THE SMALL INTESTINE

Desalegn Tadesse
St. Paul
Millennium1
Medical College
Small Intestine
• consisting of the duodenum, jejunum, & ileum

• is the primary site for absorption of nutrients from

ingested materials

• extends from the pylorus to the ileocecal junction

where the ileum joins the cecum (the first part of the
large intestine).

• The pyloric part of the stomach empties into the

duodenum, duodenal admission being regulated by the
pylorus.

2
Duodenum
• The duodenum (L. the breadth of 12 fingers), the first & shortest
(25 cm) part of the small intestine, is also the widest & most
fixed part.
• pursues a C-shaped course around the head of the pancreas.
• begins at the pylorus on the right side & ends at the
duodenojejunal junction on the left side.
• This junction occurs approximately at the level of the L2
vertebra, 2-3 cm to the left of the midline.
• The junction usually takes the form of an acute angle, the
duodenojejunal flexure.

• Most of the duodenum is fixed by peritoneum to structures on

the posterior abdominal wall & is considered partially
retroperitoneal.
3
• The duodenum is divisible into four parts:
–Superior (first) part: short (approximately 5 cm) &
lies anterolateral to the body of the L1 vertebra.
–Descending (second) part: longer (7-10 cm) &
descends along the right sides of the L1-L3
vertebrae.
–Horizontal (third) part: 6-8 cm long & crosses the L3
vertebra.
–Ascending (fourth) part: short (5 cm) & begins at the
left of the L3 vertebra & rises superiorly as far as the
superior border of the L2 vertebra.

4
5
6
• The first 2 cm of the superior part of the duodenum,
immediately distal to the pylorus, has a mesentery & is mobile.

• This free part, called the ampulla (duodenal cap), has an

appearance distinct from the remainder of the duodenum.

• The distal 3 cm of the superior part & the other three parts of the
duodenum have no mesentery & are immobile because they are
retroperitoneal.

• The superior part of the duodenum ascends from the pylorus

& is overlapped by the liver & gallbladder.

• Peritoneum covers its anterior aspect, but it is bare of

peritoneum posteriorly, except for the ampulla.

• The proximal part has the hepatoduodenal ligament (part of the

lesser omentum) attached superiorly & the greater omentum
attached inferiorly.
7
• The descending part of the duodenum runs inferiorly, curving
around the head of the pancreas.

• Initially lies to the right of & parallel to the IVC.

• The bile & main pancreatic ducts enter its posteromedial wall.

• These ducts usually unite to form the hepatopancreatic ampulla,

which opens on the summit of an eminence, called the major
duodenal papilla, located posteromedially in the descending
duodenum.

The descending part of the duodenum is entirely retroperitoneal.

• The anterior surface of its proximal & distal thirds is covered with
peritoneum; however, the peritoneum reflects from its middle
third to form the double-layered mesentery of the transverse
8
colon, the transverse mesocolon.
• The inferior or horizontal part of the duodenum runs
transversely to the left, passing over the IVC, aorta, & L3
vertebra.

• It is crossed by the superior mesenteric artery & vein, & the root
of the mesentery of the jejunum & ileum.

• Superior to it is the head of the pancreas & its uncinate process.

• The anterior surface of the horizontal part is covered with

peritoneum, except where it is crossed by the superior
mesenteric vessels & the root of the mesentery.

• Posteriorly it is separated from the vertebral column by the right

psoas major, IVC, aorta, & the right testicular or ovarian vessels

9
• The ascending part of the duodenum runs superiorly & along
the left side of the aorta to reach the inferior border of the body
of the pancreas.

• Here it curves anteriorly to join the jejunum at the

duodenojejunal junction, supported by the attachment of a
suspensory muscle of the duodenum (ligament of Treitz).

This muscle is composed of a slip of skeletal muscle from the

diaphragm & a fibromuscular band of smooth muscle from the
third & fourth parts of the duodenum.

Contraction of this muscle widens the angle of the

duodenojejunal flexure, facilitating movement of the intestinal
contents.

• The suspensory muscle passes posterior to the pancreas &

splenic vein & anterior to the left renal vein. 10
11
Arterial supply
• The arteries of the duodenum arise from the celiac
trunk & the superior mesenteric artery.

• the gastroduodenal artery (a branch of the celiac trunk)

via its branch, the superior pancreaticoduodenal artery,
supplies the duodenum proximal to the entry of the bile
duct into the descending part of the duodenum.

• the inferior pancreaticoduodenal artery (a branch of

superior mesenteric artery) supplies the duodenum
distal to the entry of the bile duct.

