Digestive system

Dr Kartikeya Singh
 Oesophagus
• Starts From the lower end of the pharynx .
• Lower border of the cricoid
cartilage(cricopharyngeus muscle).
• Opposite to the lower border of the body of the
C6 vertebrae.
• Situated between the trachea and vertebral
column.
• End in the cardiac end of the stomach(T12).
• 25 cm long.
Cervical part of the oesophagus(C6-T1)
• Anteriorly
-Trachea and right and left recurrent laryngeal
nerve.
• Posteriorly
- vertebral column & longus colli muscle
• On each side to the corresponding lobe of the
thyroid gland.
- thoracic duct (LEFT SIDE)
 Thoracic esophagus
• T1- T10
• Anteriorly
-Trachea
-Right pulmonary artery
- Left Bronchous
- Pericardium with left atrium
- Diaphragm
 Posteriorly
• Vertebral column
• Right intercostal arteries
• Thoracic duct
• Thoracic aorta
• Azygous vein
• Diaphragm
 Constriction of the oesophagus
• First
-15 cm from the incisor-cricopharyngeus muscle.
• Second
-22.5 cm from the incisor teeth- aortic arch.
• Third
-27.5 cm from the incisor teeth- left bronchus.
• Fourth
- 37.5 cm - diaphragm
 Right
• Right lung and Pluera
• Azygous vein
• Right vagus
 Left
• Aortic arch
• Left Subclavian artery
• Thoracic duct
• Left Lung & pluera
• Left vagus
 Abdominal part of esophagus
• T10-T12
• Passes through oesophageal hiatus(opening in
diapharagm
• 1.25 cm long.
• Anterior
- Posterior side of the liver
- Left vagus
• Posterior
- Left and right crus of diaphragm
- Aorta
• Right
- Caudate lobe of the liver
• Left
- Fundus of the stomach
 Histology
• Adventitia- outermost layer
- Loose connective tissue
- No serosa
• Muscularis propia
- Outer longitudinal muscle fiber
- inner circular muscle fiber
- Upper 1/3 is striated
- Middle 1/3 is mixed
- -lower 1/3 is smooth
• Sphincter of esophagus
- Upper esophageal sphincter (Striated)
- Lower esophageal sphincter (smooth)
• Submucosa
- Vein , lymphatic, blood vessel
• Mucosa
- Muscularis mucosa
- Lamina propia
- Nonkeratinized stratified squamous epithelium
- Converting to simple columnar epithelium at cardiac
end.
 Venous drainage
• Cervical part- inferior thyroid vein via left
brachiocephalic vein
• Thoracic part- Azygous vein
• Abdominal part- Left gastric vein
 Arterial supply
• Cervical- inferior thyroid artery
• Thoracic – esophageal branches of the
bronchial artery
• Abdominal- esophageal branches of left
gastric artery and splenic artery
 Lymphatic drainage
• Cervical part- cervical nodes
• Thoracic part- posterior mediastinal nodes
• Abdominal part- left gastric & coeliac nodes
• Parasymphatic
- Recurrent laryngeal nerve (Upper 1/2)
- Righ & left vagus (Lower half)
• Symphatic
- Middle cervical ganglion(upper half)
- Thoracic ganglion (lower half)
 9 region of abdomen
• Horizontal lines-
- Transpyloric lines
- Transtubercular region
• Vertical lines
- Right lateral
- Left Lateral
 Peritoneum
• Peritoneum is a large serous membrane lining
the abdominal cavity.
• Histology- outer layer fibrous tissue
- inner layer of mesothelial cell(secret serous
fluid- lubricate the surface)
• Two layers
- Parietal peritoneum
- Visceral peritoneum
• Parietal peritoneum- outer layer lining the
abdominal cavity and pelvic cavity.
• Visceral peritoneum- inner layer lining the
outer surface of viscera.
• Parietal peritoneum- loosely attached to the
wall of the extraperitoneal connective tissue.
• Visceral peritoneum- firmly attached the
outer surface of the viscera.
 Relation of peritoneum with various
organ
• Intraperitoneal- within the abdominal cavity &
freely movable.
- Stomach, jejunum, ileum, caecum, appendix,
transverse colon, spleen, liver, first & fourth part
of duodenum
• Retroperitoneal- Develop outside the abdominal
cavity & posterior to intraperitoneal.(completely
immovable)
-- 2nd & 3rd part of Duodenum, pancreas, kidney,
ureter, suprarenal gland.
• Secondary intraperitoneal- Ascending colon,
descending colon, rectum (completely
immovable
• Subperitoneal- inferior to the intraperitoneal
and outside the intraperitoneal.
- Urinary bladder, prostate, seminal vesicles,
cervix, fallopian tube, vagina
 Fold of peritoneum
• Small intestine- messentary
• Colon- Mesocolon
• Stomach- omentum-Greater & lesser omentun
(4 layer)
- Greater omentum- Greater curvature-
Policeman of abdomen
- Lesser omentum- Lesser curvature
- Mesoappendix- appendix
 Function of peritoneum
• Movement of the viscera
• Protection of viscera
• Absorption & dialysis
• Healing& adhesions
• Storage of fat
 Peritoneal cavity
• two parts
- Greater sac(Larger part of the peritoneal cavity
- Lesser sac(Smaller part of the peritoneal cavity)
- Lesser sac is situated behind the stomach
- Both sac communicates with each other through
foramen of monro/ Epiploic foramen
 Clinical anatomy of peritoneum
• Inflammation of peritoneum is called
peritonitis.
