ANATOMY OF DIGESTIVE SYSTEM: STOMACH & SMALL INTESTINE

DR. HERMIZI HAPIDIN SCHOOL OF HEALTH SCIENCES HEALTH CAMPUS UNIVERSITI SAINS MALAYSIA

hermizi@kck.usm.my hermizi@kck usm my 23th February 2012

OBJECTIVES

At the end of this lecture, the students should understand :

1) Introduction to Lower Gastrointestinal (GI) Tract 2) Gross Anatomy of Stomach 3) Relations Blood Supply Lymphatic Drainage & Nerve Relations, Supply,

Supply of Stomach 4) Gross Anatomy of Small Intestine 5) Bl d S Blood Supply, L l Lymphatic D i h i Drainage & N Nerve S Supply of l f Small Intestine

INTRODUCTION OF DIGESTIVE SYSTEM

The organs involved in the g

breakdown of food It has two anatomical subdivisions : a) Digestive tract b) Accessory organs

DIGESTIVE SYSTEM
Digestive tract

i.

ii.

Alimentary canal or gastrointestinal (GI) tract A tube extending from g mouth to anus (~ 9 meters long in cadaver) It includes ; Upper GIT oral cavity, pharynx, esophagus Lower GIT stomach, small intestine, large intestine
(aliment = food)

DIGESTIVE SYSTEM
Accessory organs y g

They include ; i. teeth ii. tongue t iii. salivary glands iv. liver v. gall bladder vi. pancreas

* produce variety of secretions to contribute to breakdown of f d t ff b kd f foodstuffs

STOMACH
Old

names = grinding chamber, fermentation vat, cooking pot Dilated portion of alimentary canal between esophagus and small intestine (duodenum) i t ti (d d ) Site it lies inferior to diaphragm in the epigastric, umbilical & left hypochondriac of the abdomen

Location of Stomach
Midclavicular lines Midsternal line

Subscostal line (10th costal cartilages) Umbilicus Transtubercular line (iliac tubercles)

Subscostal line

Anterior view showing location of abdominopelvic regions Anterior view showing location of abdominopelvic regions

Functions of Stomach
Stomach a) stores the food we ate b) breaks down the food into a liquidly mixture c) mix with enzymes which is chemical that breaks down food d) slowly empty that liquidly mixture into the small intestine

STOMACH
Capacity
E Empty = 50 ml of f d t l f food After meals = 1.0 to 1.5 L Extremely full = up to 4 L y p
T1
Cardiac/ esophageal sphincter

Extension
It extends between the level

of T11 & L1 vertebra f t b Upper end continues with esophagus through cardiac p g g sphincter Lower end continues with duodenum through pyloric sphincter

Pyloric sphincter

L1

GROSS ANATOMY OF STOMACH

Shape = pear shaped or J

shaped (upper part is broader than lower part) It has two ends ; i. Cardic end ii. Pyloric end It has two surfaces ; i. Anterior ii. ii Posterior It has two curvatures ; i. Lesser curvature ii. Greater curvature

Cardiac end

Lesser curvature

Greater curvature Pyloric end

GROSS ANATOMY OF STOMACH

Lesser curvature (LC) f forms right b d i ht border of stomach f t h (concave medial border) extends from cardiac orifice to pylorus l it is suspended from liver by lesser omentum Greater curvature (GC) forms longer convex lateral border of stomach gastrosplenic omentum extends from upper part of GC to spleen greater omentum extends from g lower part of GC to transverse colon

(Omentum = fat skin)

GROSS ANATOMY OF STOMACH

Stomach is covered by peritoneum (intraperitoneal organ) Peritoneum leaves lesser curvature as lesser l omentum & greater curvature as greater omentum Peritoneum = serous membrane that lines abdominal cavity & covers viscera within it Omentum = a fold of p peritoneum

Greater omentum is shown in its normal position covering most of abdominal viscera

Lesser omentum attaching liver to lesser curvature of stomach

Mesentery of small intestine

Greater Omentum
Falciform ligament Liver Gallbladder Spleen Stomach Ligamentum teres Greater omentum
(anterior to SI)

