1.

Review the esophagus: commencement, termination, location, length, constrictions, relations, neurovascular supply

Commencement:
 opposite the sixth cervical vertebra; it is continuous above with the
laryngeal part of the pharynx
 begins at the inferior border of the cricoid cartilage

Termination:
 end by entering the stomach (cardiac orifice) left 7th costal cartilage or
opposite T11

Location:
 It is between the trachea and the spine

Length:
 25-30 cm long in a normal adult

Constrictions:
1. at the beginning by the cricopharyngeus muscle
2. where the aortic arch and the left bronchus cross its anterior surface
3. where the esophagus passes through the diaphragm into the stomach at
the 10th thoracic vertebra

Relations:
 Inferiorly to the level of the roots of the lungs
o Left vagus lies anterior to it
o Right vagus lies posterior to it
 At the opening in the diaphragm it is accompanied by…
o two vagi
o branches of the left gastric blood vessels
o lymphatic vessels
 In the neck
o Posteriorly
 vertebral column
o Laterally
 lobes of the thyroid gland
o Anteriorly
 trachea
 recurrent laryngeal nerves
 In the thorax
o Anteriorly
 Trachea
 left recurrent laryngeal nerve
 left principal bronchus
 pericardium
o Posteriorly
 bodies of the thoracic vertebrae
 thoracic duct
 azygos veins
 right posterior intercostal arteries
 descending thoracic aorta at its lower end
o Right side
 mediastinal pleura
 terminal part of the azygos vein
o Left side
  left subclavian artery
 aortic arch
 thoracic duct
 mediastinal pleura
 In the abdomen
o Anteriorly
 left lobe of the liver
o posteriorly
 left crus of the diaphragm

NVS:
 The upper segment is innervated by the recurrent laryngeal nerves. The smooth fibers in the lower segment are
innervated by sympathetic fibers from the 6th -10th thoracic ganglia; with para-sympathetic fibers from the vagus.
 The inferior thyroid arteries supply the cervical segment, while the thoracic aorta takes care of the thoracic part. The
diaphragmatic and abdominal segments are supplied by branches from the esophageal branch of the left gastric
artery.
 Veins draining the blood from the upper segments join tributaries to the superior vena cava; while those from the
lower segments communicate with the veins that join the portal vein.

2. Discuss the stomach as to its shape, location, parts, relation, peritoneal attachments, NVS

Shape: J-shaped

Location: left upper quadrant, epigastric, and umbilical regions, and much of it lies under cover of the ribs; between the
esophagus and the small intestine

Parts:
 Fundus:
o dome-shaped
o projects upward and to the left of the
cardiac orifice
o usually full of gas
 Body/Corpus Ventriculi:
o level of the cardiac orifice to the level
of the incisura angularis (a constant
notch in the lower part of the lesser
curvature)
 Pyloric antrum:
o from the incisura angularis to the
pylorus
 Pylorus:
o most tubular part
o pyloric sphincter - thick muscular wall
o pyloric canal - cavity of the pylorus
 Cardia:
o part surrounding the cardiac orifice
 Lesser curvature:
o shorter concave border
 Greater curvature:
o convex border

Relation:
 Gastric curvatures
 Lesser curvature
o Right border of stomach
o from the cardiac orifice to the pylorus
 o suspended from the liver by the lesser omentum
 Greater curvature
o four or five times longer
o starts from the
 left of the cardiac orifice
 over the dome of the fundus
 along the left border of the
stomach to the pylorus
o gastrosplenic omentum (ligament)
 from the upper part of the
greater curvature to the
spleen
o greater omentum
 from the lower part of the
greater curvature to the
transverse colon
Transverse section of the lesser sac showing the
arrangement of the peritoneum in the formation of the
lesser omentum, the gastrosplenic omentum, and the
splenicorenal ligament. Arrow indicates the position of the
opening of the lesser sac.
 Anteriorly:
o anterior abdominal wall
o left costal margin
o left pleura and lung
o diaphragm
o left lobe of the liver
 Posteriorly:
o lesser sac
o diaphragm
o spleen
o left suprarenal gland
o upper part of the left kidney
o splenic artery
o pancreas
o transverse mesocolon
o transverse colon

Structures situated on the posterior abdominal wall behind the

stomach.
Peritoneal attachments:
 parietal peritoneum
o anterior abdominal wall surfaces
o lateral abdominal wall surfaces
o posterior abdominal wall surfaces
o inferior surface of diaphragm and pelvis
 visceral peritoneum
o surfaces of intraperitoneal organs (i.e., stomach, jejunum, ileum, transverse colon, liver, spleen)
o anterior aspect of retroperitoneal organs (i.e., duodenum, L & R colon, pancreas, kidneys, adrenal glands)

Peritoneal ligaments and mesenteric reflections in the adult.