- Localised peritonitis- Particular part of the
peritoneum
-generalised peritonitis- whole peritoneum-
leading to septicaemia-MODS
• Ascities
• Pneumoperitoneum-
• Haemoperitoneum-
• Paracentesis-
• Greater omentum- Policemen of abdomen
- retard the spread of infection by ruptured
vermiform appendix & peptic ulcer.
• Laprotomy-
• Laproscopic-
 Clinical anatomy of esophagus
• Gastroesophageal reflux disease (GERD)- occurs when
stomach acid repeatedly flows back into the tube
connecting your mouth and stomach (esophagus).
• Symptoms- heart burn
• Cause- loss of incompetence of lower
gasteroesophageal sphincter.
- obesity
- Pregnancy
- Spicy food
- Tea
- Choclate
• Achalasia cardia-is a rare disorder that makes
it difficult for food and liquid to pass from the
swallowing tube connecting your mouth and
stomach (esophagus) into your stomach.
• Cause- Paralysis of nerves of oesophagus
• Regurgitating food or saliva
• Heartburn
• Pneumonia
 Special region of peritoneal cavity
• From surgical point of view peritoneal cavity is
divided into two parts-
- Abdomen proper(Abdominal cavity)
- Pelvic cavity
• Abdominal cavity-
- Intraperitoneal
- Divided by the transverse colon & transverse
mesocolon into two parts
- Supracolic compartment
- - Infracolic compartment
• Supracolic compartment
-Left anterior space/left subphrenic space
- Lie between left lobe of liver, spleen and
diaphragm.
-Left posterior space/left subheaptic space
- Lesser omentum
• Right anterior space/Right subphrenic space
- Lie between right lobe of liver & Diaphragm
• Right Posterior space/Hepatorenal
pouch/Morrison’s pouch/Right subheapic
space
- Lie between right side of the posterior part
of liver and right kidney.
• Extraperitoneal space of supracolic
compartment-
- Left extraperitoneal space-
- Lie between left kidney & Left suprarenal
gland.
- Right extraperitoneal space
- Lie between Right kidney & Right suprarenal
gland.
• Infracolic compartment
- Right infracolic
- Lie between Ascending colon , transverse
colon & messentary.
- Left infracolic
- Lie between desending colon , sigmoid colon,
small part of transverse colon & messentary.
• Paracolic gutter
- Right lateral paracolic compartment
- Left lateral paracolic compartment
• Pelvic cavity-
- Rectouterine pouch (Pouch of Douglas)
-Lie between uterus, vagina & Rectum in
fe male
-Rectovesical pouch
- Lie between bladder & rectum in male
- Vesicouterine pouch
- Lie between bladder & uterus in Female.
 Stomach
• Most distensible & widest part of the digestive
tube.
• Connect above to the lower end of esophagus
& below to the duodenum
• Act as a reservoir of food & help in digestion.
• Location
- Epigastric, umbilicus & Left hypochondric
region.
• Shape
- Empty- J shaped
- Partially distended- Pyriform
• Size & capacity
- 25 cm long
- mean capacity(30ml) at birth
- 1000ml at Puberty
- 1.5 to 2 Lit at adult
• External features-
• Cardiac orifice
- T11
• Pyloric orifice
- L1(transpyloric)
• Lesser curvature
- Concave & form the right border of the
stomach.
- Provide attachment to the lesser omentum.
- Incisura angularis or angular notch is present.
• Greater Curvature
- Convex & form left border of the stomach.
- Provide attachment to the greater omentum.
• At its upper end there is cardiac notch which
seprate it from the esophagus.
Stomach (Visceral relation)
 Venous drainage
• Lesser curvature- Right Gastric vein & Left gastric
vein
- Right & Left gastric vein drained into hepatic
portal vein.
• Greater Curvature(Lower side)- Right
gastroepiploic vein
- Drain into Superior mesentric vein
• Greater curvature(Upper side) & fundus- Left
gastroepiploic & short gastric vein
- Drain into splenic vein
 Arterial supply
• Lesser curvature (Upper side)- Left gastric
artery(Branch of coeliac trunk).
• Lesser curvature (Lower side)- Right gastric
artrey(Branch of proper heaptic artey).
• Greater curvature (Upper side)- Left
gastroepiploic artery(Branch of splenic artery).
• Greater curvature(Lower side)- Right
gastroepiploic artery(Branch of gastroduodenal
artery).
• Fundus- Short gastric artery (Branch of splenic
artery).
 Lymphatic Drainage
• Greater curvature(upper 1/3 area)- Drain into
pancreatosplenic nodes Coeliac
nodes(Through splenic artey)
• Greater curvature(lower 1/3 area)- Drain into
Right gastroepiploic nodes Pyloric nodes
Heaptic nodes Coeliac nodes.