Small intestine

Cecum

Lesser Omentum
Liver Gallbladder Lesser omentum
(extend from liver to LC)

Stomach Duodenum Transverse colon Small intestine

Cecum Urinary bladder

Parts of Stomach
Stomach has four parts :
Cardia b) Fundus c) Body d) Pylorus Cardia surrounds superior opening of stomach Fundus dilated upper part Body inferior to fundus, located between cardiac & pyloric ends Pylorus y funnel-shaped p region of stomach
a)

Cardia C di

Fundus

Body

Pylorus

Parts of Stomach
The pylorus (gate keeper)

has two parts : i. Pyloric antrum ii. Pyloric canal Pyloric antrum (antrum = cave) proximal dilated portion that connects to the body of stomach Pyloric canal narrow portion which leads into duodenum Pyloric sphincter - thickened distal end of the canal

Pyloric orifice Pyloric sphincter Pyloric canal Pyloric antrum t

Anterior Surface of Stomach

Esophagus

Fundus

Cardia
Longitudinal muscle layer Circular muscle layer Lesser L curvature

Pyloric sphincter Duodenum

Body B d
Left gastroepiploic vessels

Oblique muscle l Obli l layer

Pylorus y

Greater curvature

Rugae

Relations of Stomach
Anteriorly Abd Abdominal wall i l ll Left costal margin Left pleura & lung Diaphragm Left lobe o liver e t obe of e Posteriorly Di h Diaphragm Spleen Left suprarenal gland Upper part of left kidney Splenic a te y Sp e c artery Pancreas Transverse mesocolon Transverse colon

Stomach Bed
Structures related to posteroinferior surface of stomach From superior to inferior, it is formed by :

Left dome of diaphragm Spleen Diaphragm Left suprarenal gland Left kidney y Transverse colon & mesacolon Splenic artery Pancreas (head, neck & body) Transverse mesocolon T l Transverse colon
other structures by lesser sac

Spleen Left suprarenal & left kidney Pancreas & Splenic artery

Spleen separated from stomach by greater sac of peritoneum while Sp ee sepa a ed o s o ac g ea e o pe o eu e

Stomach

Spleen Diaphragm Pancreas & Splenic artery Transverse colon & mesacolon

Fig. Posterior relations of stomach greater sac = main part of peritoneal cavity lesser sac / omental bursa = lies posterior to stomach Fig. Sagittal section

Stomach

Epiploic foramen/omental foramen/foramen of Winslow

Fig. Horizontal sections through abdomen

Greater sac or general cavity (red) and lesser sac / omental bursa (blue) Lesser sac is embryologically formed from an infolding of greater omentum

Histology of Stomach
Stomach wall is composed of four basic layers (inside to

outside) : a) Mucosa layer b) Submucosa c) Muscular layer d) Serous l layer

Histology of Stomach
Mucosa layer

Layer of simple columnar epithelium Contains lamina propria (areolar CT) & muscularis mucosae (s oot (smooth muscle) usc e) Submucosa layer Lie deep to mucosa layer Composed of areolar CT Muscularis layer Has 3 layers of smooth muscle ; outer longitudinal layer, middle circular l i l layer & i inner oblique l bli layer Serous layer Composed of simple squamous epithelium (mesothelium) & areolar CT

Layers of Stomach Wall

Serous layer

Muscularis layer

Mucosa layer Submucosa layer

RUGAE (Folds in mucosa layer)

Layers of the stomach wall

Surface epithelium

Mucosa

Lamina propria Submucosa (contains submucosal plexus) Muscularis externa (contains myenteric plexus) Serosa Muscularis mucosae Oblique layer q y Circular layer Longitudinal layer Stomach wall

Enlarged view of gastric pits and gastric glands Mucosa layer Gastric pits Surface epithelium ( (mucous cells) ) Gastric pit
*Gastric pits lead into gastric glands

Mucous M co s neck cells Parietal cell Chief cell

Gastric gland

Enteroendocrine cell

Gastric Gland
Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Mucous neck cell

