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DR. HERMIZI HAPIDIN SCHOOL OF HEALTH SCIENCES HEALTH CAMPUS UNIVERSITI SAINS MALAYSIA
OBJECTIVES
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
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
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
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 omentum is shown in its normal position covering most of abdominal viscera
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)
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
Esophagus
Fundus
Cardia
Longitudinal muscle layer Circular muscle layer Lesser L curvature
Body B d
Left gastroepiploic vessels
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
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
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
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
Serous layer
Muscularis layer
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
Gastric gland
Enteroendocrine cell
Gastric Gland
Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
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
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
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
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)
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
= 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
Sigmoid colon
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)
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
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
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
Interior 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
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
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
Jejunum J j
Ileum
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
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.
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
Jejunum
Jejunum
Ileum
Peyers patch
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
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)
Brunner's glands are compound, tubular, mucous glands in the submucosa of the duodenum.
Mucosa
Submucosa
Absorptive cells Lacteal Goblet cell Blood capillaries Mucosa associated lymphoid tissue Intestinal crypt Muscularis mucosae Duodenal gland
Vilus
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
Gastroduodenal artery
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
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)