral side and a concave medial surface
containing a vertical cleft called the hilum. The hilum is a small area for the
renal artery and nerves to enter the kidney, and for the renal vein and ureter
to exit. Lying atop the kidneys, on both sides, are the adrenal glands, which
serve an endocrine function in the body and don’t relate functionally to the
kidneys.

Gross Anatomy

The Kidney is composed of 2 regions, namely, the outer renal cortex and
the inner renal medulla. The cortex is light and has a granular appearance.
The darker renal medulla contains cone shaped structures called renal
pyramids, which are separated by renal columns that project inward from
the renal cortex. Each section of renal pyramid and its surrounding renal
columns are called the lobes of the kidney. Every kidney can have a range of
5 to 11 lobes each. The renal pelvis, which is the broadened superior portion
of the ureter, branches into major calices and then further into minor
calices. Minor calices are cup-shaped tubes that enclose the papillae of the
renal pyramids. In this location, the papillae drain urine from the pyramids
into the calices, which then empty into the renal pelvis.

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 Figure 1.0. Anterior frontal section diagram of the gross anatomy and blood
supply of the right kidney.

Nerve and Blood Supply

Because of the kidney’s function in cleansing the blood, they require a rich
supply of blood. During rest the kidneys receive about one quarter of the
heart’s systemic output via the renal arteries. The renal arteries branch off
of the abdominal aorta at right angles between the 1st and 2nd lumbar
vertebrae. When they reach the hilum of the kidney they branch off into five
segmental arteries. Once they enter the renal sinuses they divide even
further into the interlobar arteries. These arteries lie in the renal columns
between each renal pyramid. As they turn the corner over the bases of the
renal pyramids they transform into arcuate arteries where the cortical
radiate arteries project outward into the cortical tissue. Further, the cortical
radiate arteries reach the glomerular capsule via the afferent arteriole then
to the efferent arteriole and out to the peritubular capillaries. The blood
now exits the nephron into the cortical radiate vein, arcuate vein,
interlobar vein, and out the kidney through the renal vein into the inferior
vena cava.

Figure 2.0. Illustration of the path of blood flow entering and exiting the
kidney.

Microscopic Anatomy

The most important structural and functional portion of the kidney is the
nephron. Inside each kidney there are about one million nephron tubules
packed together. The nephron is so important because it produces urine
through filtration, resorption, and secretion. A nephron is composed of 2
structures: the renal corpuscle and the renal tubule. Inside the renal
corpuscle, which lies in the renal cortex, there is a glomerulus (a tuft of
capillaries) and a glomerular capsule surrounding it. The glomerulus is
where filtration occurs. Once the fluid has been filtered in the glomerulus it
leaves and enters the renal tubule. The renal tubule consists of the
proximal convoluted tubule, the nephron loop (Loop of Henle), the distal
convoluted tubule, and the collecting ducts. Throughout the tubules
tubular resorption occurs. Tubular resorption is the return of water and
solutes that were filtered from the blood at the renal corpuscle back into
the blood. This process occurs through active transport, facilitated diffusion,
symport, and osmosis. The structure of the tubules allows for increased time
and surface area for processing the filtrate. The processed urine then enters
the collecting ducts where they eventually drain into the minor calices and
out to the ureters.

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 Figure 3.0. Illustration of the structural characteristics of a nephron. The
vasculature surrounding the nephron loop has been removed for optimal
viewing.

THE URETERS

Gross Anatomy

The structures that follows the kidneys in the urinary tract are called the
ureters. The ureters are 10 inch long tubes that leave the kidney through
the hilum and transport urine to the urinary bladder. They descend
retroperitoneal (behind the peritoneum) through the abdominal cavity and
across the sacroiliac joint, where they then enter the posterolateral corner of
the urinary bladder obliquely. This oblique or angled entrance into the
bladder prevent backflow of urine back into the ureters.

Microscopic Anatomy

The walls of the ureters consist of 3 tissue layers called the mucosa, the
muscularis, and the adventitia. The mucosa layer is made of transitional
epithelium, which has the ability to stretch when urine fills the ureters, and
a lamina propria containing fibroelastic connective tissue for more support.
This layer also contains goblet cells that secrete protective mucous. The
middle tissue, called the muscularis, consists of 2 layers: an inner
longitudinal layer and an outer layer of circular smooth muscle. In the
inferior third of the ureter is a 3rd muscularis layer that helps with peristalsis
of urine. Peristalsis is stimulated in the muscularis layer when urine passes
through the ureters, propelling urine down to the bladder in waves. The
outer tissue of the ureter wall is the adventitia composed of typical
connective tissue.

