Anatomy

stomach & doudenum

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Objective

Introduction
Brief Embryology
Anatomy of stomach and duodenum
Blood supply ,lymphatic & innervation
Brief Histology

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Introduction
Asymmetrical, pear-
shaped, most proximal
abdominal organ of
the digestive tract

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Embryology
• forms as fusiform dilatation of the primitive foregut in the
fourth week .

• It is suspended by a dorsal mesentery and a ventral

mesentery, the septum transversum, which attaches the
ventral stomach to the liver.

• later form the greater and lesser omentum, respectively.

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 The septum transversum → hepato -duodenal &
hepatogastric ligament

 Unequal growth of walls forms the lesser and greater

curvatures

 rotate 90 degrees in longitudinal and AP axis

effect left → anterior, right → posterior

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Duodenum
 In fourth week as ventral pouching of distal forget and
proximal part of the mid gut

 Two parts meet just distal to ampulla(liver bud)

 270 degree anticlockwise rotation

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Blood supply
• Celiac –foregut
• SMA _ Mid gut
• IMA – Hindgut

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Anatomic Relationships and Gross Morphology

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GASTRIC FORM
• form and position of the stomach variable depending on posture, the
volume, and the surrounding viscera
• The empty stomach is J-shaped
• in the erect posture, the pylorus to the level of the second or the
third lumbar vertebra.
• The lowest part of the antrum often lies below the level of the
umbilicus
• The overall axis of the organ is, therefore, slightly inclined from the
vertical

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Gastric relations
gastric curvatures
Lesser curvature
• It descends from the medial side of the esophagus in front of the
crossing fibers of the right crus of the diaphragm
Greater curvature
• highest convexity, the apex of the fundus, is level with the left fifth
intercostal space, varies with respiration
• inferiorly as far as the tenth costal cartilage in the supine position,
where it turns medially to end at the pylorus.

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GASTRIC SURFACES
• Anterior (superior) surface _ empty stomach- the transverse colon lie
adjacent to the anterior surface. the abdominal wall, the left costal
margin, the diaphragm
and the left lobe of the liver

• Posterior (inferior) surface —the lesser sac, which separates the

stomach from the pan-creas, transverse mesocolon, left kidney, left
suprarenal, the spleen and thesplenic artery

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CARDIAC ORIFICE
• It is 10 cm from the anterior abdominal wall and 40 cm from the
incisor teeth.
•
• There Is no specific anatomical cardiac sphincter related to the orifice

• Internally, a 'zig-zag' squamo-columnar epithelial junction

• this Z line is often referred to as the gastro-oesophageal junction

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PYLORIC ORIFICE
• The circular pyloric constriction indicates the pyloric sphincter

• marked by a prepyloric vein crossing the anterior surface vertically

downwards.
• The pyloric orifice lies 1-2 cm to the right of the midline in the empty
stomach.
• The pyloric sphincter is a thickened circular gastric muscle with some
longitudinal fibres.

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Internal view
• Stomach is partially distended by air.
• The cardiac orifice viewed from above is closed at rest by tonic
contraction of the lower oesophageal musculature.
• mucosal rugae-cardiac orifice….'mucosal rosette'
-fundus….. gentle folds…. less pronounced….
nearly smooth
-body most pronounced folds.. Magenstrasse
-antrum….few folds… disappear

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VASCULAR SUPPLY
• predominantly from the coeliac axis
Left gastric artery- consistently largest artery from coeliac , may arise
from common hepatic artery
Right gastric artery-from the hepatic artery but often variant most
common alternative origins are from the common hepatic, left hepatic,
gastroduodenal or supraduodenal arteries
Right gastroepiploic artery
left gastroepiploic artery

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Vas…
• Short gastric arteries-from splenic artery, its divisions, or from the
proximal left gastroepiploic artery

• Posterior gastric artery rare , it arises from the splenic artery in its
middle section posterior to the body of the stomach.

• Accessory left gastric artery very rare from the distal splenic artery.

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VEINS
• drain either into the splenic or superior mesenteric veins

• Short gastric veins-drain fundus and the upper part of the greater
curvature into the splenic vein or one of its large tributaries

Left gastroepiploic vein drains both anterior and posterior surfaces and
the adjacent greater omentum into the splenic vein

Right gastroepiploic vein drain into the superior mesenteric vein

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 Left gastric vein drains into the portal vein directly at
the level of the upper border of the first part of the
duodenum.

 Right gastric vein drains directly into the portal vein at

the level of the first part of the duodenum

Posterior gastric veins distinct posterior gastric veins

may occur, drain into the splenic vein and may occur as
multiple small vessels.

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LYMPHATIC DRAINAGE
• Generally parallel the blood vessels

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 The cardia and medial half of the corpus. drain to nodes
along the left gastric and celiac axis.

 The lesser curvature side of the antrum drains to the right

gastric and pyloric nodes.

 The greater curvature half of the distal stomach drains

to the nodes along the right gas-troepiploic chain.

 The proximal greater curvature side of the stomach

drains into nodes along the left gastroepiploic or splenic hilum.

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 Innervation
 sympathetic and parasympathetic fibers

 sympathetic supply-5-10/12th thoracic spinal segments

 The parasympathetic supply is from the vagus nerves

 The gastric sympathetic nerves are vasoconstrictor to the gastric vasculature and
inhibitory to gastric musculature.

 The parasympathetic is secretomotor to the gastric mucosa and motor to the gastric
musculature. It is also responsible for coordinated relaxation of the pyloric sphincter
during gastric emptying.