Cell types

Parietal cell

Mucous neck cells (secrete thin thin, acidic mucus) Parietal cells Chief cells Enteroendocrine or G cells

Chief cell

G cell

Gastric gland

Interior of Stomach

Rugae numerous gastric folds mainly in longitudinal direction f ld flatten out when stomach is distended folds fl tt t h t h i di t d d

Arterial Supply of Stomach

Arterial supply to stomach is extremely rich & comprises of :
a) b) c) ) d) e)

Left gastric artery - coeliac axis Right gastric artery - hepatic artery Right gastroepiploic artery - gastroduodenal branch (hepatic artery) g g pp y g ( p y) Left gastroepiploic artery - splenic artery Short gastric arteries - splenic artery
Left gastric artery
COELIAC AXIS Cystic artery HEPATIC ARTERY

Shorts gastric arteries

SPLENIC ARTERY

Right gastric artery

GASTRODUODENAL ARTERY Superior pancreatiduodenal artery

Left gastroepiploic artery

Right gastroepiploic artery

Venous Drainage (Stomach)

Gastric veins parallel the arteries in possition and course :
a) b) c) ) d) e)

Left gastric vein drain into portal vein Right gastric vein p p Right gastroepiploic vein - empties in superior mesenteric vein g g pp Left gatroepiploic vein drain into splenic vein Short gastric veins

Lymph Drainage (Stomach)

Lymphatic drainage of stomach accompanies its blood vessels Stomach can be divided into three drainage zones :

a)

Area I - drains along right & left gastric vessels to aortic nodes b) Area II - drains along right epiploic vessels to subpyloric nodes & thence to ) g g pp py
aortic nodes

c)

Area III - drains via lymphatics along splenic vessels to suprapancreatic

nodes & thence to aortic nodes

Lymph drainage of stomach

Nerve Supply of Stomach

Sympathetic nerve supply of the

stomach from T5 through T9 segments of spinal cord passes to celiac plexus via greater splanchnic nerve l h i Parasympathetic nerve supply the stomach is from anterior and posterior vagal t k & d t i l trunk their branches anterior vagal trunk derived mainly from mainl f om left vagus ne e ag s nerve posterior vagal trunk derived mainly from right vagus nerve

Small Intestine

Stomach Duodenum D d Duodenojejunal flexure Jejunum Ascending colon Mesentery Ileocecal junction j ti Cecum Appendix Ileum

SMALL INTESTINE
Is

the longest part of alimentary canal li t l Extends from pylorus of stomach to ileocecal junction j Length = 3 m in a living person & 6.5 m in a cadaver (loss of muscle tone) Diameter = 4 cm in stomach & 2.5 cm at junction with large intestine Function = digestion of food and absorption of nutrients

Small intestine

Location of Small Intestine

Site

= it occupies all abdominal regions except epigastic and hypochondriac region Fixation = it is stabilized by mesentery Mesentery = peritoneal fold attaching small intestine to posterior body wall

Sagittal section

Mesentery of Small Intestine

2537
Greater omentum (retracted) Transverse colon Mesocolon Descending colon Jejunum

Mesentery

Sigmoid colon

Mesentery of small intestines holds many blood vessels

Gross Anatomy of Small Intestine

Anatomical subdivisions :

Duodenum b) Jejunum c) Ileum Duodenum = C-shaped tube which is attached to the stomach t h Jejunum = is the coiled midsection Ileum = the final section, which leads into the large intestine
a)

Small Intestine Duodenum

C-shaped tube about 25 cm

long & width 3 75 cm 3.75 Joins stomach to jejunum The first & shortest part of p small intestine The widest & most fixed part Curves around the head of pancreas Begins at pylorus on right side & ends at duodenojejunal junction on left side Partially retroperitoneal

Duodenum

Small Intestine - Parts of Duodenum

Duodenum is divided into four

parts : a) First (superior) part b) Second (descending) part c) Third (horizontal) part d) Forth (ascending) part First part of duodenum It is 5 cm long Lies anterolateral to the body of L1 vertebra

