DUODENUM

STRUCTURE / RELATIONS - Pylorus to jejunum - 4 parts: superior (D1), descending (D2), horizontal (D3) and ascending (D4) - Vertebral level: D1=L1, D2=L2, D3=L3, D4=L2 - duodenojejunal junction around level of L2 and left of midline - junction makes acute angle duodenojejunal flexure

DUODENUM

Superior part (D1) - called duodenal cap/bulb - anterolateral to body of L1 vertebrae - passes posterosuperiorly from pylorus - partly within peritoneum but distally becomes retroperitoneal - anterior relations liver and gallbladder - posterior relations bile duct, portal vein and IVC - inferior relations pancreatic head - Superior gallbladder + liver Descending part (D2) - retroperitoneal - runs inferiorly curving around pancreas - to right and parallel to IVC - post (& lateral) relations right kidney and adrenal gland - medial head of pancreas - anterior transverse volon and mesentary - posteromedial wall bile and pancreatic ducts unite to form hepatopancreatic ampulla which open at major duodenal papilla 1

DUODENUM Horizontal (inferior) part (D3) - longest & most posterior - passes over IVC, aorta and L3 - ant : SMA and SMV and mesenteric root - posteriorly right psoas and ureter, IVC, aorta and right gonadal vessels - superior: pancreas Ascending part (D4) - shortest part - passes superiorly and to left side of aorta, on left psoas muscle - ant : stomach - becomes jejunum where it emerges from the retroperitonium at L2 - inferior mesenteric vessels raise another peritoneal fold lateral to the fourth part of the duodenum the paraduodenal fossa lies between these ARTERIAL SUPPLY - 1st 2.5 cm: right gastric & right gastroepiploic - 2.5cm to midway 2nd part: superior pancreaticoduodenal arteries. Arise from the gastroduodenal branch of hepatic artery which passes behind first part of duodenum - remainder : inferior pancreaticoduodenal arteries. First branch on SMA

VENOUS DRAINAGE - 1st part: prepyloric vein portal vein - 2-4th parts: to veins corresponding to arteries SMV & IMV LYMPHATIC DRAINAGE - pancreaticoduodenal nodes (located along pancreaticoduodenal artery) pyloric lymph nodes along gastroduodenal artery into celiac INNERVATION - enteric nervous system with sympathetic (celiac and SM plexus) and parasympathetic (vagus)

EMBRYOLOGY / VARIENTS Formed by terminal part of foregut and cephalic part of mid gut. Abnormal position = malrotation of gut Abnormal development = duodenal stenosis / atresia

DUODENUM o accessory duct opens more anteriorly than the main pancreatic duct o third part indented by aorta posteriorly and SM vessels anteriorly o ligament of Treitz should lie to the left of the first part if not think of malrotation with small bowel lying on right side and large bowel lying on left side CT / MRI o Junction of stomach and duodenum marked by increased thickness of the pyloric muscle posterior to left lobe of liver o Gastroduodenal artery maybe seen posterior to first part of duodenum Angiographic o Full angiography of coeliac and SMA USS o Gas in duodenum hinders visualisation of eg common bile duct which runs behind first part of duodenum o Identified as being next to head of pancreas.

RADIOLOGY APPLICATION barium studies o first part passes posteriorly and superiorly it is foreshortened in AP views o ampulla visualised in two thirds of normal examinations o opening of accessory pancreatic duct in less than one quarter 1

DUODENUM

DUODENUM