Gripping pain !

unbearable

Hope not an attack !

Hell with the exams !

It is eating me !

Pain abdomen could be fromIndigestionWorms in intestinesHyperacidity - APDExcess alcohol intakeUlcer stomach / DuodenumInjury to abdomen - Trauma

Other multifarious factors ?

Most of the times

The target organ / Viscus is

Duodenum

Du-deka-dactulos (L)Length of Duodenum = width of 12 fingers

Hirophilus 300 BC

DUODENUM

10 in /25 cm

Shortest, dilated and most fixedproximal part of Small intestine.

Devoid of mesentery

Fixed to post. Abd. Wall.

C – shaped curvatureCurved around head of pancreas

Lies above umbilicus opp. to 1, 2 & 3 rdLumbar VertebraeReceives Bile duct and pancreatic duct.Interposed bet. Stomach and intestines (Both are active digestive areas in GIT)

Duodenum

Duodenum – 3 flexures

1

23

1. Superior duodenal flexure

2. Inferior duodenal flexure

3. Duodeno-jejunal flexure.

25 cm long & Subdivided into 4 parts

First / upper part – 5 cmSecond / vertical part – 7.5 cmThird / horizontal part – 10 cmFourth / ascending part – 2.5 cm

1st

2nd

3rd 4th

Duodenum - parts

Duodenum – peritoneal relations

Duodenum is mostly retroperitoneal and Fixed except at its two ends whereit is suspended by folds of peritoneum.

Anteriorly the duodenum is partly Covered with peritoneum.

Extends from pylorus to Sup. Duodenal flexure,directed upwards, backwards & to Right

Length – 5 cm(Surface projection 2.5 cm)

Peritoneal relations:

prox. 2.5 cm movable. Attached to lesser omentum above and to greater omentum below.Distal 2.5 cm is fixed. Retroperitoneal.Covered with peritoneum only on anterior aspect.

Duodenum 1st part (5 cm)

Visceral relations:Anteriorly : Quadrate lobe of liver, and gall bladder.

Posteriorly : Gastroduodenal art., bile duct, and portal vein.

Superiorly : Epiploic foramen.

Inferiorly : Head & neck of pancreas.

Duodenum 1st part

Relations of 1st part Duodenum sagittal section viewed from left side

Posterior relations

Duodenum – peculiarities of first part

a) Most movable part, behaves more of stomach than duodenumb) Supplied by end arteriesc) May be affected by peptic ulcerd) Devoid of circular mucous folde) Seen as duodenal cap / Bulb in Radiographs. Du Ulcer - Trefoil deformity)Barium mealBarium sulphateDouble contrastNow replaced byEndoscopyCT / MRI

First part is supplied by end arteries

a) Supra duodenal (Art.of Wilkie) S.D.A. Br. of Gastroduodenal supplies upper margin, upper 2/3rd of anterior surface Upper 1/3rd of posterior surface of prox. ½ of first half.b) Retro duodenal branch Br. of gastroduodenal Supplies part of post. Surfacec) Infra duodenal branch Br. of Rt. Gastro-epiploic artery Supplies lower margin

C.T.

Duodenum - arterial supply 1st part

S.M.A.I.P.D.

S.D.A

Rt.G.E.A.

C.H.A

H.A.P.

G.D.A.

S.P.D.Rt.G.E.A.

Begins at superior duodenal flexure opp. L1 vertebrapasses vertically downwards - in front of hilum of Rt. Kidney - along Rt. Side of vertebral column in para vertebral gutter - Within Rt. Lateral plane - ends in inferior duodenal flexure opp. Lower border of L3 - continues with 3rd part

Duodenum – second part (7.5 cm)

Rt. Lat. Plane

Peritoneal relations:It is retroperitoneal and fixed.Ant. Surface is covered with peritoneum , except near the middle where it is directly related to colon.

Visceral relations:

Anteriorly: Right lobe of liver, Transverse colon, Root of transverse mesocolon, Small intestine.

Duodenum – second part

Posteriorly :

Entirely non-peritoneal1. Ant. Surface of Rt. Kidney close to

hilum2. Rt. Renal vessels, pelvis of Rt.

Ureter3. Rt. Psoas major muscle4. Rt. Edge of inferior vena cava5. Sometimes part of Rt. Supra renal

Duodenum – second part

Duodenum – second part – posterior relations

Laterally: Rt. Colic flexure

Medially:Head of pancreas,

Anastomoses of Superior & Inferior pacreaticoduodenal vessels

Bile duct and Main pancreatic duct

Duodenum – second part

Circular folds Plica Circularis – Permanent, circular & thick.Major duodenal papilla (on post. Medial wall of 2nd part 10 cm distal to pylorus) Bile duct & pancreatic ducts open on summit (Ampulla of vater)Minor duodenal papilla 2 cms above major papilla Accessry pancreatic duct opensPlica Semicircularis arches above major papillaPlica longitudinalis vertical fold downwards from major papilla Sometimes vertical fold upwards from major papilla marks Bile duct

Duodenum – Interior of second part

Structure of Hepato-pancreatic ducts

Bile duct

Pancreatic duct

Sphincter pancreaticus

Sphincter AmpullaeBD + PD(Ampulla of Vater)

Hepato pancreatic ampulla

Sphincter Choledochus(Choledochus = Bile duct)

This sphincter is always present. Normally keeps lower end of bile duct closed. As a result, bile formed in the liver keeps accumulating in gall bladder and undergoes considerable concentration. With a fatty meal the sphincter opens and bile stored in the gall bladder is poured into the duodenum. “Gall stones – Cholecystitis”

(Major duodenal papilla)

Extends from inf. Duodenal flexureto front of aorta at L3 level

Relations - Anteriorly :Covered by peritoneum except attachment of root of mesentery

Ant. Surface crossed by Sup. Mesenteric vessels and root of mesentery

Duodenum – 3rd part (10 cm)

Posteriorly:

Non peritoneal1. Rt.psoas major muscle2. Right ureter3. Inf. Vena cava4. RT. Gonadal vessels5. Abdominal aorta6. Origin of inferior Mesenteric art.

