OS

206: Abdomen and Pelvis

Duodenum, Pancreas and Spleen

Dr. G. Teodosio

November 12, 2013

TOPIC OUTLINE
I.

II.

III.

Spleen
A. Characteristics
B. Ligaments
C. Surface Features
D. Borders
E. Vessels
F. Innervation
Pancreas
A. Characteristics
B. Parts
C. Vessels
D. Innervations
E. Ducts
Small intestine
A. Characteristics
B. Parts
1. Duodenum
2. Jejunum and Ileum
I. SPLEEN

A. CHARACTERISTICS
Location

In the left hypochondriac region (left upper

abdominal quadrant) closely related to the left
lung, left pleural cavity, and left ostophrenic
recess

Under the cover of the left 9th-11th ribs in the

midaxillary line
o if the left-side lower ribs and/or upper
lumbar transverse processes are
fractured, the spleen is also most likely
damaged/ruptured

Usually not palpable

o in case of hypertrophy/enlargement, do
NOT palpate possibility of rupture
and can be fatal

Position assessed by percussion

o Normal: dull area over 9th-11th ribs,
should not go beyond midaxillary line
o Abnormal (i.e. enlargement): dull area
over 9th-10th ribs
Functions

Prenatal Hemapoetic organ

Afterbirth identifies, removes, and destroys

expende RBCs and broken down platelets;
recylces iron and globin

Largest lymphatic organ lymphocyte

proliferation and immune response

Blood reservoir

Can self-transfuse in times of hemorrhagic

stress

Clinical Correlation

Blunt force trauma to the abdomen (e.g. crush

injury, punch/blow)

When diseased, can possibly rupture from mild

mechanical stimulation (e.g. palpation)

Fig 1. Anterior View of the Spleen

Fig 2. Lateral View of the Spleen

Almira, Aldwin, Jasmine

B. LIGAMENTS
Attach to the medial aspect of spleen hilum
Gastrosplenic ligament
o From the hilum to the left part of the
greater curvature
o Contains short gastric arteries and left
gastroepiploic artery
Splenorenal ligament
o From the front upper half of the left
kidney to the hilum of spleen
C. SURFACE FEATURES
Diaphragmatic Surface
o Convex and smooth
o Beneath left lead of diaphragm and
adjacent ribs
Visceral Surface
o Gastric Surface

Upper part of posterior stomach

Adjacent to notch located on

superior border
o Renal Surface

Lateral upper part of left kidney

Near inferior border, absence

of notch on this side

Fig 3. Surface Impression of the Spleen

Impressions
o Colic Impression
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Spleen, Pancreas
and Small Intestine
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Over phrenocolic ligament and
left flexure of colon

Supports lower spleen

Pancreatic Impression

Related to tail of pancreas

below lateral hilum of spleen

Forms left boundary of

omentum

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Fig 5. Venous Drainaige of Pancreas, Spleen and

Duodenum
Lymphatics

Splenic hilum - where splenic lymphatic

vessesls leave

Pancreaticosplenic lymph nodes relate to the

posterior and superior boreder of the pancreas

D. BORDERS
Anterior and Superior
o Notch in lower third
o Palpable notch differentiates spleen
enlargement from LUQ tumors
Posterior (Medial) and Inferior
o Smooth and rounded
o Separates renal and phrenic surfaces

E. VESSELS
Arterial Supply

Splenic artery spearates the renal surface

from the phrenic surface; originates from the
celiac trunk

Left and right gastroepiploic/gastro-omental

arteries
Fig 6. Lymphatic Drainage of Pancreas, Spleen and
Duodenum

F. INNERVATION
Nerves of the spleen (vasomotor) - from the
coeliac nerve plexus distribtued around splenic
artery
II. PANCREAS

A. CHARACTERISTICS
Soft, elongated, lobulated organ
In epigastric and left hypochondriac regions
An accessory digestive gland, producing
pancreatic juices from acinar cells, and glucagon
and insulin from islets og Langerhans
Retroperitoneal: crosses L1-L2 vertebral bodies

Fig 4. Arterial Supply of Pancreas, Spleen and Duodenum

Venous Drainage

Splenic vein

Fig 7. Location of the Pancreas

B. PARTS
Head
o Expanded part embraced by the C-shaped
curve of the duodenum to the right of the
superior mesenteric vessels (SMV)
o Fits snugly in the curve of the duodenum

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Pancreatic tumor can possibly obstruct

the common bile duct due to pressure on
the 2nd part of the duodenum where the
common bile duct enters. This presents
as jaundice and chalk-colored stool.

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There may also be referred pain to the
ipsilateral shoulder, (sub)scapular, and
flank.