• Lesser curvature(2/3 area)-Drain into Left
gastric nodes Coeliac nodes.
• Pyloric part- Drain into pyloric nodes, Heaptic
nodes Coeliac nodes.
 Part of stomach
• Two part- Cardiac & Pyloric by Line drawn
through incisura angularis.
• Cardiac
• Fundus- Convex dome shaped structure
- Filled with gas
• Body of the stomach-Between Fundus &
Pyloric antrum
• Gastric gland distribute mainly in fundic &
body part of the stomach.
-Mucous cell , Chief cell or peptic or zymogen
cell
- Parietal or oxyntic cell.
• Pyloric part
- Pyloric antrum
- Connect body of stomach to the pyloric canal
- 7.5 cm long
- Richest in mucous cell
• Pyloric canal
- 2.5 cm long
- Terminate into pylorus
 Histology
• Outer Serosa
- Areaoar connective tissue+ mesothelial cell
• Muscular coat
- Outer longitudinal muscle fiber
- inner circular muscle fiber
(At pylorus it thicken to form pyloric sphincter
- Deepest Oblique muscle fiber(Fundic & body
part)
• Submucosa
- Contain blood vessel, Lymphatics, nerve plexus
• Mucosa
- Mucosa of the empty stomach form gastric
rugae(foldind of mucosa).
- In distended stomach rugae become flattend.
- Rugae are longitudinal along the lesser curvature &
irregular other sites
- -Mucosa mainly contain gastric gland.
- -Mucosa have small depression called gastric pit
- -Each gastric gland open on a gastric pit.
 Duodenum
• It is the shortest , widest & most fixed part of the small
intestine.
• Extend from the pylorus to the duodenojejunal flexure.
• Lie at the level of the umbilicus opposites first, second
& third lumbar vertebrae.
• Length & Parts-
- First or superior – 5 cm
- Second or descending part-7.5 cm
- Third or Horizontal- 10cm
- Fourth or ascending- 2.5cm
 First Part
• Starts at pylorus and end at superior duodenal
flexure.
• Proximal 2.5 cm is movable & distal 2.5cm is
retroperitoneal.
• Visceral relation
- Anteriorly
- Quadrate lobe of liver & gallbladder
- Posteriorly
- Gastroduodenal artery, bile duct & portal vein
• Superior
- Epiploic foramen
• Inferior
- Head & Neck of the pancreas
 Second part
• Starts at Superior duodenal flexure & end at
inferior duodenal flexure.
• Retroperitoneal
• Visceral relation
- Anteriorly
- Right lobe of liver, Transverse colon, small
intestine
- Posteriorly
- Anterior surface of the right kidney, inferior vena
cava, Right psoas major muscle.
• Medially
- Head of the pancreas & bile duct
• Laterally
- Right colic flexure.
 Third part
• Starts at inferior duodenal flexure at right side of the 3rd Lumbar vertebrae
• Retroperitoneal
• Passes horizontally & end at 4th part in front of the aorta.
• Anteriorly
- Superior mesenteric vessels
- Root of the mesentery
• Posteriorly
- Right ureter
- Inferior vena cava
- Right Psoas muscle
- Right testicular or ovarian vessel
- Inferior vena cave
- Abdominal aorta with inferior mesentric artery
• Superior
- Head of the pancreas with uncinate process
• Inferiorly
- Coils of jejunum
 Fourth part
• Start at L3 at the end of the 3rd part &
terminate at L2 at the duodenojejunal flexure.
• Anteriorly
- Transverse colon, stomach & lesser sac
• Posteriorly
- Left sympathetic chain, Left renal artery, Left
gonadal artery & inferior mesenteric vein.
• Right
- Upper part of the root of the mesentery
• Left
- Left kidney & ureter.
 Suspensory muscle of
Duodenum/Ligament of Treitz
• Fibromuscular band which suspend &
supports the duodenojejunal flexure.
• Arises from the Right crus of diaphragm ,
passes downwards behind the pancreas & is
attached to the posterior portion of the
duodenojejunal flexure.
• Normally its contraction increases the angle of
the duodenojejunal flexure.
 Arterial Supply
• First Part of duodenum
- Right Gastric artery
- Supraduodenal artery(Branch of common
heaptic artery).
- Retroduodnal artery (Branch of
gastroduodenal artery).
- Right Gastroepiploic artery(Branch of
gastroduodenal artery).
• Second Part
- Superior pancreaticoduodenal artery(Branch of
gastroduodenal artery)
• Third Part
- Inferior pancreaticoduodenal artery(Branch of
Superior mesentric artery).
• Fourth Part
- Duodenal Branch (Right Jejunal artery).
 Venous drainage
• Anterior & superior Pancreaticoduodenal vein
(Drainage into Superior mesentric vein).
• Posterior & superior Pancreaticoduodenal vein
(Drainage into Portal vein)
• Anterior & inferior pancreaticoduodenal vein
(Drainage into Superior mesentric vein)
• Posterior & inferior pancreaticoduodenal
vein(Drainage into Superior mesentric vein).