These attachments partition the abdomen into nine potential
spaces: right and left subphrenic, subhepatic,
supramesenteric and inframesenteric spaces, right and left
paracolic gutters, pelvis, and omental bursa (shown in inset
on right).  

 peritoneal cavity – divided into 2 parts

o greater sac
 main compartment and extends from the diaphragm down into the pelvis
o lesser sac
 smaller and lies behind the stomach
 in free communication with one another through an oval window called the opening of the lesser sac, or the epiploic
foramen
 intraperitoneal - almost totally covered with visceral peritoneum
 Retroperitoneal - lie behind the peritoneum and are only partially covered with visceral peritoneum
 Peritoneal ligaments - two-layered folds of peritoneum that connect solid viscera to the abdominal walls
o Liver is connected to the diaphragm by
 falciform ligament
 coronary ligament
 right and left triangular ligaments

NVS:
 all arteries derived from branches of the celiac artery
o left gastric artery
 from the celiac artery
 supplies the lower third of the esophagus and the upper right part of the stomach.
o right gastric artery
 from the hepatic artery
 supplies the lower right part of the stomach
o short gastric arteries
 from the splenic artery
 supply the fundus
o left gastroepiploic artery
 from the splenic artery
 supply the stomach along the upper part of the greater curvature
o right gastroepiploic artery
  from the gastroduodenal branch of the hepatic artery
 supplies the stomach along the lower part of the greater curvature

 veins drain into the portal circulation

o left and right gastric veins
 drain directly into the portal vein
o short gastric veins and the left gastroepiploic veins
 join the splenic vein
o right gastroepiploic vein
 joins the superior mesenteric vein

 Nerve Supply
o sympathetic fibers derived from the celiac plexus
o parasympathetic fibers from the right and left vagus nerves

 anterior vagal trunk

o formed in the thorax mainly from the left
vagus nerve
o divides into branches that supply the
anterior surface of the stomach
o hepatic branch
o pyloric branch
 posterior vagal trunk
o formed in the thorax mainly from the right
vagus nerve
o divides into branches that supply mainly the
posterior surface of the stomach
o celiac and superior mesenteric plexuses and
is distributed to the intestine as far as the
splenic flexure and to the pancreas

  sympathetic innervation of the

stomach carries a proportion of pain-transmitting
nerve fibers
  parasympathetic vagal fibers are secretomotor to the gastric glands and motor to the muscular wall of the stomach
 pyloric sphincter receives motor fibers from the sympathetic system and inhibitory fibers from the vagi

3. Discuss the duodenum as to its shape, length, location, parts, relations, NVS

Shape: C-shaped tube

Length: (25 cm) long

Location: lies mostly in the upper retroperitoneum; situated in the epigastric and umbilical regions; commences @ duodeno-
pyloric junction; ends @ 2nd lumber vertebra

Relations:
1st Part
 pylorus and runs upward and
backward on the transpyloric
plane at the level of the first
lumbar vertebra
 Anteriorly: The quadrate lobe of
the liver and the gallbladder
 Posteriorly: The lesser sac (first
inch only), the gastroduodenal
artery, the bile duct and portal
vein, and the inferior vena cava
 Superiorly: The entrance into the
lesser sac (the epiploic foramen)
 Inferiorly: The head of the
pancreas (Fig. 5-26)
2nd Part
 Runs vertically downward in front
of the hilum of the right kidney
on the right side of the second
and third lumbar vertebrae
 halfway down its medial border,
the bile duct and the main pancreatic duct pierce the duodenal wall
 They unite to form the ampulla that opens on the summit of the major Posterior relations of the duodenum and
duodenal papilla the pancreas. The numbers represent the
four parts of the duodenum.
 accessory pancreatic duct, if present, opens into the
duodenum a little higher up on the minor duodenal
papilla
 Anteriorly: The fundus of the gallbladder and the
right lobe of the liver, the transverse colon, and the
coils of the small intestine
 Posteriorly: The hilum of the right kidney and the
right ureter
 Laterally: The ascending colon, the right colic flexure,
and the right lobe of the liver
 Medially: The head of the pancreas, the bile duct, and
the main pancreatic duct
3rd Part
 runs horizontally to the left on the subcostal
plane, passing in front of the vertebral
column and following the lower margin of
the head of the pancreas
 Anteriorly: The root of the mesentery of the
small intestine, the superior mesenteric
vessels contained within it, and coils of
jejunum
 Posteriorly: The right ureter, the right psoas
muscle, the inferior vena cava, and the aorta
 Superiorly: The head of the pancreas
 Inferiorly: Coils of jejunum
4th Part
 runs upward and to the left to the
duodenojejunal flexure
Pancreas and anterior relations of the kidneys.
 Flexure is held in position by a peritoneal fold, the ligament of
Treitz, which is attached to the right crus of the diaphragm
 Anteriorly: The beginning of the root of the mesentery and coils of
jejunum
 Posteriorly: The left margin of the aorta and the medial border of
the left psoas muscle

Entrance of the bile duct and the main and accessory

pancreatic ducts into the second part of the
duodenum. Note the smooth lining of the first part
of the duodenum, the plicae circulares of the second
part, and the major duodenal papilla.

