Small Intestine

Small Intestine
• Longest part of the
alimentary canal

• Extends- from the pylorus of

the stomach to the
ileocaecal junction

• Length - about 6.5 meters

• Greater part of digestion and

food absorption takes place
• Parts

1. Upper fixed part-

Duodenum(25cm)

2. Lower mobile part

proximal 2/5th –Jejunum
distal 3/5th -Ileum
• The jejunum and ileum together measure
about 20 ft (approx.6 m) long.

• Upper two fifths of this length make up the

jejunum.

• The coils of jejunum occupy the upper left

part of the abdominal cavity, whereas the
ileum tends to occupy the lower right part of
the abdominal cavity and the pelvic cavity.
Important features
• Presence of circular
mucosal fold (plicae
circularis or valve of
Kerkring)

• Presence of villi and

microvilli

• Intestinal glands or Crypts

of Lieberkuhn
 Duodenum
• Greek word: Do-dekadactulos

• Shortest, widest and most

fixed part of small intestine
Because except for its
beginning part (2.5 cm), it is
retropetrioneal
• Extends -pyloric
end of stomach to
the duodenojejunal Pyloric
Duodenojej
unal flexure
flexure. end

• C-shaped tube that

curves around the
head of pancreas.
 Location:

• The duodenum is situated

between stomach and jejunum

• above the level of umbilicus

opposite L1,L2 n L3

• Retroperitoneal except for its

beginning

• Connected to the liver by the

hepatoduodenal ligament
• The duodenum is situated in the epigastric and
umbilical regions

• for purposes of description, it is divided into four

parts-
 Parts of duodenum
• Superior (first) part- 5
cm in length
Duodenojej
Superior unal flexure
• Descending (second) (1st) part
of
duodenum
part- 7.5cm in length

• Inferior (third) part- 10 Descending

cm in length (2nd) part of
duodenum

• Ascending (fourth) Horizontal

(3rd) part

part- 2.5 cm in length of

duodenu
Asc (4th) part of
m
duodenum
 Superior or 1st part
• Extent: pylorus to superior
duodenal flexure Superior duodenal
flexure Superior
(1st) part
of
duodenu
m

Desce

• Course nding
(2nd)
part of

– Begins at pyloric end

duode
num

– Runs upward and to the

right and backward
– Ends in superior duodenal
flexure
 Relations
• Peritoneal relations

– Proximal 2.5 cm
• Intraperitoneal
– Lesser omentum above
– Greater omentum below

– Distal 2.5 cm
• Fixed
• Retroperitoneal
• The first 2.5 cm of the superior part of the
duodenum, immediately distal to the pylorus,
has a mesentery and is mobile

• This free part, called the ampulla (duodenal

cap), has an appearance distinct from the
remainder of the duodenum when observed
radiographically using contrast medium
Peculiarities of First part

• Most movable part of

duodenum
• Supplied by end arteries
• Affected by peptic ulcer
• Devoid of plica circularis
• Duodenal cap
• Visceral relations
– Anteriorly
» quadrate lobe of the liver
» Gallbladder
– Posteriorly
» gastroduodenal artery
» bile duct
» portal vein
» inferior vena cava
– Superiorly
» epiploic foramen
– Inferiorly
» head of the pancreas
Contd…..
 Descending (second) part
– Extent: superior duodenal
Superior duodenal
flexure to flexure

inferior duodenal flexure

– Course
• descends along the right inferior duodenal
sides of the L2-L3 flexure

vertebrae
• Ends at inferior
duodenal flexure
• Peritoneal relations
– Retroperitoneal
Relations

• Visceral relations
– Ant
» fundus of the
gallbladder
» right lobe of the
liver
» transverse colon
» coils of the small
intestine
• Post-Right kidney, Rt. renal vessels,
pelvis of Rt. Ureter, Right edge of
IVC

• Med-head of pancreas , bile duct,

main pancreatic duct

• Lat-Right colic flexure

 Interior of 2 part nd

1. Plica Circularis

2. Major duodenal papilla

– Conical raised elevation at the
posteromedial aspect
– Situated – about 8-10 cm from
pylorus
– Summit of it- ampulla of vater
(which is formed by union of
bile duct with pancreatic duct
within the musculature of
duodenum. The opening is
Ampulla of vater
guarded by spincter of oddi)
3. Minor duodenal
papilla
– 2cm above the
major duodenal
papilla
– Accessory
pancreatic duct
opens on its
summit
Contd….