• The pancreaticoduodenal arteries lie in the curve b/n

the duodenum & the head of the pancreas & supply12
both structures.
• The anastomosis of the superior & inferior pancreatico-
duodenal arteries occurs approximately at the level of
entry of the bile duct or at the junction of the
descending & horizontal parts of the duodenum

• An important transition in the blood supply of the

digestive tract occurs here:
– proximally, extending orad (toward the mouth) to & including
the abdominal part of the esophagus, the blood is supplied
to the alimentary tract by the celiac trunk;

– distally, extending aborad (away from the mouth) to the left

colic flexure, the blood is supplied by the SMA.

 The basis of this transition in blood supply is

embryological; this is the junction of the foregut &
midgut. 13
• The veins of the duodenum follow the arteries & drain
into the portal vein directly or indirectly thru SMV or
splenic vein

• The lymphatic vessels of the duodenum follow the

arteries.

• The anterior lymphatic vessels  pancreaticoduodenal

lymph nodes & pyloric lymph nodes.

• The posterior lymphatic vessels  superior mesenteric

lymph nodes.
•  both in turn drain into the celiac lymph nodes.

• The nerves of the duodenum derive from the vagus,

greater & lesser (abdominopelvic) splanchnic nerves
by way of the celiac & superior mesenteric plexuses.
14
15
Paraduodenal Hernias

• There are two or three inconstant folds & fossae

(recesses) around the duodenojejunal junction.

• The paraduodenal fold & fossa are large & lie to the left
of the ascending part of the duodenum.

• If a loop of intestine enters this fossa, it may

strangulate.

During repair of a paraduodenal hernia, care must be

taken not to injure the branches of the inferior
mesenteric artery & vein or the ascending branches of
the left colic artery, which are related to the
paraduodenal fold & fossa.
16
17
Jejunum & Ileum
• the jejunum begins at the duodenojejunal flexure
where the alimentary tract resumes an intraperitoneal
course.

• the ileum ends at the ileocecal junction, the union of

the terminal ileum & the cecum.

• Together, the jejunum & ileum are 6-7 m long.

• The terminal ileum usually lies in the pelvis from which

it ascends, ending in the medial aspect of the cecum.

18
• Most of the
jejunum lies in
the left upper
quadrant of the
infracolic
compartment,
whereas most of
the ileum lies in
the right lower
19
quadrant.
Differences b/n jejunum & ileum
• Although no clear line of demarcation b/n the jejunum
& ileum exists, they have distinctive characteristics
that are surgically important.

• The jejunum & ileum make up the last two sections of

the small intestine.

• The jejunum:
– represents the proximal 2/5ths of the small intestine.
– It is mostly in the left upper quadrant of the abdomen &
– is larger in diameter, & has a thicker wall than the ileum
– The plicae circulares (circular folds of the mucosa) is large &
numerous
– Has less prominent arterial arcades (1 or 2 rows) & longer
vasa recta (straight arteries) compared to those of the ileum
– Mesenteries with windows (because contain little fat, the20two
layers adhere together & allow light to pass thru)
21
The ileum:
• makes up the distal 3/5ths & is mostly in the right
lower quadrant
• has thinner walls, shorter vasa recta, more
mesenteric fat, & more arterial arcades (3-4 rows) as
compared to the jejunum
• Small & much less numerous plicae circulares

22
23
The mesentery of the small intestine
• is a fan-shaped fold of peritoneum that attaches the jejunum &
ileum to the posterior abdominal wall.

• The root of the mesentery (~15 cm long) is directed obliquely,

inferiorly, & to the right.

• It extends from the duodenojejunal junction on the left side of

vertebra L2 to the ileocolic junction & the right sacroiliac joint.

• The average breadth of the mesentery from its root to the

intestinal border is 20 cm.

• The root of the mesentery successively crosses the ascending &

horizontal parts of the duodenum, abdominal aorta, IVC, right
ureter, right psoas major, & right testicular or ovarian vessels.

Between the two layers of the mesentery are the superior

mesenteric vessels, lymph nodes, a variable amount of fat, &24
autonomic nerves.
Arterial supply
• Supplied by the superior mesenteric artery (SMA).

• The SMA usually arises from the abdominal aorta at

the level of L1 vertebra, ~1 cm inferior to the celiac
trunk, & runs b/n the layers of the mesentery, sending
15-18 branches to the jejunum & ileum.

• The arteries unite to form loops or arches, called

arterial arcades, which give rise to straight arteries,
(vasa recta).

