Duodenal Anatomy

Overview

The duodenum is the first part of the small intestine (5-7 m), followed by the jejunum
and ileum (in that order); it is also the widest and shortest (25 cm) part. The
duodenum is a C-shaped or horseshoe-shaped structure that lies in the upper
abdomen near the midline (see the image below).

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Gross Anatomy

The pylorus of the stomach (at L1 level) leads to the duodenum, which has the
following 4 parts:

The first (superior) part, or duodenal bulb (5 cm), which is connected to the
undersurface of the liver (porta hepatis) by the hepatoduodenal ligament (HDL),
containing the proper hepatic artery, portal vein, and common bile duct (CBD); the
quadrate lobe (segment IV) of the liver and the gallbladder are in front, whereas
the CBD, the portal vein (PV), and the gastroduodenal artery (GDA) are behind it.

The second (descending) part (10 cm), which has an upper and a lower genu
(flexure); the transverse mesocolon and transverse colon are in front, and the right
kidney and inferior vena cava (IVC) are behind it; the head of the pancreas lies in
the concavity of the duodenal C

The third (horizontal) part (7.5 cm) runs from right to left in front of the IVC and
aorta, with the superior mesenteric vessels (the vein on the right and the artery on
the left) in front of it

The fourth (ascending) part (2.5 cm) continues as the jejunum

The duodenojejunal (DJ) junction or flexure is an abrupt turn (see the image below); it
is identified during surgery by the inferior mesenteric vein (IMV), which lies to its
immediate left. The DJ junction is attached to the posterior abdominal wall by the
suspensory muscle of the duodenum or the ligament of Treitz; many fossae are found
around this junction.

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 Stomach and duodenum, coronal section.

Except for its first part, the duodenum is largely retroperitoneal and therefore fixed; it has no
mesentery and is covered by peritoneum only on its anterior surface.
The first part of the duodenum divides the CBD into supraduodenal (in the HDL),
retroduodenal, and infraduodenal (retropancreatic) parts; the terminal part of the CBD is
intraduodenal (intramural) as it traverses the wall of the duodenum to open into its lumen
(see Endoscopic anatomy).

Endoscopic anatomy

The terminal part of the CBD is joined by the terminal part of the pancreatic duct in the
pancreatic head to form a common channel (called the biliopancreatic ampulla when
dilated), which runs through the medial duodenal wall and opens on the dome of the major
duodenal papilla, a nipplelike projection on the medial wall of the middle segment of the
second part (C loop) of the duodenum. The site of the greater duodenal papilla marks the
junction of the embryologic foregut and midgut.
Both ampulla and papilla are eponymously related to Vater. The greater duodenal papilla is
covered by a semicircular hoodlike mucosal fold superiorly. A smooth muscle sphincter (of

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Oddi) is present around the common channel of the CBD and the pancreatic duct and
prevents reflux of duodenal juice into the 2 ducts.

Blood supply

The duodenum (C loop) shares its blood supply very intimately with the head of the
pancreas, which lies in its concavity.
The celiac trunk (axis) arises as a branch from the anterior surface of the abdominal aorta at
the level of T12L1. It has a short length (about 1 cm) and trifurcates into the common
hepatic artery (CHA), the splenic artery, and the left gastric artery (LGA). The CHA runs
toward right on the superior border of the proximal body. The superior mesenteric artery
(SMA) comes off as the second anterior branch from the abdominal aorta (the inferior
mesenteric artery [IMA] is the third anterior branch) just below the origin of the celiac trunk
at the level of L1 behind the neck of the pancreas and descends down in front of the third
(horizontal) part of the duodenum to enter the small bowel mesentery.
The GDA, a branch of the CHA, runs down behind the first part of the duodenum in front of
the neck of the pancreas and gives off the posterior superior pancreaticoduodenal artery
(PSPDA) before it divides into the right gastroepiploic (gastroomental) artery (RGEA) and the
anterior superior pancreaticoduodenal artery (ASPDA). The GDA also gives off the small
supraduodenal artery (of Wilkie).
The inferior pancreaticoduodenal artery (IPDA) arises from the SMA and bifurcates into
anterior and posterior branches. Anterior and posterior branches of the SPDA and IPDA join
each other and form anterior and posterior pancreaticoduodenal arcades in the anterior and
posterior pancreaticoduodenal grooves, supplying small branches to the first, second, and
third parts of the duodenum (vasa recta duodeni) and to the head and uncinate process of
the pancreas.
Veins accompany the SPDA and IPDA. Superior pancreaticoduodenal veins (SPDVs) drain into
the PV, and inferior pancreaticoduodenal veins (IPDVs) drain into the SMV.
The SMV lies to the right of the SMA in front of the third part of the duodenum. The union of
the vertical SMV and the horizontal splenic vein (SV) forms the PV) behind the neck of the
pancreas. The IMV lies to the immediate left of the DJ flexure and joins the junction of SV and
SMV (or maybe SV or even SMV). The PV receives the SPDV, the right gastro-omental vein
(RGEV), the left gastric vein (LGV), and the right gastric vein (RGV) and runs up (superiorly)
behind the first part of the duodenum in the HDL) behind (posterior to) the CBD on the right
and the proper hepatic artery (HA) on the left. The portal venous system (SV, SMV, and PV)
has no valves.