Duodenum – 3rd part

Duodenum – 3rd part (10 cm)

Extends from inf. Duodenal flexure to front of aorta at L3 level

Relations – Superiorly :Head of pancreas with uncinate process.Inferior pancreatico duodenal vessels

Inferiorly :Few coils of jejunum

Extends from front of aorta to Duodeno-jejunal flexure DJ flexure is situated on the left side of L2 about 1.25 cmbelow transpyloric plan & 2.5 cms to left of median planeKept in position by suspensorymuscle of DuodenumRelations Anteriorly :Covered with peritoneum.Related to transverse colon &mesocolonPost. Inf. Surface of stomachseparated by lesser sac

Duodenum – 4th part (2.5 cm)

Posteriorly :

Left crus of diaphragmLeft psoas major muscleLeft sympathetic trunkLeft renal vesselsLeft Gonadal vesselsLeft supra renal veinInferior mesenteric vein

Duodenum – 4th part (2.5 cm)

Right side :Uncinate process of pancreas

Left side : Left kidney and ureter

Superiorly :Body of pancreas

Duodenum – 4th part (2.5 cm)

Suspensory lig. of Treitz

Fibro muscular band, which suspends and supports the duodenojejunal flexure. Arises from the right crus of the diaphragm; close to the right side of the esophagus, passes downwards behind pancreas, and is attached to the posterior surface of the duodenojejunal flexure and the 3rd & 4th parts of duodenum. Made up of stripped muscle fibers in its upper part, Elastic fibers in its middle part, and plain muscle fibers in its lower part.

DUODENUM – STRUCTUREMucous coat : simple columnar / occasional goblet

cells, covered with villiLamina propria : contains crypts of Leiberkuhn receive at their bottom openings of Brunner’s glands Submucous coat : Loose areolar tissueBlood vessels, lymphaticsMeissner’s plexusBrunner’s glandsMuscular coat:Outer longitudinal & inner circular (Separated by myenteric plexus)Serous coat from peritoneum - incomplete

DUODENUM – STRUCTURE

Sub mucous coat - Duodenal glands of BrunnerOpen at bottom of crypts of Leiberkuhn

Secretion Rich in bicarobonate ions(alkaline) Helps activation oftrypsinogen from pancreas

Most of the duodenum except 1st part is supplied by Ventral & dorsal anastomoses of Sup & Inf Pancreatico duodenal arteries.Vasa Recta arises and supply adjacent areas of duodenum and head of pancreas

Duodenum – Arterial supply

Veins Correspond to arteries and drain into sup. Mesenteric and portal vein

Duodenum – Venous drainage

Lymph vessels drain into pancreatico-duodenal lymph nodes.Efferent vessels of these nodes drain into Coeliac and sup. Mesen. group of pre-aortic lymph nodes.Some vessels drain into theHepatic nodes directly.

All lymph reaching hepatic nodesDrain into the coeliac nodes

Duodenum - Lymphatic drainage

Sympathetic nerves are derived from coeliac and sup. Mesen. Plexuses.Preganglionic fibres come from T6 to T9 segments of spinal cord.

Parasympathetic are derived from both vagus nerves .

The myenteric (Auerbach’s plexus) & Meisner’s plexusesAct as post ganglionic neurons for parasypathetic fibres only.

Duodenum - Nerve supply

1st part of Du is commonest site for Peptic ulcer.

ACID PEPTIC DISEASE:

Perforation of ant. Surface of D1TraumaAlcoholsmoking Ulcerogenic drugs (NSAID)

Duodenum - Applied anatomy

1st part of Du is commonest site for Peptic ulcer.

Third part vulnerable for injury as it lies anterior to vertebral column

Herniation of intestines into para duodenal recesses..

Stenosis of duodenum by annular pancreas

& Ca. Head of pancreas.

Pressure from sup.mesen.art. /

Shortening of ligament of Trietz.

Duodenum - Applied anatomy

Acid peptic disease and Duodenal trefoil appearance:Besides a genetic predisposition to acid peptic disease abnormal high secretion of acid and pepsin, reflux of bile and pancreatic juice to stomach, reduced amount of mucus or structurally deficient mucus, reduced submucosal blood flow, (stress and alcohol ingestion), reduced cell renewal or bicarbonate secretion are all contributory singly or in combination in the causation of acid peptic disease, Diet has a limited role in both causation and cure of the ailment. Emotional stress, delayed gastric emptying, cigarette smoking, use of ulcerogenic drugs

Duodenum - Applied anatomy

1st part of Du is commonest site for Peptic ulcer.

Narrowing of duodenum

Congenital stenosis

Duodenum - Applied anatomy

Fore gut - Celiac axis - Digestive

Mid gut - Sup. Mesenteric - Absorptive

Hindgut - Inf. Mesenteric - Excretory

Duodenum - Embryonic divisions

The 1st part and upper half of2nd part derived from foregut.

Rest of duodenum developsFrom most proximal part of midgut.

Later duodenum falls to right, themesoduodenum fuses with peritoneumof post. Abd. wall, resulting in most ofthe duodenum retroperitoneal.

The mesoduodenum persists in relation to a small part of duodenum adjacent to pylorus. This is the part seen in radiographs as duodenal cap.

Stomach lifted upGI Tract - Duodenum