Outline

Anatomical characteristics
Land marks
Blood supply and lymphatics
Function and disease
1
Gastrointestinal tract
Esophagus
2
Muscular tube
25 cm long
3 constrictions
1. Cricopharygeus ms
2. Broncho-aortic
3. Diaphragm
15 cm
40 cm
(2)
(3)
(3)
(2)
(1)
Internal circular /External longitudinal
Upper : striated muscle
Middle: mixed
Lower: smooth muscle
Muscles of esophagus
3
Circular muscle layer
Cricopharyngeal muscle
Esophageal hiatus: T10 vertebra
T10
Esophagogastric junction
4
Phrenicoesophageal ligament
- movement in respiration and swallow
Cardiac notch
Z-line: EG junction (T11)
Lower esophageal sphincter
Phrenicoesophageal ligament
Z-line
Abdominal part of the esophagus
Phrenicoesophageal
ligament
Abdominal esophagus
Left gastric artery
Left inferior phrenic artery
*
*
5
Arterial supply
Left gastric artery
Left inferior phrenic artery
Submucosal vein
1. Left gastric vein
2. Esophageal vein,
then Azygosvein
Venous drainage
6
Azygos vein
Left gastric vein
Esophageal vein
(plexus)
Portal vein
Nerves of esophagus and stomach
7
Left vagus nerve
Anterior vagal trunk
Right vagusnerve
Posterior vagal trunk
- Esophageal plexus (vagal trunks) +thoracic sympathetic trunk
Esophageal plexus
Posterior vagal trunk
Disease of esophagus
8
Gastroesophageal Reflux Disease
Achalasia (deficiency of inhibitory neuron in lower esophagus)
Esophageal varices
GERD
Stomach:
food blender and reservoir
9
Greater curvature
Angular incisure
Lesser curvature
Fundus
Cardia
body
Pyloric
antrum
Pyloric
canal
Angular notch
10
Fundus
Cardia()
- superior opening
Body
Pyloric part
- antrum(wide)
- canal
- pylorus (sphincter)
Gastric folds (Rugae)
Pyloric part and GC side
11
Muscle:
-outer: Longitudinal
-middle: Circular
-Inner: Oblique
Blood supply of stomach
12
Celiac trunk
Left gastric a.
Common hepatic a.
Splenic a.
Right gastric a.
Left gastro-omental a.
Right gastro-omental a.
Celiac trunk
Common hepatic artery
Splenicartery
Left gastric artery
Right gastric artery
Hepatic proper a.
Gastroduodenal a.
Right Gastroepiploic a.
Left Gastroepiploic a.
Short gastric a.
Arterial supply: Celiac trunk
13
Gastroepiploic a.
=gastro-omental a.
Venous drainage
Right / left gastric veins portal vein *
Left gastro-omental and short gastric veins splenic vein
Right gastro-omental vein superior mesenteric vein (SMV)
Prepyloric v. (for identifying pylorus)right gastric v.
14
*
1
2
Gastro-omental vein
Short gastric vein
S
M
V
1=left gastric vein
2=right gastric vein
15
Lymphatic drainage:
Initial
Secondary (subsequent )
16
Parasympathetic nerve supply of the stomach
17
Anterior vagal trunk (left vagus nerve)
- anterior surface
- hepatic/duodenal branch
- anterior gastric branch
Anterior vagal trunk
Duodenal branch
hepatic branch
Ant. gastric branch
Posterior vagal trunk (right vagus
nerve)
-celiac branch, celiac. plexus*
- posterior gastric branch
*
*
celiac branch
Perforated peptic ulcer
18
Wikipedia
Pylorus: thickened circular muscle
19
Pyloric stenosis
20
antrum
Radiology 2003;227:319
Duodenum ()
21
C- shape; 12 fb
Retroperitoneum
( except superior portion)
Four parts:
1. Superior(1st)
2. Descending(2
nd
)
3. Inferior (horizontal)
- SMA/V; mesenteric root
4. Ascending
S
H
A
D
Duodenal cap (first 2 cm of superior part ; mesentery)
Major papilla: opening of bile and pancreatic duct
Duodeno-jejunal flexure, L2
IVC
22
*
SMA
23 www.learningradiology.com
24
Duodenojejunal flexure
ligament of Treitz (suspensory muscle of duodenum)
25
1. Supraduodenal a. common hepatic artery (*) Celiac trunk
2. Superior pancreaticoduodenal artery
3. Inferior pancreaticoduodenal artery
Arterial supply of duodenum: transition zone
26
*
Supraduodenal a.
