Upper GIT

At the end of the plenary the students must be able to:1. Describe the anatomy, relations and blood supply of the oesophagus. 2. Describe the anatomy, relations, blood supply and lymphatic drainage of the stomach. 3. Describe the anatomy and relations of duodenum. 4. List the gross differences between jejunum and ileum 5. Explain the blood supply of the small intestines and outline the lymph nodes draining the small intestines. 6. Describe the anatomy of mesentery of small intestines with functional correlation. 7. Describe the nerve supply of oesophagus, stomach & small intestine.

UPPER GASTROINTESTINAL TRACT

Mouth

Pharynx

Oesophagus

Stomach

Small Intestine a. Duodenum b. Jejunum c. Ileum

a. Rectum b. Anal canal.

Large Intestine a. Cecum &Appendix b. Ascending colon c. Transverse colon d. Descending colon e. Sigmoid colon

Questions
What is the lining epithelium of oesophagus? At which vertebral level does oesophagus pierce the diaphragm? What are the two layers of peritoneum? What is the epithelial lining of the peritoneum called? What are the two subdivisions of the peritoneal cavity?

Tongue External features

Epiglottis Foramen cecum Pharyngeal part

Dorsal surface 2 parts by the terminal sulcus

Dorsal surface
Circumvallate pappillae

Terminal sulcus Oral part anterior two thirds Shows lingual papillae

Apex / Tip

Inferior / ventral surface

INNERVATION OF THE TONGUE 1. Motor supply: All the intrinsic and extrinsic muscles the tongue are supplied by the hypoglossal or 12th CN except palatoglossus which is supplied by the accessory [11th CN] 2. Sensory supply (1) Anterior 2/3 General sensation lingual nerve Taste chorda tympani branch of 7th CN. (2) Posterior 1/3 Both general & taste by 9th CN. (3) Near epiglottis Both general & taste by vagus

Pharynx
1

Extends from the base of the skull to the inferior border of the CV 6. It conducts food to oesophagus and air to larynx and lungs.
Parts:1.Nasopharynx posterior to nose and superior to soft palate 2.Oropharynx posterior to mouth 3.Laryngopharynx posterior to larynx

2
3

Nasopharynx Tubal Opening- Lateral Wall

Oropharynx Palatine tonsil- Lateral Wall Palatopharyngeal fold Palatoglossal fold

Mucosa and Tonsil removed Palatoglossus Palatopharyngeus Tonsillar arteries Tonsillar branch of Glossopharyngeal Nerve

OESOPHAGUS

? ? OESOPHAGUS

The oesophagus is a muscular tube connecting the pharynx and stomach. Length 25 to 30 cm (10 inches) Extent - Begins level of CV 6 or lower border of cricoid cartilage - Ends at the level of TV 11

Constrictions of oesophagus
4 constrictions 1.At its origin - at level of 6th C.V. or 6 inches from the incisor teeth

2. Where it is crossed by the arch of aorta

- at the level of 4th T.V., 10 inches from the incisor teeth

3. Where it is crossed by left main bronchus

- at the level of 5th T.V., 11 inches from the incisor teeth) 4. Where it pierces the diaphragm at 10th T.V., 15-16 inches for the incisor teeth

Anterior view

Posterior view

Anterior relations Trachea & left recurrent laryngeal nerve, - left bronchus, - pericardium & left atrium (oblique sinus), - diaphragm Posterior relations Upper 10 TV, - thoracic duct (at TV5), - azygos vein & hemiazygos vein, - descending thoracic aorta & right posterior intercostal arteries

Blood supply of oesophagus

Arterial supply
1. Inferior thyroid artery 2. Branches from the bronchial artery 3. Branches from the descending thoracic aorta. 4. Inferior phrenic artery 5. Left gastric artery Venous drainage Thoracic part into azygos vein [systemic]; - Abdominal part into left gastric vein [portal]. Nerve supply Oesophageal plexus (ANS)

Applied anatomy 1. Knowledge of constrictions of oesophagus is important for (1) Introducing surgical instruments (3) Foreign bodies may lodge at the constricted sites.

2. Lower end of oesophagus is the site of oesophageal varices in portal hypertension.

Lesser curvature

STOMACH Esophagus
LES

Fundus

Lesser omentum

Cardiac region

Body

2
Greater Curvature Duodenum 2nd part
Greater Omentum

Pyloric Sphincter

Antrum Pylorus

LESSER SAC- Opening and posterior relationships

S D TC

Transverse Mesocolon

Pancreas

 Anteriorly: Anterior abdominal wall, left costal margin, left pleura & lung, the diaphragm & left lobe of liver. Posteriorly;also known as the Stomach Bed: Lesser sac, the diaphragm, spleen, left suprarenal gland, upper part of left kidney, splenic artery, pancreas, transverse mesocolon and transverse colon. Posterior gastric ulcer might erode the stomach bed and in perforation of gastric ulcer, haemorrhage occurs into the lesser sac.