• Left gastroepiploic vein (Drain into splenic vein)
 Lymphatic supply
• Most of the lymph drainage occurs through
Pancreaticoduodenal nodes.(Inside the loop of
duodenum)
pyloric nodes
Pancreaticoduodenal nodes Heaptic nodes
Superior mesentric nodes
Cisterna Chyli Coeliac nodes
 Histology of Duodenum
• Outermost serosa
• Muscularis Externa
- Outer longitudinal muscle fiber
- Inner circular muscle fiber
• Submucosa
- Contain blood vessels & lymphatics
- Specilized mucous secreting gland-Brunner’s gland.
- secrete an alkaline fluid containing mucin, which
protects the mucosa from the acidic stomach contents
entering the duodenum.
• Mucosa
- Outermost muscularis mucosa(Smooth muscle)
- Middle Lamina propia(Connective tissue)
- Innermost Mucous membrane(Simple columner
epithelium)
- Fold of mucous membrane is called plica circularis
- also known as Kerckring folds/valves, plicae
circulares or just small bowel folds, are the mucosal
fold starting from the second part of the duodenum,
they are large and thick at the jejunum and
considerably decrease in size distally in the ileum to
disappear entirely in the distal ileal bowel loops.
• Finger like projection of mucous membrane-villi
• Larger & numerous in duodenum & jejunum , smaller &
fewer in ileum.
- forming a brush border that absorbs nutrients
• In mucous membrane there are small invagination-Crypt
of Liberkuhne(Intestinal gland)
• Complete epithelium lining is replaced every two to four
days.
• enterocytes-absorb water & electrolyte
• Enteroendocrine-Gastrointestinal Hormone
• Panath cell- Antimicrobial lysozyme
• Goblet cell- secret mucus
 Jejunum and ileum
• Mobile 2/5 of the small intestine(Jejunum)
• 2.5meter in length(Jejunum)
• Mobile 3/5 of the small intestine(Ileum)
• 3.5 meter in length(ileum).
• Occupies upper part of the small intestine(Jejunum)
• Occupies lower Part of the small intestine(ILEUM)
• Wall of the jejunum is more thicker & vascular in comparison to
ileum.
• Lumen of the jejunum is more wider in comparison to ileum.
• Villi & plicae circularis is larger & more numerous in jejunum in
comparison to ileum.
• Peyer ‘s patches are present only in ileum.
 Blood supply of Jejunum
• Jejunal branches of the superior mesentric
artery supply the jejunum
• Jejunal branches form circular loop called
Arcades.
• From the arcades smaller arteries called vasa
recta is originate which supply the whole
jejunum in length.
• Drained by jejunal branches of the superior
mesentric vein.
 Blood supply of Ileum
• Ileal branches of the superior mesentric artery
supply the ileum.
• Ileal branches form circular loop called Arcades.
• From the arcades smaller arteries called vasa
recta is originate which supply the whole Ileum in
length.
• Drained by ileal branches of the superior
mesentric vein.
• Note- Vasa recta is longer & fewer in jejunum ,
Shorter & more numerous in ileum.
 Large Intestine
• Extend from ileocaecal junction to the anus.
• 1.5 meter in length.
• Part of Large intestine
- Caecum
- Ascending Colon
- Right Colic Flexure
- Transverse Colon
- Left Colic Flexure
- Descending Colon
- Sigmoid Colon
- Rectum
- Anal Canal
- In between the terminal part of the ileum & caecum there is narrow tube like
structure are found called vermiform appendix.
- Greater wall of the large intestine is fixed except transverse colon, appendix &
sigmoid colon.
• Caecum
- 6 cm long & 7.5 cm wide
- Terminal end of ileum is opened into the caecum-
Illeocaecal opening
- Illeocaecal opening –illeocaecal valve.
- Valve have two lips-upper lip & lower lip
- Valve have two frenula- Anterior& posterior
frenula.
- Valve prevent regurgitation from caecum to ileum
 Visceral relation
• Anterior
- Coil of intestine & anterior abdominal wall
• Posterior
- Muscle- Right Psoas major muscle & illacus
- Nerve-Genitofemoral & Femoral
- Vessel-Testicular or ovarian
- Retrocaecal appendix
- External illiac artery
 Vermiform appendix
• Worm like structure arising from the posteriomedial wall of
the caecum
• 2cm below the ileocaecal valve
• 2 to 20 cm in length
• Average -9cm in length
• Diameter-5 mm
• Position
- Right illiac fossa
- Base of the appendix is fixed but tip can point anyway.
- Base is situated 2cm below the ileocaecal opening.
- 2cm below the junction of the transtubercle line & right
lateral planes.
• Position
- paracolic-11’o clock
- Retrocaecal- 12’o clock
- Splenic position-2’o clock
- Preileal-infront of the ileum
- Postileal-Back of the ileum 3’o clock
- Pelvic- 4 or 5’oclock
- Subcaecal-6’o clock
 Blood Supply
• Appendicular artery
• Branch of iliocolic artery
• Venous drainage
- Appendicular, iliocolic & Superior mesentric
vein.
 Clinical anatomy
• Inflammation of appendix is known as appendicitis.
• Pain caused by appendix is first felt in umbilicus region – referred
pain.
• At last it felt in right illiac fossa due to inflammation of the parietal
peritoneum.