Nerves

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 The duodenum is supplied with parasympathetic nerves by hepatic and celiac branches of
the anterior and posterior vagi, respectively, and with sympathetic nerves by branches of the
celiac plexus.

Lymphatic drainage

Lymphatics from the duodenum drain into pancreaticoduodenal, supra- and infrapyloric,
superior mesenteric, and celiac lymph nodes (LNs).

Microscopic Anatomy

The wall of the duodenum contains the same 4 layers that are seen in the remainder
of the small bowel--namely, the mucosa (lined with columnar epithelium, containing
lamina propria and muscularis mucosa), the submucosa, the muscularis propria (with
inner circular and outer longitudinal layers), and the serosa (only on its anterior
surface). The duodenal mucosa is characterized by the presence of Brunners glands,
which secrete mucus.

Pathophysiologic Variants

The following anomalies may be noted:

Duodenal atresia (stenosis) is associated with Down syndrome and manifests

as neonatal gastric outlet obstruction; a radiograph of the abdomen reveals a
double bubble (one in the fundus of the stomach and the other in the first part of
the duodenum)
In malrotation of gut, the duodenojejunal flexure lies to the right (instead of
normal left) of the spine. A Ladds band runs across the duodenum and obstructs it;
patients present clinically with signs of duodenal obstruction

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 Other Considerations

The following considerations should also be taken into account:

In blunt abdominal trauma, duodenal injuries are often associated with

pancreatic injuries.
A deformed duodenal bulb (on barium swallow and on endoscopy) can occur in
chronic (healed) peptic (duodenal) ulcer
Peptic ulcer perforation occurs on the anterior wall of the first part of the
duodenum
Bleeding in the duodenal ulcer comes from the gastroduodenal artery (GDA),
which runs vertically down behind the first part of the duodenum; a duodenotomy is
performed on the anterior wall of the first part of the duodenum to control the
vessel from inside the duodenum
Pyloroplasty involves a longitudinal incision in the stomach (antrum) and the
first part of the duodenum as well; the incision is then closed transversely
An inflamed gallbladder can be adherent to the first part of the duodenum
Gall bladder cancer can infiltrate the first part of the duodenum and cause
gastric outlet obstruction (GOO)
Duodenal (gastric outlet) obstruction is present in most patients with
pancreatic head cancer
The first part of the duodenum is mobile and can be used for a biliary-enteric
anastomosis (choledochoduodenostomy)
With a side-viewing (flexible) endoscope in the second part of the duodenum,
the common bile duct (CBD) and the pancreatic duct can be cannulated through the
papilla, and radiographs can be obtained after injection of radiologic contrast
medium (endoscopic retrograde cholangiopancreatography [ERCP])
Papilla may bleed after endoscopic papillotomy; control of bleeding involves
duodenotomy (in the second part) and transduodenal sphincteroplasty
Internal hernias can occur into the fossae around the duodenojejunal (DJ)
flexure
The Cattell Braasch maneuver is downward (inferior) mobilization of the
hepatic flexure of the colon and the right transverse colon before mobilization of
the duodenum
Kocherization is anterior and leftward mobilization of the second part (C loop)
of the duodenum after incision of the parietal peritoneum on its right aspect; the
inferior vena cava (IVC) and left renal vein (LRV) are encountered posteriorly

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 Periampullary cancers include those of the lower CBD, ampulla, pancreatic
head, and duodenum (including the papilla) within 1-2 cm of the ampulla
Duodenal resection alone, without pancreatic resection, is technically difficult
because of intimate sharing of blood supply
Pancreaticoduodenectomy is required for resection of the pancreatic head and
periampullary cancers because of the shared blood supply between the head of the
pancreas and the second part (C loop) of the duodenum
The duodenum is at risk for intraoperative injury during right hemicolectomy
and right nephrectomy

Contributor Information and Disclosures

Author
Vinay Kumar Kapoor, MBBS, MS FRCSEd, FACS, FACG, FICS, FAMS, Professor of Surgical
Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India

Vinay Kumar Kapoor, MBBS, MS is a member of the following medical societies: American College of
Gastroenterology, American College of Surgeons, International College of Surgeons, Royal College of
Surgeons of Edinburgh, Medical Council of India, Association of Surgeons of India, National Academy of
Medical Sciences (India), Indian Society of Gastroenterology, Indian Association of Surgical
Gastroenterology

Disclosure: Received educational grant from Sanofi for to publish a book on venous thrombo-
embolism; Received honoraria from Pfizer for speaking and teaching; Received honoraria from Astra
Zeneca for speaking and teaching.
Chief Editor
Thomas R Gest, PhD Professor of Anatomy, Department of Medical Education, Texas Tech University
Health Sciences Center, Paul L Foster School of Medicine

Disclosure: Received royalty from Lippincott Williams & Wilkins for other.

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