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 Figure 4.0. The 3 tissue layers of the ureter function as protection,
movement of urine (peristalsis) and structure.

THE URINARY BLADDER

Location in the Body

The urinary bladder is a muscular sac that stores and expels urine out of the
body. It lies inferior to the peritoneal cavity on the pelvic floor and is directly
posterior to the pubic symphysis of the coxal bone. There are slight
differences in males and females in the location of the bladder. In females
the bladder lies anterior to the uterus, vagina, and rectum. In males the
bladder lies anterior to the rectum and the prostate gland lies directly
inferior.

Figure

5.0. Labelled diagram of the urinary bladder, ureters, and urethra of a female.

Gross Anatomy

The shape of the bladder depends on whether or not it is empty or full. A full
bladder is roughly spherical and as it gets more full it pushes superiorly into
the abdominal cavity. In contrast, an empty bladder has the shape of an
upside down pyramid, with 4 corners and triangular surfaces. The
posterolateral surface, again, is where the ureters enter the bladder
obliquely. The anterior angle (apex) is made of a fibrous band called the
urachus. Urachus means “urinary canal of the fetus” and is a closed part of
what used to be an embryonic tube called the allantois. The inferior angle,
also called the neck, is the area that drains urine from the bladder and into
the urethra for excretion. A significant area inside the urinary bladder, called
the trigone, is where the openings for both ureters and the urethra form a
triangular area. This area is important clinically as it is a common site of
infection persistence. Conditions related to the urinary tract are further
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described in the Clinical Conditions section of the Abdomen. Next: Glands of the Abdomen
 Microscopic Anatomy

Just like the ureters, the urinary bladder consists of 3 layers: a

mucosa/lamina propria, a muscularis, and an adventitia. The muscularis
layer, more often called the detrusor muscle, is made up of very intertwined
smooth muscle fibers. These fibers are arranged in an inner and outer
longitudinal layer and an inner circular layer. When the detrusor muscle
(de-tru’sor; “to thrust out”) contracts during urination, it squeezes the urine
out of the bladder. In a state of emptiness the bladder collapses into its
pyramidal shape and the inner mucosa forms folds, or rugae. As urine
accumulates, the walls of the bladder stretch and the rugae flatten,
allowing for adequate amounts of urine to be stored with a low pressure
change. Because of the bladders great ability to stretch and distend, a full
adult bladder can hold about 500ml of urine, which is 15 times the volume
at empty.

Figure 6.0. Image (with most internal organs removed) of the gross
anatomy of the kidneys connecting to the urinary bladder via the ureters.
Notice how the ureters exit the kidney through the hilum and enter the
urinary bladder at an angle obliquely.

THE URETHRA

The function of the urethra as part of the urinary tract is to simply transport
urine out of the body in women, and urine and semen out of the body in
men. Micturition, which is also known as voiding or urination, is the process
of emptying the bladder via the urethra. The urethra is a thinly lined lube
consisting of an inner mucosa and smooth muscle. Where the bladder and
urethra meet, the detrusor muscle thickens to form the internal urethral
sphincter. The function of this sphincter is to keep the urethra closed when
urine isn’t being passed through. The second, and last, sphincter of the
urethra is called the external urethral sphincter. It is formed by a skeletal
muscle called the urogenital diaphragm, and inhibits urination that isn’t
voluntary. There are also some vast differences of the urethra in men and
women. In women the urethra is very short (~3-4 cm) and opens at the
external urethral orifice posterior to the clitoris. The very short urethra is a
large reason why women are much more susceptible to urinary tract
infections, as it is easier for bacteria to travel through the urethra to the
bladder. In males, the urethra is roughly 5 times the length of a females (~20
cm) and is composed of three regions: the prostatic urethra, the
membranous urethra, and the spongy urethra. The prostatic urethra runs
through the prostate gland for about 2.5 cm and then transitions into the
membranous urethra, which runs through the membrane-like urogenital
diaphragm muscle for another 2.5 cm. The spongy urethra, the longest
portion, is about 15 cm long and passes through the entire length of the
penis where it opens at the tip via the external urethral orifice.

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 Figure 7.0. Illustration of a male urethra highlighting the 3 sections of the
urethra: prostatic, membranous, and spongy.

