Clinical anatomy of the digestive

system
Dr. Badru Ssekitooleko
 The Esophagus

Narrow Areas of the Esophageal Lumen

The esophagus is narrowed at three sites: at the beginning, behind

the cricoid cartilage of the larynx; where the left bronchus and
the arch of the aorta cross the front of the esophagus; and where
the esophagus enters the stomach. These three sites may offer
resistance to the passage of a tube down the esophagus into the
stomach
 Cont.
Achalasia of the Cardia (Esophagogastric Junction)
The cause of achalasia is unknown, but it is associated with a
degeneration of the parasympathetic plexus (Auerbach's plexus)
in the wall of the esophagus. The primary site of the disorder
may be in the innervation of the cardioesophageal sphincter by
the vagus nerves. Dysphagia (difficulty in swallowing) and
regurgitation are common symptoms that are later accompanied
by proximal dilatation and distal narrowing of the esophagus.
 Cont.
• Bleeding Esophageal Varices
At the lower third of the esophagus is an important portal systemic venous
anastomosis . Here, the esophageal tributaries of the left gastric vein
(which drains into the portal vein) anastomose with the esophageal
tributaries of the azygos veins (systemic veins). Should the portal vein
become obstructed, as, for example, in cirrhosis of the liver, portal
hypertension develops, resulting in dilatation and varicosity of the
portal systemic anastomoses. Varicosed esophageal veins may rupture,
causing severe vomiting of blood (hematemesis).
 Stomach
• The stomach is the dilated portion of the alimentary canal
and has three main functions: It stores food (in the adult it
has a capacity of about 1500 mL), it mixes the food with
gastric secretions to form a semifluid chyme, and it
controls the rate of delivery of the chyme to the small
intestine so that efficient digestion and absorption can
take place.
 Cont.
Much of the stomach lies under cover of the lower ribs. It is roughly J-
shaped and has two openings, the cardiac and pyloric orifices; two
curvatures, the greater and lesser curvatures; and two surfaces, an
anterior and a posterior surface .
•Trauma to the Stomach
Apart from its attachment to the esophagus at the cardiac orifice and its
continuity with the duodenum at the pylorus, the stomach is relatively
mobile. It is protected on the left by the lower part of the rib cage.
These factors greatly protect the stomach from blunt trauma to the
abdomen. However, its large size makes it vulnerable to gunshot
wounds.
• Gastric Ulcer

The mucous membrane of the body of the stomach and, to a lesser extent, that
of the fundus produce acid and pepsin; controlled by two mechanisms:
nervous and hormonal. In the surgical treatment of chronic gastric and
duodenal ulcers, attempts are made to reduce the amount of acid secretion
by sectioning the vagus nerves (vagotomy) and by removing the gastrin-
bearing area of mucosa, the antrum (partial gastrectomy).

An ulcer if situated on the posterior wall of the stomach may perforate into the
lesser sac or become adherent to the pancreas. Erosion of the pancreas
produces pain referred to the back. The splenic artery runs along the upper
border of the pancreas, and erosion of this artery may produce fatal
hemorrhage.
 Cont.
A penetrating ulcer of the anterior stomach wall may result in the escape of
stomach contents into the greater sac, producing diffuse peritonitis. The
anterior stomach wall may, however, adhere to the liver, and the chronic ulcer
may penetrate the liver substance.

Gastric Pain

The sensation of pain in the stomach is caused by the stretching or spasmodic

contraction of the smooth muscle in its walls and is referred to the epigastrium.
It is believed that the pain-transmitting fibers leave the stomach in company
with the sympathetic nerves. They pass through the celiac ganglia and reach the
spinal cord via the greater splanchnic nerves.
 Cont.
Cancer of the Stomach
Because the lymphatic vessels of the mucous membrane and sub
mucosa of the stomach are in continuity, it is possible for cancer
cells to travel to different parts of the stomach, some distance
away from the primary site. Cancer cells also often pass through
or bypass the local lymph nodes and are held up in the regional
nodes.
 Cont.
For these reasons, malignant disease of the stomach is treated by total
gastrectomy, which includes the removal of the lower end of the esophagus and
the first part of the duodenum; the spleen and the gastrosplenic and
splenicorenal ligaments and their associated lymph nodes; the splenic vessels; the
tail and body of the pancreas and their associated nodes; the nodes along the
lesser curvature of the stomach; and the nodes along the greater curvature, along
with the greater omentum. The continuity of the gut is restored by anastomosing
the esophagus with the jejunum.
 Duodenum