• McBurney’s point is the site of maximum tenderness in Right illiac
fossa.
• This point lies at the junction of the lateral 1/3 & medial 2/3 of the
line joining the umbilicus & Anterior superior illiac spine.
• Hyperasthesia in sherran triangle.
• Rebound Tenderness
• Pain, vomiting , fever.
• Constipation.
• Loss of appetite.
 Ascending Colon
• 12.5 cm long
• Extend from caecum to the Right colic flexure.
• Right Colic flexure(Hepatic flexure)
- Junction of the Ascending & Descending
colon.
- Impression on the inferior surface of liver.
- Flexure lie on Right Kidney.
- Lie at L2 level.
 Transverse colon
• 50 cm long
• Extend from Right Colic flexure to Left colic
flexure
• Left Colic Flexure (Splenic flexure)
• Lie on Left Kidney & Spleen
• Impression on Spleen
• Lie at T12 Level.
 Descending colon
• Extend from Left Colic flexure to Sigmoid
colon.
• 25 cm long.
 Sigmoid Colon
• 37.5 cm long
• Extend from upper boundary of the pelvic
brim upto the 3rd piece of Sacrum .
• Pelvic colon.
Anterior caecal artery
Posterior caecal artery
Both are the branches are the
iliocolic artery
Iliocolic artery is the branch of
the superior mesentric
vein(SMA).
 Blood supply of the colon
• Ascending colon- Right colic artery(SMA)
• Right colic flexure
• Transverse colon Middle colic artery(SMA)
• Left colic flexure
• Descending colon-Left colic artery (IMA)
• Sigmoidal colon- Sigmoidal branches(IMA)
• Blood supply of colon – Marginal artery of Drummond.
• Terminal branches from the marginal artery are
distributed to the colon as vasa longa & vasa brewia.
 Histology of Large intestine
• Outermost Serosa
• Muscularis externa
- Outer longitudinal muscle fiber
- Here it form thin layer & major portion of it
form 3 ribbon like band called Taenia coli.
- Taenia Libera
- Taenia mesocolia
- Taenia Omentalis
• Present on caecum, ascending colon,
Transverse colon, Descending colon, Sigmoid
colon.
• Taenia Libera
- Anteriorly- caecum, ascending colon &
descending colon ,Sigmoid colon
- Inferiorly- Transverse colon
• Taenia mesocolia-
- Posteriomedial- caecum, ascending & descending
colon, Sigmoid colon.
- Posteriorly- Transverse colon(attachment site of
the mesocolon)
• Taenia Omentalis-
- Posteriolaterally- caecum, ascending &
descending colon, sigmoid colon
- Anteriosuperior- Transverse colon
• Inner circular muscle fiber
• Due to Taenia large intestine is puckered and
sacculate – Haustra
• Epiploic appendages- Small bag of peritoneum
filled with fat & hang from the Taenia coli.
- Present all over the large intestine except
appendix, caecum & rectum
- Most numerous on the sigmoid colon &
posterior surface of the transverse colon.
 PANCREAS
• Mixed gland- Exocrine & Endocrine both.
• Location
- L1 & L2
- Posterior to the stomach
- Retroperitoneum
• Size & Shape
- J Shape
- 15-20 cm long, 2.5-3.8 cm wide & 1.2 – 1.8 cm
thick
 Part of the Pancreas
• From right to left
• Head
- Lie within the concavity of duodenum
• Neck
• Body
- Some Part of the body project upward & rest on
superior border called Tuber omentale
• Tail
• Uncinate Proces
- hook like extension from the lower part of the head of
the pancreas,
 Head of the Pancreas
• Lie within the C shaped duodenum.
• Head have
- 3 Border- Superior, inferior & Lateral
- 2 Surface- Anterior & Posterior
- 1Process-Uncinate Process
• Visceral relation
- Superior Border- 1st Part of Duodenum & Superior
Pancreaticoduodenal artery & vein
- Inferior Border- 3rd Part of duodenum & Inferior
Pancreaticoduodenal artery & Vein.
- Lateral Border- 2nd Part of Duodenum, Bile Duct & anastomosis of
the Superior & Inferior pancreaticoduodenal artey .
• Anterior Surface
- First Part of Duodenum
- Transverse Colon
- Jejunum
• Posterior Part
- Inferior vena cava
- Right crus of diaphragm
- Bile duct
- Renal vein
• Uncinate Process
- Anteriorly
- Superior Mesentric artery & vein
- Posteriorly
- Aorta
 Neck of Pancreas
• Anteriorly
- Pylorus
• Posterirly
- Superior mesentric vein & Portal vein
 Body of Pancreas
• 3 Border- Anterior, Superior & inferior
• 3 Surface- Anterior, Posterior & inferior
• Anterior Border
- Root of the Transverse mesocolon
• Superior Border
- Coeliac trunk
- Hepatic artery (Right)
- Splenic artery (Left)
• Inferior border
- Superior mesentric vessel (Right)
• Anterior Surface (Covered with peritoneum)
- Lesser sac & Stomach
• Posterior Surface
- Left crus of the Diaphragm
- Left Kidney
- Left suprarenal gland
- Left Renal vessel
• Inferior Surface
• Duodenojejunal flexure
• Jejnum
• Left colic flexure
 Tail of the Pancreas
• Lie within the Lineorenal ligament together
with the splenic vessel.