Attachment of the root of the mesentery of the small

intestine to the posterior abdominal wall. Note that
it extends from the duodenojejunal flexure on left of
the aorta, downward and to the right to the
ileocecal junction. The superior mesenteric artery
lies in the root of the mesentery
NVS:
Arteries
 superior pancreaticoduodenal artery
o a branch of the gastroduodenal artery
o supplies upper half
 inferior pancreaticoduodenal artery
o a branch of the superior mesenteric artery
o supplies lower half
Veins
 superior pancreaticoduodenal vein
o drains into the portal vein
 inferior vein
o joins superior mesenteric vein
Nerve
 derived from sympathetic and parasympathetic (vagus) nerves from the celiac and superior mesenteric plexuses
Lymph Drainage
 follow the arteries and drain upward via pancreaticoduodenal nodes to the gastroduodenal nodes and then to the
celiac nodes and downward via pancreaticoduodenal nodes to the superior mesenteric nodes around the origin of the
superior mesenteric artery.

4. Discuss the mucosal lining and muscular walls of the esophagus, stomach, duodenum.

Esophagus
 upper 1/3 striated muscle
 2/3 smooth muscle
 2 layers of fibers
o Inner circular
o Outer longitudinal
 Thinner layer anteriorly due to posterior fibro-muscular wall of trachea
Stomach
 mucosa is a thick layer with a soft, smooth surface that is mostly reddish brown in life but pink in the pyloric region.
 In the contracted stomach the mucosa is folded into numerous folds or rugae, most of which are longitudinal. They
are most marked towards the pyloric end and along the greater curvature.
 The rugae represent large folds in the submucosal connective tissue rather than variations in the thickness of the
mucosa covering them, and they are obliterated when the stomach is distended
 submucosa is a variable layer of loose connective tissue. It contains thick bundles of collagen, numerous elastin fibres,
blood vessels and nervous plexuses, including the ganglionated submucosal (Meissner's) plexus.

 muscularis externa is a thick muscle coat immediately under the serosa, with which it is closely connected by
subserous loose connective tissue. From innermost outwards, it contains oblique, circular and longitudinal layers of
smooth muscle fibres. The layers are not always easily separated: the circular layer is poorly developed in the
oesophageal region, but is thickened at the distal pyloric antrum to form the anular pyloric sphincter; the outer
longitudinal layer is most pronounced in the upper two-thirds of the stomach; the inner oblique layer is most obvious
in the lower half.
 The actions of the muscularis externa of the stomach produce a churning movement that mixes food with the gastric
secretions. When the muscles contract, they reduce the volume of the stomach and throw the mucosa into
longitudinal folds or rugae (see above). The folds flatten as the stomach distends with food and the musculature
relaxes and thins. Muscle activity is controlled by a network of unmyelinated autonomic nerve fibres and their ganglia
which lie between the muscle layers in the myenteric (Auerbach's) plexus.
Duodenum
 mucous membrane of the duodenum is thick
 first part of the duodenum it is smooth
 remainder of the duodenum it is thrown into numerous circular folds called the plicae circulares
 the site where the bile duct and the main pancreatic duct pierce the medial wall of the second part is a small,
rounded elevation called the major duodenal papilla
 accessory pancreatic duct, if present, opens into the duodenum on a smaller papilla about 0.75 in. (1.9 cm) above the
major duodenal papilla.
5. Map out the topography of the stomach and duodenum in the abdomen of a live individual using the regions and
quadrants as reference.

Stomach
The stomach lies in a curve within the left hypochondrium and epigastrium although, when distended and pendulous, it may lie
as far down as the central or hypogastric regions. The epigastrium is the usual place to auscultate for a ‘succussion splash'
caused by chronic gastric stasis in upper intestinal obstruction.
Duodenum
The first part of the duodenum sometimes lies just above the trans-pyloric plane, depending on its mobility and length. The
second part usually lies in the transpyloric plane just to the right of the midline, and the third part usually lies in the subcostal
plane across the midline. The fourth part often lies in the transpyloric plane to the left of the midline, although its position
varies according to the length of its mesentery.