SGD14:Esophagus,Stomach,andDuodenum

1.Reviewtheesophagus:commencement,termination,location,length,constrictions,relations,
andneurovascularsupply.

Theesophagushascervical,thoracic,andabdominalparts,extendingfromthelower
endofthepharynx
Commencement:(C6vertebrae)
Termination:(T11or12vertebrallevel).

Whenasubjectisintheerectposition,itisabout25to30cmlong.
amedianstructurethatliesfirstbehindthetracheaandthenbehindtheleftatrium.
beginstodeviatetotheleftbelowtheleftmainbronchus.
Intheposteriormediastinumitisrelatedtothevertebralcolumnasastringisrelatedto
abow.
Hencethereisa(retrocardiac)spacebetweenitandthevertebrae,whichisvisible
radiographicallyinobliqueandlateralviews.
Theesophagushasconstrictions
(1)atitscommencement[cricopharyngeusmuscle]
(2)frequentlywhereitiscrossedbytheleftmainbronchus&archoftheaorta
(3)claspingfibersoftherespiratorydiaphragmatlevelof10thoracicvertebra
Neurovascularsupply
Cervicalsegment:inferiorthyroidarteries
Thoracicsegment:bronchialarteries,directbranchesoftheaorta,phrenicarteries,
esophagealarteries
Abdominalsegment:Leftgastricartery
Uppersegmentinnervatedbyrecurrentlaryngealnerves
Lowersegmentinnervatedbysympatheticfibersof6th10ththoracicganglia
parasympatheticfibersfromvagus

Gastroesophagealjunction(ofLeriche)
distinguished microscopically by a gradual and moderate thickening of both the
longitudinalandcircularmusclelayers
junction usually maintained at 60degree angulation to the left, a factor in preventing
regurgitation of substances from stomach, with constricting action of encircling fibers
fromrespiratorydiaphragm

Esophagealplexus
fromthevaginerves,formedaroundthoracicsegmentofesophagus
reunited just above diaphragm to form two nerves (left) anterior and (right) posterior
vagaltrunk
both nerves pass through esophageal opening of diaphragm and continue into the
abdomentoinnervatethestomachandtherestofGItract
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2.Discussthestomachastoitsshape,location,parts,relation,peritonealattachments,
neurovascularsupply,andlymphaticdrainage.
Shape
roughJshaped,twosurfaces,anteriorandposteriorsurface
Twoopenings
cardiacorificewhereesophagusentersthestomachnoanatomicsphincter
pyloricorificeformedbypyloriccanal,circularmusclecoatofstomachismuchthicker
Twocurvatures
greatercurvatureextendsfromleftofcardiacorifice,overdomeoffundus,alongleft
borderofstomachtopylorusgastrosplenicomentumextendsfromupperpartofgreater
curvatureofspleen,andgreateromentumextendsfromlowerpartofthegreater
curvaturetothetransversecolon
lessercurvaturerightborderofstomach,extendsfromcardiacorificetothepylorus
suspendedfromliverbylesseromentum,hasanangularnotch
Location
situatedattheupperpartoftheabdomen
extendingfrombeneaththeleftcostalmarginregionintoepigastricandumbilicalregions
liesundercoveroflowerribs
Parts
Fundusdomeshaped&projectsupwardandtotheleftofcardiacorificeusuallyfullof
gas
Body
extendsfromlevelofthecardiacorificetoleveloftheincisuraangularis,constant
notchinthelowerpartofthelessercurvature
anteriorandposteriorsurfacesarecoveredbyviscerallayerofperitoneum
(serouscoatseparatedfrommuscularcoatbythinlayerofextraperitoneal
tissue)
ventralsurfaceofstomachincontactwithinferiorsurfaceofliver
pyloricendisclosetoquadratelobeoftheliverandgallbladder

Pyloricantrumextendsfromincisuraangularistothepylorus
Pylorusmosttubularpartofthestomach
pyloricsphincter
(thickmuscularwall),
pyloric
canal
(cavityofthepylorus)
Pyloricendcommencesasafunnelshapedantrumpyloricumwiderpart
taperstoatubularpyloriccanaldistally
Twopartscanbedifferentiatedexternallybypresenceofindentationonthe
greatercurvaturesulcusintermedius/softerwallsoftheantrumincontrastto
hardsolidityofthepylorus
prepyloricvein[ofMayo]