• Lower surface of spleen
 Arterial Supply
• Superior Pancreaticoduodenal artery
• Inferior Pancreaticoduodenal artery
• Pancreatic branches of the Splenic artery
 Venous drainage
• Superior Pancreaticoduodenal vein (Portal
vein)
• Inferior Pancreaticoduodenal vein (Superior
mesentric artery)
• Pancreatic Branches (Splenic vein)
 Duct of Pancreas
• Exocrine Part
- Drained by 2 duct
- Main Pancreatic duct (Duct of Wirsung)
- Accessory Pancreatic duct(Duct of Santorini)
• Main Pancreatic duct
- Lumen- 3 mm
- Have many small tributaries which join it perpendicular.
- Start within the tail of the Pancreas & bend at the neck to run downwards
backwards & to the right of the head
- combine with bile duct in the Head Region.
- After combination it is called Hepatopancreatic duct (Ampulla of Vater).
- Hepatopancreatic duct open into the 2nd part of the duodenum at the
major duodenal Papilla.
- 8 to 10 cm distal to pylorus.
- Sphincter of Oddi – Hepatopancreatic opening
• Accessory Pancreatic duct
- Begin in the lower part of the Head
- Communicate with main pancreatic duct &
open into the 2nd part of duodenum at minor
duodenal papilla.
- 6 to 8 cm distal to the pylorus.
• Endocrine part
• Islet of Langerhans
- Alpha cell (20%)
- Beta cell(75%)
- Delta cell(4%)
- PP Cell (1%)
 Spleen
• Wedge shaped organ
• Soft & highly vascular.
• Location
• Mainly in Left hypochondriac region &
Partially in epigastric region.
• Between9 to 11 ribs
• Between T10 & T12
• Size & Weight
- Variable
- Average 2.5 cm thick, 7.5 cm broad &12.5 cm
long.
- 7 ounce (198 gm)
• Position
-Directed downwards, forwards & Laterlly
- Making an angle of 45% with horizontal.
 External feature
• Two End
- Anterior End / Lateral End
- Downwards & Forwards
- Reach the midaxillary line
- Posterior End/ Medial End
- Upwards & Backwards
- Upper pole of Left Kidney
• 3Border
- Superior Border
- marked along the upper border of the ninth rib
- superior border of the spleen is notched by the
anterior end.
- Inferior Border
- along the 11th rib
- Intermediate Border
• 2 Angles
- Anterobasal Angle
- Junction of the Superior border & Anterior End.
- Clinical angle of the spleen
- Posterobasal Angle
-junction of the inferior border & Anterior end
2 Surface
Diaphtragmatic surface
Visceral surface
 Peritoneal relation
• Gastrosplenic ligament
-Extend from Hilum to the Greater curvature of
spleen
• Linorenal Ligament
- Extend from hilum to the Anterior end of Left
kidney.
• Phrenicocolic ligament
• Extend from splenic flexure of colon to the
diaphragm
• Support the anterior end.
 Visceral Relation
• Fundus of stomach, Anterior Surface of Left
kidney, Splenic flexure of colon, tail of
pancreas.
Note- Hilum lies between superior &
intermediate ares
 Blood supply of spleen
• Arterial supply
- Splenic artery (Branch of Coeliac trunk)
• Venous supply
- Splenic vein
Note – Behind the neck of the pancreas splenic
vein combined with Superior mesentric vein
& form Hepatic portal vein.
 Histology
• Outer covering- capsule
• Trabeculae
- Numerous septa (trabeculae) extend from
the capsule into the parenchyma of the spleen
• Inner Mass- Parenchyma
- White Pulp (25%)
- Consisting of lymphatic nodules
- B cells (Antibody Production)
- Macrophages
- Red Pulp(75%)
- Cord of Billroth (Splenic cords)-connective tissue
 Clinical Anatomy
• Splenomegaly
• Splenectomy- Partial splenctomy & Whole
splenectomy.
• Splenic Puncture
• Reffered Pain
- Left Shoulder (Kher’s sign)
 Clinical Anatomy of Pancreas
• Acute Pancreatitis
- a condition where the pancreas becomes
inflamed (swollen) over a short period of time.
- Cause- Alcohal, Gall stone
- Clinical Diagnosis
- Leaning forward help to relieve the pain,
- Cullen’s sign- hemorrhagic discoloration of the
umbilical area
- Turner’s sign- Blue discoloration of the left flank
• Symptoms
- Epigastric Pain
- Vomiting
- Fever
- Jaundice (Gall Stone)
 Chronic Pancreatitis
• a progressive inflammatory disorder that
leads to irreversible destruction of exocrine
and endocrine pancreatic parenchyma
caused by atrophy and/ or replacement with
fibrotic tissue.
 Symptoms
• Pain in the upper belly that spreads into the back.
• Pain in the belly that gets worse when you eat or
drink alcohol.
• Diarrhea or oily stools.
• Nausea and vomiting.
• Severe belly (abdominal) pain that may be
constant or that comes back.
• Weight loss.