THE SPLEEN

The spleen is a secondary organ of the lymphatic system, where it filters

blood and most importantly acts as the location of immune responses to
blood-borne pathogens. The spleen is located in the upper right quadrant of the abdomen, it’s
located under the rib cage and diaphragm.The roughly fist sized organ, which is the
largest lymphoid organ, attaches to the lateral border of the stomach by
means of the gastrosplenic ligament and is about 5 inches in length. Its
concave anterior surface gives it a jellyfish like shape, curving around the
left side of the stomach. The spleen it has two important ligaments; the gastrosplenic and the
splenorenal ligaments. The outside of the spleen has two surfaces: gastric and
renal. The splenic artery and vein enter the spleen through the hilum on
the gastric surface. Its outer capsule consists of dense irregular connective
tissue and some smooth muscle. The connective tissue capsule fibers form
bundles, called trabeculae, which extend inside the spleen to divide it into
multiple compartments. Inside each of these splenic compartments is an
area of red pulp (mostly red blood cells) and an area of white pulp (similar
to lymphoid follicles in a lymph node). The white pulp provides immune
function to the spleen while the red pulp is responsible for the spleen’s
ability to dispose of old and worn out blood cells. The white pulp consists of B and T
lymphocytes surrounding the arteries of the spleen and the red pulp is made up of mostly splenic cords
and venous sinuses. The spleen is also a storage center for blood platelets for life.

Figure 8.0. Cross section of the spleen showing the inner tissues separated
into compartments by the trabeculae.

Gallbladder

This muscular sac is made up of the neck, body, and fundus. The gallbladder
has many ducts attached to it. The cystic duct is the first duct coming out of
the neck of the gallbladder, it joins with the common bile duct and
common hepatic duct. The cystic duct has heister lining the walls which are
mucosal folds, that helps move bile through the duct. The gallbladder can
store 30-50 ml of bile at one time, and the parasympathetic nervous system
contracts the gallbladder to release the bile into the biliary tree. The
common duct is connected to the bile duct and two ducts from each lobe of
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the liver. The common hepatic duct takes the bile from the left and right
 lobe of the liver and delivers it to the duodenum through the common
hepatic duct. The bile duct is connected by the common hepatic duct and
the cystic duct. The bile duct empties into the pancreatic duct to empty bile
into the pancreases. The gallbladders blood supply comes from the cystic
artery and its vein is by the cystic vein, which drains into the portal vein. The
nerve innervation for the sympathetic actions of the gallbladder is
controlled by the coeliac plexus, the parasympathetic is controlled by the
vagus nerve.

Liver

The liver is located in the right hypochondrium (the superior portion of the
abdomen) and in epigastric areas. The liver has two different surfaces the
visceral and the diaphragmatic. The diaphragmatic is the anterior superior
surface of the liver, this portion touches the diaphragm and is sometimes
referred to as the bare area, it curves outward and is very smooth. The
visceral surface is the posterior inferior surface of the liver; this surface is
covered with peritoneum excluding the porta hepatis. The peritoneum is a
layer of connective tissue that lines most of the coelomic organs in the
abdomen. The liver is split into four sections the left, the right lobe, the
caudate lobe and the quadrate lobe; these lobes are divided by the
falciform ligament. The porta hepatis is a deep fissure that divides the
caudate and quadrate lobes. The liver has multiple ligaments, the falciform,
coronary, and triangular (left and right). Along with many ligaments, the
liver also has many spaces, subphrenic, subhepatic and Morison’s pouch.
The blood supply for the liver comes from a branch of the hepatic artery,
and the venues supply is a branch of the hepatic portal vein entering the
liver. The liver’s blood supply system is quite unique, it has a dual blood
supply with the hepatic arteries and the hepatic portal vein, this is called
the hepatic portal system. The vein carries venous blood that has been
taken from the spleen, gastrointestinal tract and its associated organs to the
liver, hepatic veins carry blood out of the liver via the inferior vena cava. The
system picks up nutrients and carries it to the liver for processing and
storage. This system consists of two separate capillary bed lying between
the arterial supply and venous drainage. The hepatic portal vein carries the
deoxygenated blood that’s been cleaned by the liver. Related to the
gallbladder the branch of the bile duct exits the liver. Innervation for the
liver is supplied by the hepatic plexus, more specifically the fcoeliac plexus
for sympathetic functions, and the vagus nerve for parasympathetic
functions. Gilsson’s capsule, the layer of connective tissue surrounding the
liver has its own separate innervation by the lower intercostal nerves. The
liver has a specific cellular organization, hepatocytes, the cells of the liver
are organized into lobules, the lobules are hexagon shaped with a central
vein in the middle of each for draining. The hepatocytes carry out almost
every function, each one has three periphery structures which are referred
to as the portal triad. 500-1000ml of bile is produced a day by hepatocytes,
the bile is a green alkaline liquid produced for digestive purposes. The
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hepatocytes have a rough endoplasmic reticulum for blood protein
 production, as well as a smooth endoplasmic reticulum helps with the
production of bile salts and removes blood born poisons. An organelle in
the liver called peroxisomes detoxifies other poisons such as alcohol.
Sinusoids are a blood vessel found near the portal triads, they carry blood
towards the central vein. Within the sinusoids, there are hepatic
macrophages that fight against bacteria and other unwanted partials in the
blood and removes old blood cells from the blood. Plasma is produced in
mass amounts in the sinusoids to coat the hepatocytes.