27
Superior pancreaticoduodenal artery
Inferior pancreaticoduodenal artery
GDA
SMA
Superior mesenteric artery (midgut)
Gastroduodenal artery (GDA)
Common hepatic artery (foregut)
Veins of the duodenum
28
Follow the arteries
Drain into: portal vein, SMV, splenic vein
Anterior:
pancreaticoduodenal LN.
pyloric LN.
Posterior:
superior mesenteric LN.
Efferent lymphatic vessels
celiac LN.
The lymphatic vessels of the duodenum
- follow the arteries
29
Highly convoluted (6~7 m long)
Diameter: gradually smaller (3 cm- ->2 cm)
Infra-colic compartment
Attached abdominal wall by a mesentery
Jejunum and ileum: Duodenojejunal flexure -
ileocecal junction
30
Fan-shaped peritoneum
vessels, lymph nodes, fat,
and autonomic nerves
Root of mesentery
Directed obliquely
Left side of L2 vertebra to right sacroiliac joint
Structures crossed
J ejunum
Deeper red; thick heavy wall
Large, packed circular folds
Long vasarecta
Large, few arcades
Few lymphoid nodules
Ileum
paler pink; thin light wall
Small, sparcecircular folds
Short vasarecta
Short, many arcades
Many lymphoid nodules
31
*
Superior mesenteric artry (SMA)
32
-L1 (inferior to celiac trunk)
-15-18 branch J . & I.
-Arterial arcade-vasa recta
-Perivascular nerve plexus
SMA
Celiac trunk
SMV
Ischemic bowel disease
Superior mesenteric vein
-Right to SMA/ Posterior to pancreas neck
-Unite with splenicvein to form the portal vein
33
Superior mesenteric vein
Portal vein
34
-Lacteals in villi
-Lymphatic plexus in the wall
-Lymph nodes in mesentery
J uxta-intestinal LN
Mesenteric LN
Superior mesenteric LN
Intestinal trunks
Cisterna chyli
- elongated, thin wall
- right side of T12
Lymphatic drainage of the small intestines
35
Large intestine: Ileocecal junction ~ anal canal
(1.5m~1.8 m)
:
1. Haustra (small pouch)
2. Omental appendices
3. Three Teniae coli
bands of smooth muscles
Cecum
()
Sigmoid
colon
Transverse colon
Ascending
colon
Descending
colon
Rectum
()
Cecum ()
36
7.5 cm
No mesentery
lifted freely
Cecal folds
Ileocecal valve (lips)
Appendix
V
Cecal folds
appendix
Ileocolic
artery
Orifice of
appendix
Vermiform appendix ()
37
Blind diverticulum
6-10 cm long
Variable position:
retrocecal (64%)
Base: teniae coli
Mesoappendix:
Appendicular artery
Appendicitis
38
Shifting pain: T10 to RLQ
McBurney's Point
Spinoumbilical line (ASIS - umbilicus)
Ascending colon, transverse colon, descending colon
Phrenicocolic
ligament
Gastrocolic
ligament
39
paracolic gutter
Ascending colon
40
Hepatic flexure
2
nd
retroperitoneum
Right paracolic gutter (*)
*
*
*
Transverse colon
41
Most mobile/ Transverse mesocolon (inferior border of pancreas)
Right colonic flexure ~ left colonic flexure (phrenicocolic ligament)
Root of mesentery
Sigmoid mesocolon
?
?
Descending colon
42
Left colic flexure to
sigmoid colon
25cm
2
nd
Retroroperitoneal
paracolic gutter
S- shaped
iliac fossa to S3 vertebrae
Teniae coli terminate, rectosigmoid
Long mesentery: sigmoid mesocolon
Sigmoid colon ()
43
P
44
Sigmoid Mesocolon:
Inverted V
Ext iliac vessels-bifurcation of common iliac a.-Sacrum
Blood supply of large intestines
45
Variations
- Right colic artery
- Middle colic artery
- Left colic artery
1
2
3
Marginal artery
(J ustacolicartery)
SMA and IMA territory
IMA
SMA
SMA(midgut)
IMA(hindgut):
Left colic artery
Sigmoid arteries
Superior rectal artery
Marginal artery
46
47
A- &T-colon: SMV
D- and sigmoid colon:
IMV
Venous drainage
48
Epicolic nodes
paracolic nodes
Intermediate
colic nodes
Superior/inferior
mesenteric nodes
intestinal trunks
cisterna chyli
49
Rectum ()
50
Rectosigmoidjunction
(S3 vertebrae)
Recto-sigmoid junction
Transverse folds of rectum
(valves of Houston)
Peritoneal reflection
No taenia
Peritoneal reflection
S
M
I
Dentate line
Dentate line
Ana canal
Anal canal
Take home message
Junction of GI tract
Blood supply of each part
Lymphatic drainage of stomach
51