 LIVER
• Weight-1600gm in male
-1300gm in female
• Normal size is 7 cm for women and 10.5 cm for
men.
• Largest gland of the body
• Location
- Right hypochondriac, greater part of epigastric &
Left hypochondriac region up to left lateral line.
 External features
• 5Surface
- Anterior
- Posterior
- Superior
- Inferior
- Right
• 1 Border
- Inferior Border
- Separate the Anterior & Inferior Surface
 Lobs of Liver
• Divided into Right & Left Lobe by falciform ligament.
• Ligaments of Liver
• Falciform ligament- Anterior & Superior
• Ligamentum Teres- Inferior
• Ligamentum venosum- Posterior
• Coronary Ligament-Attaches the liver to the diaphragm,
and the right kidney and adrenal gland.
• Right Lobe
- Larger
- Contribute 5/6 of the Liver
- Have Caudate & Quadrate Lobe
- Have all the 5 Surface
 Caudate Lobe
• Situated on Posterior Surface
• Right- Inferior vena cava
• Left- Fissure of Ligamentum venosum
• Inferiorly –porta hepatis
• Superiorly –Continue with superior surface
• Connected to the Right Lobe- caudal Process
 Quadrate Lobe
• Situate on Inferior surface.
• Anteriorly- Inferior Border
• Posteriorly- Porta Hepatis
• Right- Fossa of Gall Bladder
• Left- Ligamentum teres
 Porta Hepatis
• Lie between quadrate & caudate lobe.
• Portal vein, hepatic artery , nerves enter
through it
• Right & Left hepatic duct & Lymphatics exit
through it.
 Left Lobe of Liver
• Form 1/6 of the Liver
• Have inferior, Anterior, Posterior & Superior
Surface
Visceral relation
• Anterior Surface
- Xiphoid Process
- Anterior abdominal wall
- Diaphragm
- Lungs
- Pleura
- Ribs 7 to 11
• Posterior surface
- Bare area (Diaphragm)
- Inferior vena cava
- Caudate Lobe-Coeliac trunk
- Ligamentum venosum- Left Br. Of Portal vein
- Posterior surface of Lt. Lobe- oesophageal
impression
• Superior surface
• Middle concavity- cardiac impression
• Left & Right- Diaphragm
• Inferior Surface
- Gastric impression
- Fissure of Ligamentum teres
- Quadrate Lobe- pylorus
- First part of duodenum when the stomach is
empty
- Fossa of Gall bladder
- Colic impression
- Right Renal impression
• Right Surface
- Ribs 7 to 11
- Diaphragm
- Pleura
- Lung
 Extrahepatic biliary apparatus
• Collect bile from the Liver store it in the
gallbladder & transmit it to the 2nd part of the
duodenum.
• Right & Left Hepatic duct
• Common hepatic duct
• Gall Bladder
• Cystic duct
• Bile duct
• Right &Left Hepatic duct
- Emerge at the porta Hepatis from Right & Left
Lobe.
• Common Hepatic duct
- Formed by the union of the Right & Left
Hepatic duct.
Note- Accessory hepatic duct- 15%
- Connect Right lobe directly to the gall bladder
 Gall Bladder
• Pear shaped reservoir
• Location
- Inferior surface of the Right Lobe of the Liver
• Dimension & Capacity
- 7 to 10 cm long, 3cm broad
- 30 to 50 ml
 Part of Gallbladder
• Fundus
• Body
• Neck
• Cystic Duct
- 3 to 4 cm long
- Begins at the neck of the gallbladder & end by
joining the common hepatic duct.
• Common Bile Duct
- 8cm long , Diameter 6mm
- Formed by the union of the cystic & common
hepatic duct near porta hepatis.
 Blood Supply of Liver
• 20%- Hepatic artery
• 80%- Hepatic Portal vein
• Arterial System(Fully Oxygenated)
- Right & Left Hepatic artery(branch of Proper
hepatic artery)
-Proper Hepatic artery is branch of Common
Hepatic artery(Branch of coeliac trunk)
• Hepatic Portal vein Supply(Partially
Oxygenated)
-Right & Left Hepatic portal vein(Branch of main
hepatic portal vein)
- Main Hepatic portal vein(Formed by superior
mesentric vein & Splenic vein)
• In the Sinusoids of the Liver there is mixing of
Hepatic arterial blood & Hepatic portal vein.
 Venous Drainage
• Hepatic vein(Drained blood from sinusoids)
• Hepatic vein arranged into two group
• Upper & Lower Group
• Upper Group
- Right Hepatic vein
- Middle Hepatic vein Inferior vena cava
- Left Hepatic vein
• Lower Group
- Variable number of small vein- Inferior vena cava
 Hepatic Segment
• On the basis of the intrahepatic distribution of the
Hepatic artery, Hepatic vein, Portal vein & Bile Duct.
• Right Functional Lobe
• Left Functional Lobe
• Right Functional Lobe
- Right Anterior (V & VIII)
- Right Posterior(VI & VII )
• Left Functional Lobe
- Left Lateral ( II & III)
- Left Medial (I & IV)
 RECTUM
• Placed between the sigmoid colon & Anal canal.