Liver inferior view

Liver Posterior view

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 Liver anterior view

Photo from http://teachmeanatomy.info/abdomen/viscera/liver/

Pancreas

The pancreas has two important functions, the exocrine and endocrine. For
information on the endocrine functions of the pancreas go to the ventral
organ section of the abdominal gland.

The pancreas’ exocrine functions as an important part of the digestive

system. As 99% of the pancreas’ volume is dedicated to the exocrine
function. The pancreas is responsible for producing digestive enzymes and
buffers to be released into the duodenum. These are carried to the
duodenum through the pancreatic ducts, more specifically the duct of
Wirsung. There are also smaller accessory pancreatic ducts called Santorini
ducts. At the Duodenal papilla, the common bile duct meets up with the
pancreatic duct to be released into the duodenum.

The pancreas produces a wide variety of enzymes to finish the breakdown

of the macronutrients before moving on into the rest of the small intestine,
the ileum and jejunum, and colon where nutrient absorption occurs. The
table below shows the enzymes released by the pancreas and each of the
macronutrients it works on. The pancreas also releases bicarbonate which
is a buffer that reduces the acidy of the acidic chyme that comes out of the
stomach. A buffer is required to neutralize the acidy to prevent damaging
the sensitive lining of the small intestine.

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 Enzyme What it breaks down
Pancreatic alpha- Carbohydrates to
amylase monosaccharides
Fats/lipids into fatty acids
Pancreatic lipase and glycerol with the help
from bile from the
gallbladder
Nuclease RNA and DNA
Proteolytic enzyme
(include Proteases, Proteins into amino acids
peptidase)

Proteolytic enzymes make up about 70% of the all the pancreatic enzymes
produced. This remains inactive until they are released into the small
intestine. Examples of some specific proteolytic enzymes that are released
by the pancreas include trypsinogen, chymotrypsinogen,
procarboxypeptidase, and proelastase.

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Greater Omentum

The greater omentum is referred to as the “protector of the abdomen”, it’s

located at the greater curve of the stomach. It folds under itself and
connects to the transverse colon. This organ is the largest peritoneal fold in
the body, the fold is transparent and riddled with gastroepiploic arteries and
drainage veins. This large tissue comes off the peritoneum and consists of
fat, connective tissue, and portions of the lymphatic system. These
lymphatic vessels aid in removing toxins and waste in this region. This great
organ is divided into four different layers two anterior and two posteriors.
The left side is a connection site for the gastrosplenic ligament and the right
side is a connection site for the proximal duodenum. The main vessels that
supply the greater omentum are the left, right and middle omental arteries.
These arteries have smaller branches and drainage veins coming off them,
the left and right artery supply the vascular system through an
anastomosis. The greater omentum has seven important functions:

1. The greater omentum deposits fats around various adipose tissue and
this aids in keeping intestines warm.
2. The lymphatic portion absorbs edema fluid in great amounts, which is a
fluid that accumulates and causes swelling.
3. Plays a role in support and protection of organs.
4. Macrophage contained within protects against abdominal infections,
the greater omentum can actually move to infected areas to send white
blood cells to help fight off the infection.
5. With its ability to move it can move to surround areas of trauma and
isolate it from areas surrounding it to prevent further damage or spread
of infection.
6. Moves to sites of injury or infection to prevent drainage into the
peritoneal cavity. (mostly appendix)
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7. Surgeons can use as graphing material.
 Mesentery

The mesentery surrounds many of the visceral organs in the abdominal

region. Characteristics of the mesentery include two folds of peritoneal
tissues holding the large and small intestines from touching the posterior
side walls of the abdomen. This allows movement to occur, while still
keeping all structures anchored it in place. The mesentery provides a space
for blood vessels, nerves, and lymphatic vessels to run through. The
mesentery is split up into different bending sections: the duodenojejunal,
ileocaecal, hepatic, splenic and some in-between the descending portion
and sigmoid colon, the sigmoid and rectum.