• The SMA & its branches are surrounded by a

perivascular nerve plexus thru which the nerves are
conducted to the parts of the intestine supplied by this
25
artery.
Venous drainage
• Drained by superior mesenteric vein.

• It lies anterior & to the right of the SMA in the root of

the mesentery.

• The SMV ends posterior to the neck of the pancreas,

where it unites with the splenic vein to form the portal
vein.

26
27
Lymphatic drainage
• Specialized lymphatic vessels in the intestinal villi (tiny
projections of the mucous membrane) that absorb fat
are called lacteals.

The lacteals  lymphatic plexuses in the walls of the

jejunum & ileum  lymphatic vessels b/n the layers of
the mesentery.

• Within the mesentery, the lymph passes sequentially

thru three groups of lymph nodes:
– Juxta-intestinal lymph nodes: located close to intestinal wall.
– Mesenteric lymph nodes: scattered among the arterial arcades.
– Superior central nodes: located along the proximal part of the
SMA.

•  mesenteric lymph nodes  superior mesenteric 28

lymph nodes.
Innervation
• The sympathetic fibers in the nerves to the jejunum &
ileum originate in the T8 -T10 segments of the spinal
cord & reach the superior mesenteric nerve plexus thru
the sympathetic trunks & thoracic abdominopelvic
(greater, lesser, & least) splanchnic nerves.

• The presynaptic sympathetic fibers synapse on cell

bodies of postsynaptic sympathetic neurons in the
celiac & superior mesenteric ganglia.

• The parasympathetic fibers in the nerves derive from

the posterior vagal trunks.

• The presynaptic parasympathetic fibers synapse with

postsynaptic parasympathetic neurons in the myenteric
& submucosal plexuses in the intestinal wall. 29
• In general,
– Sympathetic stimulation reduces motility of the intestine &
secretion & acts as a vasoconstrictor, reducing or stopping
digestion & making blood (& energy) available for fleeing or
fighting.

– Parasympathetic stimulation increases motility of the

intestine & secretion, restoring digestive activity following a
sympathetic reaction.

• The small intestine also has sensory (visceral afferent)

fibers.

• The intestine is insensitive to most pain stimuli,

including cutting & burning; however, it is sensitive to
distension that is perceived as colic (spasmodic 30
abdominal pains).
Large Intestine
• The large intestine:
– absorbs water from the indigestible residues of the liquid
chyme,
– converts it into semisolid stool or feces
– stores it temporarily & allows to accumulate until defecation
occurs.
• consists of the cecum; the appendix; the ascending,
transverse, descending, & sigmoid colon; the rectum; &
the anal canal.

• can be distinguished from the small intestine by:

– Omental appendices (appendices epiploicae): small, fatty,
omentum-like projections.
– Three teniae coli
– Haustra: sacculations of the wall of the colon b/n the teniae
– A much greater caliber (internal diameter).
31
32
33
The teniae
• The teniae coli (thickened bands of smooth muscle representing
most of the longitudinal coat) begin at the base of the appendix
as the thick longitudinal layer of the appendix splits to form three
bands.

• The teniae run the length of the large intestine, merging again at
the rectosigmoid junction into a continuous longitudinal layer
around the rectum.

• Because the teniae are shorter than the intestine, the colon
becomes sacculated b/n the teniae, forming the haustra.
• The three teniae coli are:
(1) mesocolic, to which the transverse & sigmoid mesocolons
attach;
(2) omental, to which the omental appendices attach; &
(3) free (L. libera), to which neither mesocolons nor omental
34
appendices are attached.
Cecum & Appendix

• The cecum is the first part of the large intestine that is

continuous with the ascending colon.
 It is a blind intestinal pouch, approximately 7.5 cm in both
length & breadth,
 located in the right lower quadrant, within 2.5 cm of the
inguinal ligament
 lies in the iliac fossa inferior to the ileocecal junction
 is almost entirely enveloped by peritoneum, however has no
mesentery

• If distended with feces or gas, the cecum may be

palpable thru the anterolateral abdominal wall.

35
• The terminal ileum enters the cecum obliquely & partly
invaginates into it.

• This manner of entrance produces ileocolic lips

(superior & inferior) at the ileal orifice, which form the
ileal papilla.

• The folds meet laterally to form ridges, called the

frenula of the valve.

• When the cecum is distended or when it contracts, the

frenula tighten, closing the valve to prevent reflux from
the cecum into the ileum.

The valve probably does prevent reflux from the

cecum into the ileum as contractions occur to propel
contents up the ascending colon & into the transverse
36
colon.
37
The appendix ( also vermiform appendix, L. vermis: worm-like)

• is a blind intestinal diverticulum (6-10 cm in length) that

contains masses of lymphoid tissue.