• Absence of three Large intestine features
• Begins at Rectosigmoid junction & end at
Anorectal (2 to 3cm below tip of the coccyx )
• Position
- S3 to S5 & coccyx.
• Direction
- Run Downwards & backwards, then downwards
& in the end downward and forward.
• Size
- 12 cm long , Diameter- 4cm
• Curvature
- Anterioposterior curvature
- Lateral Curvature
• Anterioposterior curvature(2 curve)
- Sacral flexure (Concavity of sacrum & coccyx)
- Perineal flexure (Anorectal junction)
• Lareral curve-3
- Upper lateral (Convex to right)
- Middle Lateral (Convex to Left)
- Lower Lateral (Convex to right)
• Peritoneal Relation-
• Upper 1/3- Covered with peritoneum in front & Sides
• Middle 1/3- Covered with peritoneum in front
• Lower 1/3- Lack of Peritoneum
-Lie below the rectovesical pouch & rectouterine pouch
 Visceral Relation
• In male (Anteriorly)
- Upper 2/3 – Rectovesical pouch
- Coil of ileum & Sigmoid colon
- Lower1/3- Base of urinary bladder
- terminal part of ureter
- Seminal vesicals, vasa deferns, Prostate
• In Female (Anteriorly)
- Upper 2/3- Rectouterine Pouch
- Coil of ileum & Sigmoid colon
- upper part of vagina
- Lower1/3- Lower Part of vagina
 Posteriorly
• Saccrum
• Coccyx
• Piriformis muscle
• Levator ani muscle
• Coccygeus muscle
 Histology
• Outermost serosa
• Muscularis externa
- Outer Longitudinal
- Inner circular
• Submucosa
• Mucosa
- Two types of fold
- Longitudinal Fold
- Transverse Fold
• Longitudinal Fold- present in empty rectum
- Lower part of rectum
- Temporary
• Transverse Fold- Permanent
• Horizontal Fold, Houston’s valve, Plica
transversales- 4 in number
- First transversae fold
- Second transversae fold
- Third transversae fold
- Fourth transversae fold
 Arterial Blood Supply
• Superior rectal artery(Branch of inferior
mesentric artery).
• Middle Rectal artery(Branch of Internal iliac
artery).
• Median sacral artery(Branch of Aorta)
 Venous Drainage
• Superior rectal vein (Inferior mesentric vein)
• Middle rectal vein (Internal iliac vein)
• Median sacral vein (Left common iliac vein).
 Anal Canal
• Situated below the level of the Pelvic Diaphragm
between Right & Left Ischioanal fossa.
• Present in Posterior Triangle(Anal Triangle).
• Length
- 3.8cm long
• Position
- Extend from Anorectal junction up to the Anus.
- 4cm below the tip of the coccyx.
 Relation
• Anteriorly
- Perineal body (In both sex)
- Membranous urethra(In male)
- Lower end of vagina (In Female)
• Posteriorly
- Anococcygeal Ligament
- Tip of the coccyx
 Mucosa of Anal canal
• Divided into three Parts
• Upper Mucous Part
- 15 mm long
- 6 to 10 vertical fold- Anal column of Morgagni
- Vertical fold are connected to each other by
transverse fold- Anal Valve.
- Anal canal together form transverse Line-
Pectinate Line.
- Have Anal glans- Secretion of these gland
produce Peculiar smell.
• Middle part
• 15 mm long
• Pecten or Transition Zone
• Have Bluish appearance
• Lower End have whitish line- Line of hilton
• Lower Part
• 8 mm long
• Have Sebaceous gland, sweat gland & hair.
 Anal Sphicter
• Internal Anal Sphincter(Involuntary)
• External Anal Sphincter(Voluntary)
• Internal Anal Sphincetr
- Extend from upper end up to the Hilton’ Line
- Modification of Circular Muscle fiber.
- 30 mm long
• External Anal Sphincter
- Modification of Striated Muscle
- Whole Length of Anal Canal
 Arterial Supply
• Part above the pectinate line is supplied by
superior rectal artery(IMA)
• Part below the pectinate line is supplied by
inferior rectal artery.(Inferior Pudendal artery)
 Clinical Anatomy of Anal canal
• Piles-swollen veins in your anus or rectum.
- True Piles- occur above the pectinate line
- Superior rectal vein(Internal Piles)
- False Piles- Below the pectinate line.
- Inferior rectal vein(External Piles)
- Classification on the basis of position
- Primary Piles- 3, 7,11‘o clock position.
3‘o clock- Left Lateral
7‘o clock- Right Posterior
11‘o clock- Right Anterior
• Cause
• Absence of valve
• Poor support to vein
• Pregnancy
• Constipation
• Fissure in ano
• Occur due to Ruptured of Anal valve
• Cause- Dry stool
- It causes Spasm of Anal Sphincter
• Fistula-in-ano
- Occur due to Spontaneous ruptured of the
anal abscess or may follow surgical drainage of
abscess
• Anal abscess- infection of the anal gland.
 Clinical Anatomy of Rectum
• Digital per rectal Examination(PR)
- Examination of rectum region through finger
- Prostate
- Seminal Vesicles
- Cervix
- Presenting fetal part
- Anorectal anomalies