Photo from https://www.mayoclinic.org/diseases-conditions/swollen-lymph-

nodes/multimedia/mesentery/img-20007559

Intro to GI Tract
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 After completing this section readers should be able to identify

> structures of digestive tract and key features

> layers of digestive tract organs including unique sections

> anatomical position of the organs of the digestive tract

> blood supply of digestive tract organs

> nerve innervation of digestive tract organs

You’ve probably heard the expression “trust your gut”, or “you are what you
eat”. But does your gut really have a brain? Are you really made of food?
Well yes… and no. Your “gut”, your gastrointestinal tract, your digestive
system, alimentary canal, or whatever you want to call it is a complex
system that takes complex substances (food) and breaks them down into
less complex parts (nutrients and minerals) that are essential to maintain
bodily functions, and life as we know it. Everyday your body regenerates
upwards of 50 billion cells, and it needs nutrition to promote that
regeneration – meaning that your body uses the essential nutrients and
minerals from food to rebuild it’s own cells. The enteric nervous system
innervates the entire digestive tract. This involves a very specific monitoring
process, thus your digestive tract relies on a vast network of nerve plexus’ to
relay information, and maintain homeostasis – these nerve plexus live in the
layers of your digestive tract. They are essentially the “brain in your gut”.

The digestive system has the vital responsibility of breaking food down and
converting it into nutrients and energy to nourish and sustain the body. It is
made up of organs and accessory organs that all play a critical role in this
process. This section will cover the anatomical features of the system and
core structures that food travels through during the digestive process. The
GI tract starts at the mouth, but for organizational purposes, this section
begins at the esophagus and ends with the large intestine. These regions
are depicted in figure 1. Blood supply and nerve innervation will also be
covered. The gut is innervated by the enteric nervous system; the enteric
nervous systems is distributed throughout the walls of the gut. It’s main
function is to initiate peristalsis (muscle contractions that pass bolus/chyme
through the tract) and trigger the release of digestive hormones. The plexus
responsible for peristalsis is called “Auerbach’s plexus” and it is located
between the muscular layers. Additionally, the Meissner’s plexus lies in the
submucosa, it’s role is control of secretions and blood flow. Parasympathetic
and sympathetic impulses also trigger nerves to inhibit or promote activity.
They are influenced by other sensory nerve endings located in the epithelial
lining.

Figure 1. Organs of the digestive system.

Picture the human body as a giant tube, and the alimentary canal is the
hole in the middle. Food travels through the tube “outside of the body” in
the lumen, during this process the body extracts what it needs, and
disposes of what it doesn’t. The external layer is the interface between the
GI tract and surrounding tissue, it is referred to as either the adventitia or
the serosa, depending on its location in reference to the peritoneum (serous
membrane of abdominal cavity). A common theme of anatomy is “form fits
function”; each of the passageways has a unique structure with implications
for the type of digestion, mechanical or chemical, and specific to the
absorption that occurs at each site. In general, the GI tract has 4 distinct
layers; the mucosa, submucosa, muscular and serosa. While these layers
are common to each section, each organ has unique features with diverse
functional implications, table 1 summarizes these differences. For
anatomical reference, this text refers to the 9 divisions of the abdomen as
shown in figure 2.

Table 1. Summary of the 4 layers of the gastro-intestinal tract, highlighting

region specific features.

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 adventitia
(adhered)
mucosa submucosa muscularis
externa / serosa
(suspended)

stratified
esophagus
squamous
cells
proximal
elastic fibers A
simple
distal
columnar
cells

mucosal
cells
gastric oblique
stomach gastric rugae S
pits layer
gastric
rugae

small intestine:
brunner’s
glands A/S
Duodenum circular
N/A S
Jejunum folds, villi
peyer’s S
ileum
patches

large intestine:

Ascending
goblet
colon
cells
Transverse A
intestinal
and taenia coli S
glands
sigmoid A
lymphatic
colon
structures
Descending
colon

appendix see large lymphoid no taenia S

intestine nodules coli

Esophagus

Structure and key features

The Esophagus, sometimes referred to as the Oesophagus, is the 25cm

muscular tube that connects the pharynx (throat) to the stomach. It is
described in 3 parts, Cervical (4cm), Thoracic (20cm), and Abdominal (12cm).
The superior opening of the esophagus is surrounded by a group of skeletal
muscles called the upper esophageal sphincter or UES. The
Cricopharyngeus is the main muscle responsible for the closing of the
esophagus which is a vital function of the structure as it ensures that food
doesn’t re-enter the pharynx.

Peristalsis is the process of moving food along the digestive tract, it is the
result of a series of circular and longitudinal muscular contractions. No
digestion occurs in the esophagus – it is simply responsible for moving food
from the mouth to the stomach.