• Trauma to the Duodenum

Apart from the first inch, the duodenum is rigidly fixed to the posterior abdominal
wall by peritoneum and therefore cannot move away from crush injuries. In
severe crush injuries to the anterior abdominal wall, the third part of the
duodenum may be severely crushed or torn against the third lumbar vertebra.
• Duodenal Ulcer

As the stomach empties its contents into the duodenum, the acid chyme is squirted
against the anterolateral wall of the first part of the duodenum. This is thought
to be an important factor in the production of a duodenal ulcer at this site.
 Cont.
An ulcer of the anterior wall of the first inch of the duodenum may perforate into the
upper part of the greater sac, above the transverse colon.

The transverse colon directs the escaping fluid into the right lateral paracolic gutter and
thus down to the right iliac fossa.

The differential diagnosis between a perforated duodenal ulcer and a perforated

appendix may be difficult.

An ulcer of the posterior wall of the first part of the duodenum may penetrate the wall
and erode the relatively large gastroduodenal artery, causing a severe hemorrhage. The
gastroduodenal artery is a branch of the hepatic artery, a branch of the celiac trunk
 jejunum
The jejunum and ileum measure about 20 ft (6 m) long; the upper two fifths of
this length make up the jejunum. The jejunum begins at the duodenojejunal
flexure, and the ileum ends at the ileocecal junction.

•Trauma to the Jejunum and Ileum

Because of its extent and position, the small intestine is commonly damaged
by trauma. The extreme mobility and elasticity permit the coils to move freely
over one another in instances of blunt trauma.
 Cont.
• Mesenteric Arterial Occlusion

The superior mesenteric artery, a branch of the abdominal aorta, supplies an extensive
territory of the gut, from halfway down the second part of the duodenum to the left
colic flexure. Occlusion of the artery or one of its branches results in death of all or
part of this segment of the gut. The occlusion may occur as the result of an
embolus, a thrombus, an aortic dissection, or an abdominal aneurysm.

• Mesenteric Vein Thrombosis

The superior mesenteric vein, which drains the same area of the gut supplied by the
superior mesenteric artery, may undergo thrombosis after stasis of the venous bed.
Cirrhosis of the liver with portal hypertension may predispose to this condition.
• Meckel's Diverticulum
the remains of the yolk stalk of the embryo, which, when persisting abnormally as a
blind sac or pouch in the adult, is located on the ileum a short distance above

the cecum; it may be attached to the umbilicus and, if the lining includes gastric

mucosa, peptic ulceration and bleeding may result.

• Mesenteric Tumors and Cysts

A tumor or cyst of the mesentery, when palpated through the anterior
abdominal wall, is more mobile in a direction at right angles to the
line of attachment than along the line of attachment.
 cont
Pain Fibers from the Jejunum and Ileum

Pain fibers traverse the superior mesenteric sympathetic plexus and pass to the
spinal cord via the splanchnic nerves. Referred pain from this segment of the
gastrointestinal tract is felt in the dermatomes supplied by the 9th, 10th, and
11th thoracic nerves.

Strangulation of a coil of small intestine in an inguinal hernia first gives rise to

pain in the region of the umbilicus. Only later, when the parietal peritoneum
of the hernial sac becomes inflamed, does the pain become more intense and
localized to the inguinal region .
 Large Intestine
• The large intestine extends from the ileum to the anus. It is divided into the
cecum, appendix, ascending colon, transverse colon, descending colon, and
sigmoid colon. The rectum and anal canal are considered in the sections on
the pelvis and perineum. The primary function of the large intestine is the
absorption of water and electrolytes and the storage of undigested material
until it can be expelled from the body as feces
 Cont.
• Variability of Position of the Appendix

The inconstancy of the position of the appendix should be borne in mind when
attempting to diagnose an appendicitis. A retrocecal appendix, for example,
may lie behind a cecum distended with gas, and thus it may be difficult to
elicit tenderness on palpation in the right iliac region. Irritation of the psoas
muscle, conversely, may cause the patient to keep the right hip joint flexed.

An appendix hanging down in the pelvis may result in absent abdominal

tenderness in the right lower quadrant, but deep tenderness may be
experienced just above the symphysis pubis.