• It arises from the posteromedial aspect of the cecum

inferior to the ileocecal junction.

• Has a short triangular mesentery, the mesoappendix,

which derives from the posterior side of the mesentery
of the terminal ileum.

• The mesoappendix attaches to the cecum & the

proximal part of the appendix.

• The cecum is supplied by the ileocolic artery, the

38
terminal branch of the SMA.
• The appendicular artery, a branch of the ileocolic
artery, supplies the appendix.

• A tributary of the SMV, the ileocolic vein, drains blood

from the cecum & appendix.

• The lymphatic vessels from the cecum & appendix

pass to lymph nodes in the mesoappendix & to the
ileocolic lymph nodes that lie along the ileocolic artery.

• Efferent lymphatic vessels pass to the superior

mesenteric lymph nodes.

39
Innervation
• Nerve supply to the cecum & appendix derives from
the sympathetic & parasympathetic nerves from the
superior mesenteric plexus.

• The sympathetic nerve fibers originate in the lower

thoracic part of the spinal cord, & the parasympathetic
nerve fibers derive from the vagus nerves.

• Afferent nerve fibers from the appendix accompany the

sympathetic nerves to the T10 segment of the spinal
cord.

40
Position of the Appendix
• The position of the appendix is variable, but it is usually
retrocecal.

• A retrocecal appendix extends superiorly toward the

right colic flexure & is usually free.

• It occasionally lies beneath the peritoneal covering of

the cecum, where it is often fused to the cecum or the
posterior abdominal wall.

• The appendix may project inferiorly toward or across

the pelvic brim.
41
• The anatomical position of the appendix determines
the symptoms & the site of muscular spasm &
tenderness when the appendix is inflamed.

• The base of the appendix lies deep to a point that is

one third of the way along the oblique line joining the
right ASIS to the umbilicus (the McBuney point on the
spinoumbilical line).

In unusual cases of malrotation of the intestine, or

failure of descent of the cecum, the appendix is not in
the lower right quadrant.
When the cecum is high (subhepatic cecum), the
appendix is in the right hypochondriac region & the 42
pain localizes there, not in the lower right quadrant.
43
Colon

• The colon lies first to the right of the small intestine,

then successively superior & anterior to it, to the left of
it, & eventually inferior to it.

• It is described as of four parts: ascending, transverse,

descending, & sigmoid - that succeed one another in
an arch.

44
The ascending colon
• is the second part of the large intestine.

• It passes superiorly on the right side of the abdominal

cavity from the cecum to the right lobe of the liver,
where it turns to the left at the right colic flexure
(hepatic flexure).

• It is secondarily retroperitoneal along the right side of

the posterior abdominal wall.

• It is covered by peritoneum anteriorly & on its sides;

however, in approximately 25% of people it has a short
mesentery.

• It is separated from the anterolateral abdominal wall by

the greater omentum. 45
The arterial supply
• Blood supply to the ascending colon & right colic
flexure is from branches of the SMA, the ileocolic &
right colic arteries.

• These arteries anastomose with each other & with the

right branch of the middle colic artery

• a series of anastomotic arcades begins with the

middle colic & is continued by the left colic & sigmoid
arteries to form a continuous arterial channel, the
marginal artery (juxtacolic artery), that parallels &
extends the length of the colon close to its mesenteric
border.

46
Venous drainage

• Tributaries of the SMV, the ileocolic & right colic veins,

drain blood from the ascending colon.

• The lymphatic vessels:

 the epicolic & paracolic lymph nodes  ileocolic &
intermediate right colic lymph nodes  superior
mesenteric lymph nodes

• The nerves derive from the superior mesenteric nerve

plexus.

47
48
The transverse colon
• is the third, longest, & most mobile part of the large
intestine (~45 cm long).

• It crosses the abdomen from the right colic flexure to

the left colic flexure.

• The left colic flexure (splenic flexure) is usually more

superior, more acute, & less mobile than the right colic
flexure.

• It lies anterior to the inferior part of the left kidney &

attaches to the diaphragm thru the phrenicocolic
ligament.

• the transverse colon is variable in position, usually

hanging to the level of the umbilicus (L3 vertebral 49
level).  in tall thin people it may extend into the pelvis
• The transverse mesocolon loops down, often inferior to
the level of the iliac crests, & is adherent to or fused
with the posterior wall of the omental bursa, hence
freely movable.

• The root of the transverse mesocolon lies along the

inferior border of the pancreas & is continuous with the
parietal peritoneum posteriorly.