At the inferior end of the esophagus is the lower esophageal sphincter or

LES. It is classified as a physiological sphincter, lacking specific muscles. It is
located at the gastroesophageal junction. This opening allows food into the
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 stomach, and when functioning correctly, closes to prevent the acidic
liquids of the stomach from travelling back up. If these muscles are
weakened, acid reflux can occur; the acidic contents of the stomach enter
the upper digestive tract which can damage the esophageal lining. This
type of damage can potentially lead to complications such as esophageal
cancer if not treated.

Layers

As previously suggested, the digestive tract is comprised of 4 functionally

significant tissue layers; the mucosa, submucosa, muscularis, and
adventitia. The esophagus is unique as it contains a mixture of skeletal and
smooth muscle. These layers are summarized in table 1.

Anatomical position

The esophagus lies posteriorly to the trachea, and is continuous with the
laryngeal part of the pharynx. It extends from the lower border of cricoid
cartilage of the larynx at C6, penetrates the abdomen via the esophageal
hiatus, descending into the superior mediastinum of the thorax at T10, and
enters the cardiac orifice of the stomach at T11. The junction is marked by a
transition of stratified squamous epithelium of the esophageal mucosa, to
the simple columnar epithelium of the gastric mucosa. The
phrenoesophageal ligament – bit of a mouthful, but “phreno” relates to the
diaphragm, and “esophageal” relates to the esophagus – connects the
esophagus to the border of the hiatus (opening) in the diaphragm, which
permits independent movement of the two appendages.

Blood supply

The cervical portion of the oesophagus is supplied by the inferior thyroid

arteries. Blood is supplied to the thoracic region via the esophageal
branches of the descending thoracic aorta and bronchial arteries. Lastly, the
abdominal part is supplied by the esophageal branches of the left gastric
and phrenic arteries.

Nerve innervation

The motor and sensory functions here are controlled by branches of the
glossopharyngeal and vagus nerves. The sympathetic fibres originating
from T5-T9 spinal segments are sensory and vasomotor.

Stomach

Structure and key features

The stomach is a crescent shaped, receptacle organ that stores food

between the esophagus and intestines. It is commonly divided into four
regions differing based on the shape and actions (form fits function!). The
narrow transition from the esophagus is called the cardia. Within the cardia
is the lower esophageal sphincter. The cardia empties into the body, the
central and largest region of the stomach. The stomach also bulges
superiorly creating the fundus, where gases released through chemical
digestion are stored. The inferior section of the stomach is the pylorus,
where the pyloric sphincter controls the flow of chyme (partially digested
food) between the stomach and the duodenum.

As mentioned previously, the transition from the esophagus to the stomach

is observable via the change in the epithelial composition. The junction is
marked by a transition of stratified squamous epithelium of the esophageal
mucosa, to the simple columnar epithelium of the gastric mucosa. The
differing epithelial layers, are associated with different functional
requirements (re: form fits function!).

The size and position of the stomach varies greatly among body types,
weight, volume, fluid / food content, body posture and respiration.

Layers
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 As previously stated, the digestive tract is comprised of functionally
significant tissue layers. A unique feature of the stomach is that it has three
complete muscular layers – longitudinal, circular and oblique – that allow
for the churning motion. However, similar to the other sections of the
digestive tract, the stomach is comprised of 4 layers; the mucosa,
submucosa, muscularis, and adventitia. Each region of the stomach has a
unique composition of mucosal glands.The layers of the stomach are
summarized in table 1.

Anatomical position

The stomach changes orientation and position in relation to respiration,

content, and bodily posture. This text will consider the stomach from a
supine position, dividing the abdominal region into 9 quadrants (see figure
2). From this perspective, the cardia and fundus sit posteriorly to the costal
cartilage of the 6th rib. The pylorus sits above and below the junction of the
epigastric and umbilical regions. The greater curvature extends from the
5th intercostal space down to the hypochondrium, entering the upper
middle part of the left lateral flank and meets the pylorus in the umbilical
region. The lesser curvature extends from the cardia to the uppermost
aspect of the pylorus at a junction called the angular notch.

Blood supply

The most superior portion of the greater curvature and the fundus (see
figure 3) are supplied by the short gastric arteries, branches of the splenic
artery. The inferior part is supplied by the right gastric artery, a branch of the
hepatic artery which branches from the common hepatic artery.