4. Plica semicircularis

5. Plica longitudinalis
 Inferior (third) part
– Extent-inferior
duodenal flexure- L3
vertebra

• Peritoneal relations
– Retroperitoneal
– Anterior surface is covered
by peritoneum except
• median plane ( crossed
by superior mesenteric
vessels and root of
mesentery)
 Visceral relation of 3rd part
• Ant-
• Superior mesenteric vessels,
• root of mesentery
• Post-
• right ureter,
• right gonadal vessels,
• IVC, abdominal aorta

• Sup-head ,body of pancreas,

uncinate process

• Inf-jejunum
 Ascending (fourth) part
• Small and last segment of
duodenum

• Course
– Begins in front of aorta
– runs upward and end at
duodenojejunal flexure (at
the left of L2)
– flexure is held in position -
ligament of Treitz
 Ligament of Treitz

• Suspensory muscle of duodenum

• Fibro-muscular band which arises from right crus
of diaphragm to postero-superior surface of
duodeno-jejunal flexure.
 Relations- fourth part

• Peritoneal relations
– Mostly retroperitoneal

• Visceral relations
– Anteriorly
• root of the mesentery
• coils of jejunum
• Posteriorly
» The left margin of
the aorta
» left psoas muscle
» Inferior mesenteric
vein
• Left side
» Left Kidney
» Left ureter
• Right side
» Uncinate process of
pancreas
» Root of mesentery
• Superiorly
» Body of pancreas
 Arterial supply
• 1st part-supra-duodenal artery and duodenal br. of gastro-
duodenal artery
• 2nd part upto major duodenal papilla-superior
pancreatico-duodenal artery
• Rest-inferior pancreaticoduodenal artery
• Venous drainage
– The superior and inferior pancreaticoduodenal
veins drain into SMV------portal vein
 Lymphatic drainage
• Upward-
via pancreaticoduodenal
nodes

celiac nodes

• downward -
via pancreaticoduodenal
nodes

superior
mesenteric
nodes
 Nerve Supply

• Sympathetic nerve
– Pre-ganglionic fibers—T6-T9 spinal segment
– Post-ganglionic fibers- coeliac and SM plexus

• Parasympathetic nerves
– Pre-ganglionic fibers- vagus
– Post-ganglionic fibers- auerbach and meissner
plexus
• Duodenal cap
• Triangular shadow in 1st part Clinical Anatomy
of duodenum observed by
Duodenal cap
barium meal study
(Radiologically)
• Produced because 1st part of
duodenum is kept patent filled
with the barium, protrusion of
pylorus into the proximal half
of the 1st part of duodenum
and rest of the duodenum
being retroperitoneal remains
collapsed and presents
floccular shadow.
• Any deformity in the
duodenal cap will
indicate mainly
peptic ulcer and
malignant growth
• Duodenal ulcer

• Duodenal ulcers (peptic ulcers) are inflammatory erosions of the

duodenal mucosa

• Most of the/(65%) duodenal ulcers occur in the posterior wall of

the superior part of the duodenum within 3 cm of the pylorus

• Occasionally, an ulcer perforates the duodenal wall, permitting the

contents to enter the peritoneal cavity and causing peritonitis

• Although bleeding from duodenal ulcers commonly occurs,

erosion of the gastroduodenal artery (a posterior relation of the
superior part of the duodenum) by a duodenal ulcer results in
severe hemorrhage into the peritoneal cavity and subsequent
peritonitis
• Superior mesenteric artery syndrome-compression of
3rd part of duodenum produce duodenal stasis
• Mesenteric arterial occlusion- occlusion of this artery
or one of its branches results in death of all or part of
this segment of the gut

• Internal hernia
( site- superior, para, retro
And inferior duodenal
recesses of peritoneum)
Thank you