Crossed anteriorly by root of the

transverse mesocolon
Separated from the body by pancreatic
incisures (formed by the SMV)

o
o
o

Rests posteriorly on inferior vena cava, right

renal artery and vein, and left renal vein

Uncinate process (projection from inferior

pancreatic head) extends medially to the
left, posterior to the superior mesenteric
artery

Neck
o
o
o
o

Body
o
o
o
o
o

Short (1.5-2 cm)

Overlies SMV, forming a groove
posteriorly
Anteriorly adjacent to stomach pylorus
Posteriorly, SMV joins splenic vein
hepatic portal vein
Triangular cross-section
Anteriorly covered with peritoneum
and forming part of stomach bed
Posteriorly devoid of peritoneum and
in contact with SMV, aorta, left
suprarenal gland, left kidney
Lateral to SMV
Overlies aorta and L2 verterbra, above
transpyloric plane and beneath omental
bursa

Tail
o
o
o
o

Anterior to left kidney

Close to splenic hilum and left colic
flexure
Relatively mobile
Passes between layers of splenorenal
ligament with splenic vessels

removal of duodenal part during

pancreatic resection
Body and Tail:
o ~10 splenic artery branches
o Dorsal, inferior, great pancreatic arteries

Venous Drainage

Pancreatic veins - correspond to pancreatic

arteries; tributaries of splenic and superior
mesenteric parts

Mostly empty into splenic vein (joins) SMA

(forms) hepatic portal vein

Fig 9. Venous Drainage of the Pancreas

Fig 8. Parts of Pancreas

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Lymphatics

Follow blood vessels

Most terminate at the pancreaticosplenic lymph

nodes lie along splenic artery

Some terminate at the pyloric lymph nodes

Drain into superior mesenteric lymph nodes or

coeliac lymph nodes (via hepatic lymph nodes)

D. INNERVATION
From CN X and abdominopelvic splanchnic
nerves
Parasympathetic and sympathetic fibers reach
pancreas by passing along the arteries from
celiac plexus and superior mesenteric plexus;
also distributed to pancreatic acinar cells and
islets
Parasympathetic fibers: secretomotor, but
pancreatic secretion is primarily mediated by
secretin and cholecystokinin (formed by epithelial
cells of duodenum and upper intestinal mucosa;
stimulated by acid contents
E. DUCTS

C. VESSELS
Arterial Supply

Pancreatic arteries splenic artery (forms)

arcades with pancreatic gastroduodenal artery
and Superior Mesenteric Artery (SMA)

Head:
o Anterior and posterior
pancreaticoduodenal arteries are
branches of gastroduodenal artery
o Anterior and posterior inferior
pancreaticoduodenal arteries are
branches of SMA
o Shares same blood supply as
duodenum (via two arterial arcades
embedded in anterior and posterior
surface of pancreatic head) , requiring
Almira, Aldwin, Jasmine

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B. PARTS

Fig 10. Ducts of Pancreas with related structures

Duct of Wirsung (Main Pancreatic Duct)

o Runs the length of the pancreas
collecting radicles from the entire body
and tail from the posteroinferior part of
the head including the uncinate process

Begins in the tail and runs through the

parenchyma of the gland to the
pancreatic head where it turns inferiorly
and is closely related to the common
bile duct
o Ampulla of Vater duct of Wirsung +
common bile duct

Duct of Santorini (Minor Pancreatic Duct)

o 2 cm superior to main duct
o Drains anterosuperior part of the head
nd
o Opens into the descending (or 2 ) part
of the duodenum at the summit of minor
duodenal papilla
o Usually communicates with the main
pancreatic duct (60% of the time)
o Sometimes larger than the main
pancreatic duct and not connected to it

fusion or lack thereof during

pancreatic development
explains variations of the ducts
Clinical Correlations

Carcinoma of the head of the pancreas usually

shows itself by painless progressive jaundice and
distention of the gallbladder due to compression
of the common biliary duct
o Compresses and obstructs bile duct
and/or hepatopancreatic ampulla
o Effects: Causes: Obstruction,
enlargement of gallbladder, and
jaundice (obstructive jaundice)

90% of people with pancreatic cancer have

ductular adenocarcinoma

Carcinoma involving the neck and body involves

portal or IVC obstruction
o

III. SMALL INTESTINES

A. CHARACTERISTICS
Site of digestion and food absorption
6-7 m long
From pylorus to ileocecal valve
Jejunum and ileum: long greatly coiled parts
attached to the posterior abdominal wall by
mesentery
o jejunum: proximal 2/5
o ileum: distal 3/5

Almira, Aldwin, Jasmine

Fig 11. Parts of Duodenum

1. Duodenum

20-25 cm long

First part of the small intestine

Shortest, widest, and most sessile part of the

small intestine

No mesentery; partially covered by the

peritoneum

Curves in a C around the head of the pancreas

4 PARTS
1st Part/Superior Duodenum

5 cm long; extends from the pylorus to the neck

Most movable of all parts

Anteriorly covered by peritoneum but bare

posteriorly (except near pylorus)

Relations:
o Anteriorly: quadrate lobe of liver and
gallbladder
o Posteriorly: lesser sac, gastroduodenal
artery, bile duct, portal vein, IVC
o Superiorly: epiploic foramen
o Inferiorly: head of pancreas
2nd Part/Descending Duodenum

