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THE SMALL INTESTINE The small intestine duodenum jejunum ileum From pyloric sphincter To ileo-caecal valve ~5-6m long
SMALL INTESTINE
THE DUODENUM: POSITION AND FORM Duodenum = on posterior abdominal wall: immobile. 25cm; lies in epigastric and umbilical regions Embraces head of pancreas: C-shaped (open to left) Retroperitoneal except D1 Part adjacent to pylorus = duodenal cap
THE DUODENUM: POSITION AND FORM
4 parts: D1. Superior (5cm) D2. Descending (7-10cm) D3. Horizontal (5-7.5cm) D4. Ascending (2.5cm)
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RELATIONS OF DUODENUM
1st 2cm: similar relations to stomach Lesser omentum above, greater omentum below Covered by peritoneum Posteriorly separated from pancreas by the lesser sac Anteriorly separated from liver and GB by greater sac
Peritoneum: greater and lesser sacs
Lesser sac (in blue) =
OMENTAL BURSA
RELATIONS OF DUODENUM
1st part lies behind: Liver Gall bladder 1st part lies in front of: Gastroduodenal artery Common bile duct Portal vein 1st part lies above: Head of pancreas 1st part lies below: Free edge of lesser omentum 2nd part lies behind Right lobe of liver + GB Crossed by transverse mesocolon Coils of jejunum. 2nd part lies in front of: Medial border / hilum R. kidney R suprarenal R renal vessels and ureter Psoas major IVC. Medially related to head of pancreas, CBD, pancreaticoduodenal vessels.
RELATIONS OF DUODENUM
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RELATIONS OF DUODENUM
3rd part lies below: Pancreatic head/uncinate process 3rd part lies in front of: Right ureter and psoas Right gonadal vessels IVC Aorta with the origin of inferior mesenteric artery 3rd part lies behind: Superior mesenteric artery and vein. The anterior surface is crossed by the root of the SI mesentery
THE HEPATOPANCREATIC AMPULLA
The main pancreatic duct (of Wirsung) and the common bile duct unite in the wall D2 to form the ampulla (of Vater) This forms the major duodenal papilla. A little higher the accessory pancreatic duct (of Santorini) enters at the minor duodenal papilla.
RELATIONS OF DUODENUM
The 4th part of the duodenum continues with the jejunum. Lies to left of vertebral column on left psoas 4th part passes in front of: Left sympathetic trunk Left renal and gonadal vessels and to right of Inferior mesenteric vein Left ureter and lower pole kidney
BLOOD SUPPLY OF DUODENUM: coeliac trunk + SMA.
From common hepatic branch of coeliac trunk: gastroduodenal branch passes behind D1 Divides into [right gastro -epiploic] + superior pancreatico-duodenal Inferior pancreatico-duodenal arteries: from SMA
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JEJUNUM AND ILEUM DUODENOJEJUNAL FLEXURE
The jejunum makes up the proximal 2/5 of SI below the duodenum; remainder = ileum. SI is attached to the posterior abdominal wall by a mesentery Situated below the transverse colon, mainly central abdomen Jejunum: wider, thicker walls; mucous membrane is in circular folds; villi++ Ileum: 2-4m; paler, smaller diameter; more fat in mesentry; Peyers patches Absorbs B12 + bile salts
Lies to left of L2 Faces downwards and to left Peritoneal recesses found behind left side of D4 and behind adjacent inferior mesenteric vein
JEJUNUM AND ILEUM Jejunum lies above and to left of ileum SI mesentery runs downwards from left side L2 to right SIJ Crosses left psoas, aorta, IVC, right gonadal vessels, right psoas, right ureter
SUPERIOR MESENTERIC ARTERY
Arises L1 level [Coeliac: T12 SMA: L1 Renal arteries: L2 IMA: L3]
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SUPERIOR MESENTERIC ARTERY
Branches: Inferior pancreaticoduodenal Jejunal + ileal Ileocolic Right colic Middle colic
Arterial arcades in mesentry