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NeurovascularSupply
CeliacArtery
Origin:aorta
Commencement:emergesfromtheaorticopeningofthediaphragmusuallysurroundedbya
celiac[solar]plexusofautonomicnerveswithseveralprevertebralorcollateralganglia
Branches
leftgastricartery
commonhepaticartery
splenicartery

Arteriesderivedfrombranchesofceliacartery
a)Leftgastricartery
Origin:Celiacartery
Commencement:
Course:Passesupwardandtolefttoreachesophagus,thendescendsalonglesser
curvatureofstomach.anastomoseswithrightgastricbranchofthehepaticartery
Areasupplied:Lowerrightpartofstomach
Commonhepaticartery
a)Rightgastricartery
Origin:Hepaticartery
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 Commencement:Upperborderofpylorus
Course:Runsalongthelessercurvature
Areasupplied:Lowerrightpartofthestomach
b)Gastroduodenalbranchofhepaticartery
Course:moderatelysizedarterygivenoffjustbeforethehepatictrunkcurvesupwards.Courses
almostverticallybehindthefirstpartoftheduodenumanddividesintothefollowing
b.1)Rightgastroepiploicartery
Origin:gastroduodenalbranchofthehepaticartery
Course:passestoleftdirectionalongthegreatercurvaturewithinthefoldsofthegreater
omentum
Areasupplied:Stomachalonglowerpartofthegreatercurvature
b.2)SuperiorPancreaticoduodenalartery
dividesintoanteriorandposterior/twoseparatearteriesforthecorrespondingsurfaces
ofthepancreasandduodenum
arteriescourseclosetothemedialborderoftheduodenum
endbyanastomosingwithcorrespondingbranchesfromtheinferior
pancreaticoduodenalbranchofthesuperiormesentericartery
b.3)Rightandlefthepaticbranchespassthroughthehilusofthelivertodistributeinterlobular
branchesinitsparenchyma
c)Splenicartery
largestofthethreebranchesoftheceliacartery
coursingsinuouslytotheleftalongsuperiorborderofthebodyofthepancreascrosses
infrontofleftkidneytoenterthelienorenalligamentoftheperitoneumandthehilusof
thespleen
c.1)Shortgastricarteries
Origin:Splenicartery
Commencement:Hilumofthespleen
Course:Passforwardinthegastrosplenicomentum
Areasupplied:Fundusofstomach
Leftgastroepiploicartery
Origin:splenicartery
Commencement:hilumofthespleen
Course:passesforwardinthegastrosplenicomentum
Areasupplied:Stomachalongupperpartofthegreatercurvature

Veins
leftandrightgastricveinsdrainintoportalvein
shortgastricveinsandleftgastroepiploicveinsjointhesplenicvein
rightgastroepiploicveinjoinsthesuperiormesentericvein

NerveSupply
Anteriorvagaltrunk
Origin:formedinthethoraxmainlyfromtheleftvagusnerve
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Course:entersabdomenontheanteriorsurfaceoftheesophagus
Branches:trunk,singleormultiple,dividesintobranchesthatsupplyanteriorsurfaceof
thestomach
largehepaticbranchpassesuptotheliver,fromthisapyloricbranchpassesdownto
thepylorus
Posteriorvagaltrunk
formedbythoraxmainlyfromrightvagusnerve
entersabdomenonposteriorsurfaceoftheesophagus
trunkdividesintobranchesthatsupplymainlyposteriorsurfaceofthestomach
largebranchpassestotheceliacandsuperiormesentericplexusesandisdistributedto
theintestineasfarasthesplenicflexureandtothepancreas

LymphDrainage
lymphvesselsfollowarteriesintoleftandrightgastricnodes,leftandrightgastroepiploic
nodes,shortgastricnodes
alllymphfromstomacheventuallypassestoceliacnodeslocatedaroundrootofceliac
arteryonposteriorabdominalwall

3.Discusstheduodenumastoitsshape,length,location,parts,relations,neurovascular
supply,andlymphaticdrainage.