8-10 cm long

from the neck of the gallbladder to the lower

border of L3 vertebra

Relations:
o Anteriorly: gall bladder, fundus, right
lobe of liver, tranverse colon, coils of
small intestine
o Posteriorly: hilum of right kidney and
right ureter
o Laterally: ascending colon, right colic
flexure, right lobe of liver
o Medially: head of pancreas, bile duct
and main pancreatic duct
3rd Part/Horizontal Duodenum

10 cm long

crossed by SMV

runs horizontally to the left of the subcostal plane

begins at the lower border of the L3 vertebra and

th
ascends at the 4 part in front of the abdominal
aorta
4th Part/Ascending Duodenum

2.5 cm long

ascends to the level of upper border of the left

suspensory ligament of Treizt (which is attached
to the right crus of diaphragm)
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and Small Intestine
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marked peritoneal fold from the diaphragm to

duodenal termination

Relations:

Anteriorly: beginning of mesentery root and coils

of jejunum

Posteriorly: left margin of aorta and medial border

of psoas muscle
CLINICAL

Radiologically, after a barium meal, the superior

part appears as a triangular homogenous
shadow, known as the duodenal cap

Plicae circulares (valves of Kerkring) or

circular folds appear about 2.5 to 5 cm from the
pylorus, which are large crescentic folds which
project into the intestinal lumen
ARTERIAL SUPPLY
st

1 part: Supraduodenal, retroduodenal, and

duodenal branches from the right gastric, right
gastroepiploic, and
gastroduodenal/pancreaticoduodenal arteries
nd th

2 -4 parts: two arterial arcades

VENOUS DRAINAGE

Superior pancreaticoduodenal vein portal vein

Inferior vein superior mesenteric vein

LYMPHATICS

Upward: lymph vessels pancreaticoduodenal

nodes gastroduodenal nodes coeliac nodes

Downward: lymph vessels

pancreaticoduodenal nodes superior
mesenteric nodes
INNERVATION

Sympathetic and vagus nerves from celiac and

superior mesenteric plexuses
2. JEJUNUM AND ILEUM

Attached to the posterior abdominal wall by a fanshaped fold of peritoneum called the mesentery
of the small intestine

Root of the mesentery permits the entrance and

exit of the branches of the superior mesenteric
artery and vein, lymph vessels, and nerves into
the space between the two layers
DIFFERENCES:
Proximal Jejunum (2/5)
In upper part of
peritoneal cavity, below
left side of the
transverse mesocolon
Wider, thicker, heavier
(because of more
numerous plicae
circularis), redder
intestinal wall
Mesentery attachment
in posterior abdominal
wall above and to the
left of the aorta
Form only 1 or 2
arcades of mesenteric
arteries
Less fat in mesentery
Presence of
translucent areas
Fat deposited near the
root and scanty near
the intestinal wall

Distal Ileum (3/5)

In lower part of
peritoneal cavity
and in pelvis

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Peyers patches are visible and often palpable

on the antimesenteric border of the ileum
The mesentery of the proximal small bowel is
thinner and contains less fat between its leaves
and is more translucent than the mesentery of
the distal small bowel
There is more of a marked tendency toward
arborization and anastomosis of arterial and
venous arcades in the mesentery of the distal
ileum than in the mesentery of the proximal
jejunum

ARTERIAL SUPPLY

Branches of SMA

Intestinal branches gut (anastomose to form

arcades)

Ileocolic artery lowest part of ileum

VENOUS DRAINAGE

correspond to branches of SMA

drain into superior mesenteric vein

LYMPHATICS

Lymph vessels intermediate nodes superior

mesenteric nodes
INNERVATION

Sympathetic and vagus nerves from superior

mesenteric plexus
CLINICAL

Although trauma to the jejunum and ileum is

common, the injury is less serious compared to
trauma in the duodenum. This is because they
are able to move freely, reducing crushing impact
from blunt trauma. Penetrating injuries may selfseal through mucosal plugging.

Mesenteric arterial occlusion the superior

mesenteric artery supplies an extensive portion
of the gut. An occlusion as the result of embolus,
thrombus, aortic dissection, or abdominal
aneurysm results in death of all or part of the gut
from the duodenum to the left colic flexure.
End of Transcription
Aldwin: Hello sa mga anatomates ko, sa Sigma Row 7 & 8
at sa A-Band! :D
Almira: Sorry di ako nakalagay ng message sa initial copy.
=]] Ummhello? Also, advanced happy birthday to
Andrea Contreras (11-19)! =D

Narrower, thinner,
lighter (because of
very small or absent
plicae circularis), paler
intestinal wall
Mesentery attachment
in posterior abdominal
wall below and to the
right of the aorta
3 or more arcades of
mesenteric arteries

Abundant mesentery
fat
Laden and opaque
Uniform deposition of
fat, extending from root
to wall
Presence of Peyers
No Peyers Patches
Patches
More folds
Less folds
More vascular (redder)
Less vascular (paler)

Caliber of the small intestine diminishes as does

the thickness of its muscular wall from the
proximal jejunum to the distal ileum

Almira, Aldwin, Jasmine

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