50
Arterial supply
• the transverse colon receives mainly from the middle
colic artery, a branch of the SMA.

• It may also receive arterial blood from the right & left
colic arteries via anastomoses.

Venous drainage
• is thru the SMV.

Lymphatic drainage
• to the middle colic lymph nodes  superior mesenteric
lymph nodes.

51
Innervation
• pass from the superior mesenteric nerve plexus via the
periarterial plexuses of the right & middle colic arteries.

• These nerves transmit sympathetic, parasympathetic

(vagal), & visceral afferent nerve fibers.

52
The descending colon
• occupies a secondarily retroperitoneal position b/n the
left colic flexure & the left iliac fossa, where it is
continuous with the sigmoid colon.

• Thus peritoneum covers the colon anteriorly & laterally

& binds it to the posterior abdominal wall.

• especially in the iliac fossa, has a short mesentery in

approximately 33% of people.

• As it descends, the colon passes anterior to the lateral

border of the left kidney.

• has a paracolic gutter (the left) on its lateral aspect.53

The sigmoid colon,
• characterized by its S-shaped loop of variable length
(usually approximately 40 cm), links the descending
colon & the rectum.

• Extends from the iliac fossa to the S3 segment, where

it joins the rectum.

• The termination of the teniae coli, approximately 15 cm

from the anus, indicates the rectosigmoid junction.

• Has a long mesentery &, therefore, has considerable

freedom of movement, especially its middle part.

54
• The root of the sigmoid mesocolon has an inverted V-
shaped attachment, extending first along the external
iliac vessels & then from the bifurcation of the common
iliac vessels to the anterior aspect of the sacrum.

• The left ureter & the division of the left common iliac
artery lie retroperitoneally, posterior to the apex of the
root of the sigmoid mesocolon.

• The omental appendices of the sigmoid colon are long;

& disappear when the sigmoid mesentery terminates.

• The teniae coli also disappear as the longitudinal

muscle in the wall of the colon broadens to form a
complete layer in the rectum.
55
The arterial supply
• Blood to the descending & sigmoid colon is from the
left colic & sigmoid arteries, branches of the inferior
mesenteric artery.

 Thus, at approximately the left colic flexure, a second

transition occurs in the blood supply of the abdominal
part of the alimentary tract:

 the superior mesenteric artery supplying blood to that

part orad to the flexure (the embryonic midgut), & the
inferior mesenteric artery supplying blood to that part
aborad to the flexure (the embryonic hindgut).

56
57
• The sigmoid arteries descend obliquely to the left,
where they divide into ascending & descending
branches.

• The superior branch of the most superior sigmoid

artery anastomoses with the descending branch of the
left colic artery, thereby forming a part of the marginal
artery.

Venous drainage:
• thru the inferior mesenteric vein  splenic vein 
portal vein.

The lymphatic dainage:

 epicolic & paracolic nodes  intermediate colic lymph
nodes  inferior mesenteric lymph nodes
58
Innervation
• Orad to the left colic flexure, sympathetic &
parasympathetic fibers travel together from the
abdominal aortic plexus via periarterial plexuses to
reach the abdominal part of the alimentary tract;
however, aborad to the flexure, they follow separate
routes.

• The sympathetic nerve supply of the descending &

sigmoid colon is from the lumbar part of the
sympathetic trunk via lumbar (abdominopelvic)
splanchnic nerves, the superior mesenteric plexus, &
the periarterial plexuses following the inferior
mesenteric artery & its branches.

59
• The parasympathetic nerve supply is from the pelvic
splanchnic nerves via the inferior hypogastric (pelvic)
plexus & nerves, which ascend retroperitoneally from
the plexus, independent of the arterial supply to this
part of the alimentary tract.

• Orad to the middle of the sigmoid colon, visceral

afferents conveying pain sensation pass retrogradely
with sympathetic fibers to thoracolumbar spinal
sensory ganglia, whereas those carrying reflex
information travel with the parasympathetic fibers to
vagal sensory ganglia.

• Aborad to the middle of the sigmoid colon, all visceral

afferents follow the parasympathetic fibers retrogradely
to the sensory ganglia of spinal nerves S2-S4 60
Rectum & Anal Canal

• The rectum is the fixed (primarily retroperitoneal &

subperitoneal) terminal part of the large intestine.

• It is continuous with the sigmoid colon at the level of S3

vertebra.

• The junction is at the inferior end of the mesentery of

the sigmoid colon.

• The rectum is continuous inferiorly with the anal canal.

61
62
63
Slide 7

64
Slide 7

65