1st part

2nd part 4th part 3rd part

Small Intestine - Parts of Duodenum

Second part of duodenum

It i 7 t 10 cm l is to long Descends along right sides of L1 through L3 vertebrae Third part of duodenum It is 6 to 8 cm long Crosses L3 vertebra Forth part of duodenum It is 5 cm long Begins at left of L3 vertebra & rises superiorly as far as superior border of L2 vertebra and continues with jejunum

1st part

2nd part 4th part 3rd part

Jejunum J j

Interior of Duodenum

(flexure at junction of first and second parts of duodenum)

Superior duodenal flexure 1st part (superior) ampulla (no circular folds) 2nd part (descending) Minor duodenal papilla Duodenojejunal flexure Valves of Kerckring (circular folds) Major duodenal palilla (of Vater) Longitudinal fold Head of pancreas 3rd part (horizontal) 4th part (ascending) Superior mesenteric artery and vein Jejunum

Interior of Duodenum

Plicae circulares

2nd part of duodenum

Major duodenal papilla

Note smooth muscle lining of 1st part of duodenum, plicae circularis (circular folds) of 2nd part of duodenum Major duodenal papilla is a small rounded elevation at site where bile duct & main pancreatic duct pierce medial wall of 2nd part of duodenum

Small Intestine Jejunum & Ileum

Jejunum

begins at duodenojejunal fl d d j j l flexure (L2) & ileum ends at ileocecal junction Jejunum & ileum = 6 to 7 m long (jejunum 2/5, ileum 3/5) Coils of jejunum & ileum are suspended by mesentery from posterior abdominal wall & freely movable Most jejunum lies in left upper quadrant & most ileum lies in i ht lower quadrant li i right l d t

Duodenum
Ascending colon Mesentery

Pylorus of stomach

Jejunum

Ileocecal Il l junction Cecum

Jejunum J j

Ileum

Differences between Jejunum & Ileum

Characteristic Color Wall Vascularity Arcades Vasa recta / V t arteriae rectae Fat in mesentery Circular folds (plicae circularis) Jejunum Deeper red Thick & heavy Greater A few large loops Long L Less Large, tall & closely packed (valves of Kerkring) Ileum Paler pink Thin & light Less Many short loops Short Sh t More Low & sparse; absent in distal part Many a y

y p o d odu es ew Lymphoid nodules Few (Peyers patches)

JEJUNUM
JEJUNUM Mesentery Arcade of jejunal arteries Straight arteries (arteriae rectae) Serosa Longitudinal muscle layer Circular Ci l muscle layer Submucosa Mucosa Circular folds (valves of Kerckring) Solitary lymphoid nodule

Barium radiograph of jejunum

ILEUM
ILEUM Mesentery Arcade of ileal arteries Straight arteries (arteriae rectae) Se osa ( sce a Serosa (visceral peritoneum) Longitudinal muscle layer Circular Ci l muscle layer Submucosa Mucosa Circular folds Solitary lymphoid nodules Aggregate lymphoid nodules (Peyers patches) Barium radiograph of ileum

The main distinguishing feature of the jejunum is the presence of prominent Valves of Kerckring (plicae circulares) numerous folds of the mucous membrane of the small intestine.

Barium radiograph of jejunum

The ileum is almost devoid of Valves of Kerckring, but g large accumulations of lymphatic tissue or Peyer's Patches.
Barium radiograph of ileum

Peyers patches

External and internal differences between jejunum and ileum

Thick wall

Jejunum

Jejunum

Plicae circularis (valves of Kerckring)

Fat Thin wall Arterial arcades Superior mesenteric artery Fat

Ileum

Ileum

Peyers patch

Smooth mucous membrane Arterial arcades Superior mesenteric artery

Ileocecal Junction
Point where small intestine (ileum) ends ( ) as it opens into large intestine (cecum) ; occurs usually within ( g the iliac fossa (right lower quadrant of abdomen)

Iliac fossa

Histology of Small Intestine

Wall of small intestine is made of the following layers :

Serosa coat b) Muscular coat c) ) Submucosa coat d) Mucosa coat Serosa made of peritoneum Muscular made of smooth muscle fibers arranged in outer longitudinal & inner circular layers Submucosa contains loose CT & large venous plexuses (submucosa duodenum contains duodenal or Brunners glands) Brunner s Mucosa composed of a layer of epithelium, lamina propria & muscularis mucosa (Plicae circulares numerous in jejunum, Peyers patches present in ileum)
a)

Histology of Small Intestine

Villi (tufts of hair) = fingerlike projections of mucosa (0.5 1mm long)

Layers of small intestine

Histology of Small Intestine

* One mucous tubule is outlined in the image above.