LocationandDescription
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Cshapedtube,about10in.(25cm)long,joinsthestomachtothejejunum
receivesopeningsofthebileandpancreaticducts
curvesaroundheadofpancreas
firstinchofduodenumresemblesstomach,coveredonanteriorandposteriorsurface
withperitoneumhaslesseromentumattachedtoupperborder&greateromentum
attachedtolowerborder
remainderofduodenumisretroperitoneal

Parts
Firstpart
Course:Beginsatpylorusandrunsupwardandbackwardonthetranspyloricplaneat
thelevelofthe1stlumbarvertebra
slightlydilatedduodenalbulbnexttothepyloricring
enclosedandsuspendedbytheplicaecirculares
Relations
Anteriorly:quadratelobeofliverandthegallbladder
Posteriorly:lessersac(1stinchonly),thegastroduodenalartery,thebileduct
andportalvein,andinferiorvenacava
Superiorly:entranceintolessersac(epiploicforamen)
Inferiorly:headofthepancreas
Secondpart
Course:runsverticallydownwardinfrontofthehilumoftherightkidneyontherightside
ofthe2ndand3rdlumbarvertebrae.
halfwaydownthemedialborder,thebileductandmainpancreaticductpierce
duodenalwall
thetwoductsunitetoformampullathatopensonsummitofmajorduodenal
papilla
accessorypancreaticduct,opensintoduodenumhigherupontheminor
duodenalpapilla(around811cmfromthepylorus)
Relations
Anteriorly:fundusofgallbladderandrightlobeofliver,transversecolon,coilsof
thesmallintestine
Posteriorly:hilumoftherightkidneyandrightureter
Laterally:ascendingcolon,rightcolicflexure,rightlobeoftheliver
Medially:headofpancreas,bileduct,mainpancreaticduct
Thirdpart
Course:runshorizontallytotheleftonthesubcostalplane,passesinfrontofthe
vertebralcolumnandfollowingthelowermarginoftheheadofthepancreas,atthelevel
ofthe3rdlumbarvertebraorupperborderofthe4thlumbarvertebra
about78cmlong
behindandbelowthissegmentistheterminalbifurcationoftheabdominalaorta
andataninferiorlevel,theformationoftheinferiorvenacava
inferiormesentericbranchoftheaortaemergesatitsleftinferiorborder
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 rightureterandgonadalvesselsliebehinditsrightextremity
leftextremity,itiscrossedoverbythesuperiormesentericvessels
Relations
Anteriorly:rootofmesenteryofthesmallintestine,superiormesentericvessels
containedwithinit,coilsofjejunum
Posteriorly:rightureter,rightpsoasmuscle,inferiorvenacava,aorta
Superiorly:Headofthepancreas
Inferiorly:coilsofjejunum
Fourthpart
Course:runsupwardandtothelefttotheduodenojejunalflexureendsasa
duodenojejunalflexureattheleftsideofthe2ndlumbarvertebra
leftureterandgonadalvesselsliedirectlybehindthispartwiththelowerpoleof
theleftkidneyclosetoitsleftsidethemiddleofthepancreaticbodyoverlying
theflexure
flexureheldtogetherbytheligamentofTreitz,attachedtotherightcrusof
diaphragm
Relations
Anteriorly:beginningoftherootofthemesenteryandcoilsofjejunum
Posteriorly:leftmarginoftheaortaandthemedialborderoftheleftpsoas
muscle

4.Differentiatethemucosalliningandmuscularwallsoftheesophagus,stomach,duodenum.

Esophagus

NoMucosalFolds

Stomach

Withlongitudinally
directedfoldscalled
RUGAE

Duodenum

Firstpartofthe
duodenumissmooth
andtheremainderis
thrownintonumerous
circularfoldscalled
PLICAE
CIRCULARES
Withmajorandminor
duodenalpapillae

5.Mapoutthetopographyofthestomachandduodenumontheabdomenofaliveindividual
usingtheregionsandquadrantsasreference.

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Stomach
RightUpperQuadrant
EpigastricandLeftHypochondriac*region
Duodenum
Leftlowerquadrant(majority)
UmbilicalandHypogastric*(majority)

*AbdominalNineDivisions

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