Nerve innervation

The stomach receives innervation via multiple sources. The vagus nerve is
responsible for parasympathetic (the “rest and digest” system) supply to the
stomach, it enters the abdomen through the esophageal hiatus in the
diaphragm. The anterior vagal trunk supplies the front of the stomach, and
the posterior part of the stomach is supplied by the (you guessed it)
posterior vagal trunk. The sympathetic nerve supply (the “fight or flight”
system) is contributed by the celiac plexus which receives fibers from T6 –
T9, via the greater splanchnic nerve.

Clinical significance

Anti-inflammatory drugs prescribed to fight arthritis, can cause stomach or

peptic ulcers; which are sores that develop in the lining of the stomach and
small intestine. Ulcers occur when the stomach’s protective layer is broken
down and the corrosive stomach acid damages the lining. Non-Steroidal
Anti-Inflammatory drugs (NSAID’s) which are prescribed to treat
inflammation, commonly arthritis, can inhibit production of the stomachs
protective lining. Such drugs have a topical irritant effect on epithelium,
they impair the barrier properties of the mucosa, suppress gastric
prostaglandin synthesis (lipid compounds that promote tissue regeneration,
but are inflammatory in nature) and reduce gastric mucosal blood flow
which is essential for repairing the damage. Basically they interrupt the
process of protecting the stomach lining from the acidic liquids that are
essential for breaking down food.

When food is broken down according to plan, via chemical digestion in the
stomach, it is ready to enter the small intestine.

Small Intestine

Structure and key features

The stomach transitions to the small intestine via the pyloric sphincter – the
first segment that the chyme (partially digested food) passes through is
called the duodenum. The small intestine, or small bowel, is divided into 3
parts; the duodenum, the jejunum, and the ileum (not to be confused with
ilium). The small intestine is the longest organ in the body, measuring over 3
Previous: Nerves, Blood Vessels and Lymph Next: Glands of the Abdomen
 meters long. It’s length and the presence of plicae circulares and villi lined
walls contribute to its immense surface area (over 100x that of the skin!)
enabling it to be the primary location for digestion and absorption (Re: form
fits function). It is called the “small intestine” in reference to its narrow
diameter, 2.5 cm compared to the 7.6 cm opening of the large intestine. The
small intestine spans from the pylorus to the ileocaecal junction.

Layers

As previously suggested, the digestive tract is comprised of functionally

significant tissue layers. The small intestine is made up of 4 layers; the
mucosa, submucosa, muscularis, and adventitia. The mucosa of the small
intestine has 3 unique features that increase its surface area thus,
improving it’s absorptive and digestive abilities. These features are plicae
circulares (circular folds), villi (finger like projections) and microvilli (smaller
finger like projections / striated border of the villi). The rest of the 4 layers
are summarized in table 1.

Anatomical position

The small intestine is divided into three anatomical sections; the

duodenum, the jejunum, and the ileum. The proximal portion, the
duodenum, is the shortest, 5 cm in length and shaped like a “C”. It begins at
the pyloric sphincter and is considered retroperitoneal (it runs posteriorly to
the peritoneum). The duodenum runs from the pylorus to the
duodenojejunal junction and is divided into four parts; superior, descending,
inferior and ascending. The superior section is 5cm long, it ascends upwards
from the pylorus at L1, it is connected to the liver. The descending portion
curves inferiorly from L1 to L3, around the head of pancreas. The inferior
duodenum travels laterally to the left at L3, crossing the inferior vena cava
and aorta. It is inferior to the pancreas and posterior to the superior
mesenteric artery and vein. The ascending portion crosses the aorta, and
curves anteriorly to join the jejunum at the duodenojejunal flexure at
around L2. At this flexure the intestine transitions from being retroperitoneal
to intraperitoneal. The jejunum measures around 0.9 meters long. Lastly,
the ileum runs along the right side of the abdominopelvic cavity in the
umbilical and hypogastric regions – it is roughly 3-4 cm long, and it
transitions to the colon via the ileocecal sphincter.

Blood supply

The main artery that supplies the small intestine is the superior mesenteric
artery that branches from the abdominal aorta, inferior to the celiac trunk. It
also provides oxygenated blood to the proximal large intestine. It forms five
major branches including the inferior pancreaticoduodenal artery, which
supplies blood to the distal end of the duodenum. Next the intestinal
arteries that feed the tissues of the jejunum and ileum form a network of
arteries to prevent interruptions to blood flow to the intestine. The ileocolic
artery, provides blood to the terminal ileum, cecum and appendix. Nutrient
rich blood blood from the intestine is carried to the liver via the hepatic
portal vein.