Brunner's glands are compound, tubular, mucous glands in the submucosa of the duodenum.

Histology of Small Intestine

Villi (Small, finger-like projections of mucosa)

Histology of Small Intestine

Ileum

Mucosa

Submucosa

Plicae circulares - jejunum

Payers patch in ileum mucosa

Intestinal crypt = crypt of Lieberkuhn

Microvilli (brush border)

Absorptive cells Lacteal Goblet cell Blood capillaries Mucosa associated lymphoid tissue Intestinal crypt Muscularis mucosae Duodenal gland

Vilus

Enteroendocrine cells Venule Lymphatic vessel Submucosa

Intestinal Crypts
Intestinal crypt epithelium i l i h li

Secretory cells that produce intestinal juice Enteroendocrine cells Intraepithelial lymphocytes (IELs) Release cytokines that kill infected cells Paneth cells Secrete antimicrobial agents (defensins and lysozyme) Stem cells

Blood Supply of Small Intestine

Duodenum Arterial supply i l l Upper half is supplied by superior pancreaticoduodenal artery (gastroduodenal artery) Lower half is supplied by inferior pancreaticoduodenal p artery (superior mesenteric artery) Venous drainage Superior pancreaticoduodenal vein drains into portal vein (inferior vein joins superior mesenteric vein)

Portal vein Superior mesenteric vein Superior panncreaticoduodenal artery

Inferior panncreaticoduodenal artery

Arterial Supply of Duodenum

Gastroduodenal artery

Superior pancreaticoduodenal artery

Posterior superior pancreaticoduodenal artery Anterior superior pancreaticoduodenal artery

Inferior pancreaticoduodenal artery

Posterior inferior pancreaticoduodenal artery SUPERIOR MESENTERIC ARTERY Anterior inferior pancreaticoduodenal artery

Blood Supply of Small Intestine

Ileum and Jejunum Arterial supply

From branches of superior mesenteric artery Intestinal branches arise from left side of the artery & run in mesentery to reach the gut (gastrointestinal tract) They anastomose with one another to form as series of arcades Lowest part of il L t t f ileum i supplied b il is li d by ileocolic artery li t

Venous drainage Veins correspond to branches of superior mesenteric artery & drain into superior mesentery vein

Arterial Supply & Venous Drainage of Small Intestine

Superior mesenteric artery and its branches

Lymphatic Drainage of Small Intestine

Duodenum Lymph vessels follows arteries & drain ;

upward via pancreaticoduodenal nodes to gastroduodenal nodes & then to celiac nodes downward via pancreaticoduodenal nodes to superior mesenteric nodes around origin of superior mesentery artery

Jejunum & Ileum Lymph vessels pass through many intermediate mesenteric nodes & finally reach superior mesenteric nodes (situated around origin of mesenteric artery)

Celiac nodes Superior mesenteric nodes (central superior group)

Superior mesenteric S i t i nodes (juxtaintestinal group)

mesenteric lymph nodes located in immediate proximity to the jejunum or ileum

Nerve Supply of Small Intestine

Duodenum Nerves are derived from sympathetic & parasympathetic (vagus) nerves from celiac & superior mesenteric plexuses Jejunum & Ileum Nerves are derived from sympathetic & parasympathetic (vagus) nerves from superior mesenteric plexus

Practical Session 0n 05/03/2012 (MONDAY): Digestive system II

TIME 2.00 3 30 p.m. 2 00 to 3.30 p m 3.30 to 5 00 3 30 t 5.00 p.m. GROUP A B