Rectal or vaginal examination may reveal tenderness of the peritoneum in the

pelvis on the right side.
Predisposition of the Appendix to Infection
•The following factors contribute to the appendix's
predilection to infection:
•It is a long, narrow, blind-ended tube, which encourages
stasis of large-bowel contents.
•It has a large amount of lymphoid tissue in its wall.
• Predisposition of the Appendix to Perforation
The appendix is supplied by a long small artery that does not anastomose with
other arteries. The blind end of the appendix is supplied by the terminal
branches of the appendicular artery. Inflammatory edema of the
appendicular wall compresses the blood supply to the appendix and often
leads to thrombosis of the appendicular artery. These conditions commonly
result in necrosis or gangrene of the appendicular wall, with perforation.
Perforation of the appendix or transmigration of bacteria through the inflamed
appendicular wall results in infection of the peritoneum leading to a
condition called peritonitis.
Pain of Appendicitis
•Visceral pain in the appendix is produced by distention of its lumen or spasm
of its muscle. The afferent pain fibers enter the spinal cord at the level of the
10th thoracic segment, and a vague referred pain is felt in the region of the
umbilicus. Later, the pain shifts to where the inflamed appendix irritates the
parietal peritoneum. Here the pain is precise, severe, and localized
 LIVER
• Liver Trauma
The liver is a soft, friable structure enclosed in a fibrous capsule. Its close
relationship to the lower ribs must be emphasized. Fractures of the
lower ribs or penetrating wounds of the thorax or upper abdomen are
common causes of liver injury. Blunt traumatic injuries from
automobile accidents are also common, and severe hemorrhage
accompanies tears of this organ.
Because anatomic research has shown that the bile ducts, hepatic arteries,
and portal vein are distributed in a segmental manner, appropriate
ligation of these structures allows the surgeon to remove large portions
of the liver in patients with severe traumatic lacerations of the liver or
with a liver tumor. (Even large, localized carcinomatous metastatic
tumors have been successfully removed.)
• Subphrenic Spaces
Under normal conditions these are potential spaces only, and the
peritoneal surfaces are in contact. An abnormal accumulation of
gas or fluid is necessary for separation of the peritoneal surfaces.
The anterior surface of the liver is normally dull on percussion.
Perforation of a gastric ulcer is often accompanied by a loss of
liver dullness caused by the accumulation of gas over the
anterior surface of the liver and in the subphrenic spaces.
 Portal Systemic Anastomoses

• Under normal conditions, the portal venous blood traverses the liver and
drains into the inferior vena cava of the systemic venous circulation by
way of the hepatic veins. This is the direct route. However, other, smaller
communications exist between the portal and systemic systems, and they
become important when the direct route becomes blocked.
• These communications are as follows:

At the lower third of the esophagus, the esophageal branches of the left gastric
vein (portal tributary) anastomose with the esophageal veins draining the
middle third of the esophagus into the azygos veins (systemic tributary).
• Halfway down the anal canal, the superior rectal veins (portal tributary)
draining the upper half of the anal canal anastomose with the middle and
inferior rectal veins (systemic tributaries), which are tributaries of the
internal iliac and internal pudendal veins, respectively
Cont.
 Cont.
• The paraumbilical veins connect the left branch of the portal vein with the
superficial veins of the anterior abdominal wall (systemic tributaries). The
paraumbilical veins travel in the falciform ligament and accompany the
ligamentum teres.
• The veins of the ascending colon, descending colon, duodenum, pancreas,
and liver (portal tributary) anastomose with the renal, lumbar, and phrenic
veins (systemic tributaries).
 Portal Hypertension

Portal hypertension is a common clinical condition; thus, the list of portal

systemic anastomoses should be remembered. Enlargement of the portal
systemic connections is frequently accompanied by congestive enlargement of
the spleen.

Portal caval shunts for the treatment of portal hypertension may involve the
anastomosis of the portal vein, because it lies within the lesser omentum, to
the anterior wall of the inferior vena cava behind the entrance into the lesser
sac. The splenic vein may be anastomosed to the left renal vein after removing
the spleen.
• Blood Flow in the Portal Vein and Malignant Disease

The portal vein conveys about 70% of the blood to the liver. The remaining
30% is oxygenated blood, which passes to the liver via the hepatic artery.
The wide angle of union of the splenic vein with the superior mesenteric
vein to form the portal vein leads to streaming of the blood flow in the
portal vein. The right lobe of the liver receives blood mainly from the
intestine, whereas the left lobe plus the quadrate and caudate lobes receive
blood from the stomach and the spleen. This distribution of blood may
explain the distribution of secondary malignant deposits in the liver.
• End