Nerve innervation

The small intestine receives both sympathetic and parasympathetic

innervation. The sympathetic supply originates from T10 and T11 sections of
the splanchnic nerves and superior mesenteric plexus. The vagus nerve
provides parasympathetic fibers via the celiac and superior mesenteric
plexuses. The superior mesenteric artery supplies the whole small intestine
and extends to the middle third of the transverse colon before the vagus
nerve takes over. Sympathetic fibres play a role in the motor function of the
intestinal sphincters, the parasympathetic fibres stimulate peristalsis and
inhibit said sphincters.

Clinical Relevance

Crohn’s and colitis can take many forms, the most common is inflammatory
bowel disease, or “ileocolitis”, so named as it affects both the ileum and the
colon. It is a chronic condition whose cause is relatively uncertain, but is
Previous: Nerves, Blood Vessels and Lymph thought to be linked to genetics or caused by stress or Next: Glands of the Abdomen

Previous: Nerves, Blood Vessels and Lymph
malnutrition. Ileiocolitis is an autoimmune disorder, it causes damage to the
intestinal walls and inhibits its ability to absorb essential nutrients. The
inflammation causes a defensive response that attacks healthy cells,
preventing the cell walls from regenerating properly, and causing a
thickening of the intestinal wall as it is in a constant state of repair. These
circumstances cause swelling, abdominal pain, diarrhea, digestive
complications and potentially lead to fistulas and ulcers. It is not inherently
life threatening, but failing to treat symptoms or make healthy changes can
potentially lead to cancer and other complications.
Treatment is available for Chron’s disease although there is no cure. Healthy
diet changes, antibiotics, prescription medicines, herbal remedies, and
surgery are all options for reducing and managing symptoms.
Large Intestine
Structure and key features
Because of their close relationship, diseases like Crohn’s/Colitis can affect
both the small and large intestine. However, there are structural differences
between the two intestinal tracts. The small intestine turns into the large
intestine at the ileocecal valve. The large intestine is shorter, but gets its
reputation form it’s much larger diameter. It is also distinguished by the
presence of omental appendices, haustra, and teniae coli. It’s tissue layer is
common to that of the appendix and the rectum and, the large intestine is
often referred to as the colon. The large intestine can be divided into 5
sections; the cecum, appendix, colon, rectum and anal canal. It measures
approximately 1.5 m in length, about half the length of the small intestine.
The colon is further subdivided into the ascending, transverse, descending
and sigmoid colon.
Layers
Unlike the small intestine, the colon lacks villi. It’s simple columnar
epithelium, does however, contain several goblet cells. Additionally the
presence of teniae coli, found just deep to the serosa, differentiate the large
from the small intestine. Teniae coli are three incomplete layers of
longitudinal smooth muscle tissue covering the ascending, transverse, and
descending colon. The other tissue layers of the large intestine are
summarized in table 1.
Anatomical position
The large intestine starts in the right iliac region of the pelvis, below the
right waist. It makes up about one-fifth of the length of intestinal canal. The
ileum opens to the cecum via the ileocecal sphincter on the medial side,
the cecum is the proximal section of the large intestine. The cecum is
continuous with the ascending colon, it runs superiorly on the right side of
the abdomen from the right iliac fossa to the right lobe of the liver. At the
right colic, or hepatic, flexure, the colon turns left. The transverse colon is the
largest section of the large intestine. It is located between the right and left
colic flexure. The transverse colon transitions to the descending colon
(between the left colic flexure superiorly, and inferiorly to the left iliac fossa)
and then finally to the sigmoid colon. The sigmoid colon is the link between
the descending colon and rectum, it is S-shaped (hence “sigmoid”) and
turns into the rectum at the third sacral vertebrae.
Blood supply
The superior and inferior mesenteric arteries provide bloody supply to the
colon. Intra-arterial communication occurs via the marginal artery. There are
specific branches that supply specific portions of the bowel, for example, the
cecum is supplied by the ileocolic artery. Additionally, this branch supplies
the appendix via the appendicular artery. The ascending colon is supplied
through the right colic artery. The transverse colon receives blood from the
middle colic artery. The descending and sigmoid colon both receive
oxygenated blood via the left colic, and sigmoid arteries. Lastly, the rectum
and anal canal receive blood from the inferior mesenteric artery. Next: Glands of the Abdomen
 Nerve innervation

The ascending and proximal two-thirds of the transverse colon, receive

parasympathetic, sympathetic, and sensory nerve innervation via the
superior mesenteric plexus. The distal third of the transverse colon,
descending colon and sigmoid colon receive parasympathetic, sympathetic
and sensory nerve innervation from the inferior mesenteric plexus. The
inner circular and outer longitudinal smooth muscles play host to a number
of Auerbach’s plexus scattered in between.

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