Arterial Supply of the Stomach

Celiac Trunk

Left Gastric Splenic

Proper Hepatic

Common Hepatic Left GastroOmental

Gastroduodenal

Right Gastro-Omental

Right Gastric

Blood Supply of Stomach Celiac

Common Hepatic
Hepatic GastroDuodenal
Right Gastroepiploic Left Gastroepiploic Short Gastric

Left Gastric

Splenic

Superior PancreaticoDuodenal

Left Gastric Lymph nodes

Splenic Lymph nodes Coeliac lymph nodes Suprapyloric lymph nodes Left Gastro omental Lymph nodes

Right Gastro Omental lymph nodes

Small Intestine
Duodenojejunal Junction

Duodenum

1st 2nd

3rd
4th

Jejunum

Cecum Ileocecal Junction

Ileum

DUODENUM RELATIONS

1
Kidney

2
Superior mesenteric artery Inferior Vena cava Abdominal aorta

TC

TC

Ligament of Treitz (in sup. Duodenal fold) attaching duodenojejunal flexure to the diaphragm.

Semilunar folds
Hepatopancreatic Duct (Duct of Wirsung)

Major duodenal. Papilla

Small IntestineJejunum and Ileum

-They are entirely surrounded by a mesentery which consists of 2 layers of peritoneum and contains fat, vessels, lymph nodes and nerves between them. -The root of the mesentery is directed obliquely, inferiorly and to the right; it is 6 inches long and extends from the left of LV2 (duodenojejunal junction) to the right sacroiliac joint (ileocaecal junction).

Compare the arterial pattern & the luminal surface of the jejunum vs. the ileum.

Jejunum

Ileum

Differences between Jejunum and Ileum

Jejunum 1. Site In umbilical region mainly Larger or wider Shorter (upper 2/5 ) Thicker Redder because more vascular Present ( thin ) Larger and 1 or 2 in number only Longer Ileum In (umbilical) hypogastrium and inguinal regions. Smaller Longer ( lower 3/5 ) Thin Less colour or pink , because less vascular. Present (thick because of fat) Smaller and more (3- 4 in number). Shorter

2. Size ( diameter ) 3. Length 4. Wall thickness 5. Colour 6. Mesentery 7. Arterial arcades 8. Vasa recta (straight branches from the arcades )

Differences between Jejunum and Ileum

Jejunum 9. Windows or window panes 10. Mesenteric fat ( i.e. fat in between the 2 layers of mesentery) 11. Peyers patches 12. Plicae semilunaris Present and translucent in nature. Absence , therefore translucent. Ileum Opaque to light.

Abundent , therefore opaque to light.

Absence in the wall Thicker, larger & closely packed Usually empty

Present in the wall. Thin and wide apart.

13. Contents in lumen or fullness

Not usually empty .

Duodenojejunal Flexure Superior mesenteric Vasa recta Arcades

Jejunal

Ileal

Abdominal aorta

Superior Mesenteric joining Splenic vein Portal vein

Inferior Vena cava Rt & Lt Kidney

Splenic vein Coeliac trunk

Abdominal aorta

Abdominal aorta

(A) Enhanced (ie, intravenous contrast material) CT examination of the upper abdomen showing the stomach (GL, gastric lumen) with an enhancing gastric wall; incomplete distention can mimic gastric wall thickening. L, liver; A, aorta; S, spleen. (B) CT section lower in same patient showing the gastroduodenal junction (d, duodenum); note that the anterior stomach (S) wall is now much thinner with gaseous distention of the gastric lumen. G, gallbladder; pv, portal vein; P, pancreas; A, aorta; la, left adrenal gland; LK, top left kidney.

Blood supply of GI tract

1. Foregut 1. Stomach 2. Supra-ampullary part of duodenum 3. Liver

Coeliac artery

2. Midgut

1. 2. 3. 4. 5.

Infra-ampullary part of duodenum Small intestine, Caecum & appendix, Ascending colon & Right 2/3 of T. colon Left 1/3 of the transverse colon Descending colon Sigmoid colon Rectum and anal canal.

Superior mesenteric artery.

3. Hindgut

1. 2. 3. 4.

Inferior mesenteric artery.

Venous Drainage of GIT

Most venous blood of GIT drains into the Portal System. Portal vein is formed by the union of Superior mesenteric vein & Splenic vein behind the neck of pancreas. Inferior mesenteric vein drains into splenic vein.

Innervation of GI Tract
Supplied by the Autonomic nerve plexuses surrounding the arteries

Sympathetic

Parasympathetic

Fore and mid guts

(Celiac and Superior mesenteric plexuses)

Greater (T5 T9 Lesser (T9- T11) and Least splanchnic (T12) nerves

Vagi

Hindgut
(Inferior mesenteric and hypogastric plexuses)

Lumber splanchnic nerves

Pelvic splanchnic nerves (S2,3,4)

Question
Which artery is most likely to be eroded in the perforation on the posterior wall of the first part of the duodenum? What is it a branch of?