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 Sympathetic T 5-T1O?12
 ParaSympathetic -vagus

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 Stomach: Microscopic Anatomy
 The four layers typical
of the alimentary canal
• .Mucosa
– .Submucosa
– .Muscularis externa
– .Serosa

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 mucosa
Three layers
.epithelial layer
.lamina propria
.muscularis mucosa

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 Histologic analysis
 Histologic analysis suggests that in the normal stomach
.oxyntic (parietal) cell-13%
.chief (zymogenic)-44%
.mucous cells-40%
.endocrine cells-3%
All epithelial cells of the stomach
(except the endocrine cells) contain carbonic anhydrase
and are capable of producing bicarbonate.
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 In general, the antrum produces gastrin but not acid, and

 The proximal stomach produces acid but not gastrin.

 The border between the corpus and antrum migrates

proximally with age (especially on the lesser curvature
side of the stomach).

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 DUODENUM
 C shaped adult duodenum is 20-25 cm long
 Is the shortest, widest and most predictably placed part
of the small intestine
 the proximal 2.5 cm is intraperitoneal; the remainder is
retroperitoneal
 first and third lumbar vertebrae in the supine position

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. having four parts

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Superior (1st) part:
About 2in (5 cm),
mostly horizontal, and
lies anterolateral to the
body of L1 vertebra

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FIRST (SUPERIOR) PART

Relations
Length 2in(5cm)
• Anteriorly:
a. The quadrate lobe of the liver,
b. The neck of the gall bladder
• Posteriorly:
a. The bile duct.
b. The gastroduodenal artery.
c. The portal vein.
d. The inferior vena csva.
• Superiorly: the opening into the
lesser sac.
• Inferiorly: pancreas.

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SECOND (DESCENDING) PART

The second part (3 in (7.5 cm))

• Descends in a curve around the head of the pancreas.
• It is crossed by the transverse colon and lies on the right
kidney and ureter.
• Half-way along, its posteromedial aspect enters the common
opening of the bile duct and main pancreatic duct(of Wirsung) on
to an eminence called the duodenal papilla.
• The subsidiary pancreatic duct(of Santorini) opens into the
duodenum a little above the papilla

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SECOND (DESCENDING)
PART

Length: 3 inches long.

Extent: from the neck of gall
bladder to L3
Direction: descends vertically.
Peritoneal covering:
covered by the peritoneum only
on the anterior surface except
the middle part where is
crossed by transverse colon.

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 SECOND (DESCENDING) PART
Relations of the second part:
• Anteriorly:
 Upper part: right lobe of the
liver.
 Lower part: loops of the
jejunum.
• Laterally:
The right colic flexure.
The fat in front of the right kidney.

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 SECOND (DESCENDING) PART

Relations of the second

part:
•Medially:
The head of pancreas
The bile duct
• Posteriorly:
the hilum of right kidney.
the right renal vessels.
the right psoas major muscle.
.

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 THIRD (HORIZONTAL) PART(4 in (10 cm))
 Runs transversely to the left, crossing the inferior vena cava, the
aorta and the third lumbar vertebra.

 It is itself crossed anteriorly by the root of the mesentery and the

superior mesenteric vessels.

 Its upper border hugs the pancreatic head

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 THIRD (HORIZONTAL) PART

Relations of the 3rd part:

• Anteriorly:
1. The root of the mesentery.
2. The coils of jejunum.
• Posteriorly:
3. The right ureter.
4. The right psoas major muscle.
5. The right testicular (or ovarian)
vessels.
6. Inferior vena cava.
7. Abdominal aorta & origin of the
inferior mesenteric artery.
• Superiorly:
The pancrcas.
• Inferiorly:
Coils of the jejunum.
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 FOURTH (ASCENDING) PART (1 in (2.5 cm))

 Ascends upwards and to the left to end at the duodeno jejunal

junction.

 duodenal termination by the presence of the suspensory

ligament of Treitz , which is a well-marked peritoneal fold
descending from the right crus of the diaphragm to the duodenal
termination, and by visualizing the inferior mesenteric vein which
descends from behind the pancreas immediately to the left of the
duodenojejunaljunction.

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 FOURTH (ASCENDING) PART
Length: one inch long.

Extent: from the level of the 3rd to the level of the 2nd lumbar vertebrae.

Direction: ascends to end by forming the duodenojejunalflexure.

Peritoneal covering: is covered by the peritoneum anteriorly and to the

left.

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Blood supply of duodenum

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Arterial supply

from two different vessels

• CELIAC TRUNK → the 1st and 2nd parts of the duodenum are supplied
via the gastroduodenal artery and its branch, the superior
pancreaticoduodenal artery.

• SMA→the 3rd and 4th parts of the duodenum are supplied by the
inferior pancreaticoduodenal artery

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 Veinus

 Duodenal veins, follow the arteries and drain into the

portal vein some veins drain directly and others indirectly
through the superior mesenteric and splenic veins

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 Lymphatic

follow the arteries in a retrograde direction.

• The anterior lymphatic into the pancreaticoduodenal lymph nodes along

the superior and inferior pancreaticoduodenal arteries, and into the
pyloric lymph nodes along the gastroduodenal artery.

• The posterior lymphatic vessels pass posterior to the head of the pancreas
and drain into the superior mesenteric lymph nodes.
• Efferent lymphatic vessels from the duodenal lymph nodes drain into the
celiac lymph nodes.
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Innervation
• Parasympathetic innervation from the vagus

• sympathetic innervation from the greater and lesser

splanchnic nerves through celiac and superior mesenteric
plexuses and then via periarterial plexuses extending to the
pancreaticoduodenal arteries

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 thanks!

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