HIGH-YIELD SYSTEMS

Gastrointestinal

“A good set of bowels is worth more to a man than any quantity of brains.”­­ ``Embryology 368
—Josh Billings
``Anatomy 370
“Man should strive to have his intestines relaxed all the days of his life.”
—Moses Maimonides ``Physiology 381
“All right, let’s not panic. I’ll make the money by selling one of my livers. I ``Pathology 386
can get by with one.”
—Homer Simpson, The Simpsons ``Pharmacology 408
“The truth does not change according to our ability to stomach it
emotionally.”
—Flannery O’Connor

When studying the gastrointestinal system, be sure to understand the

normal embryology, anatomy, and physiology and how the system is
affected by various pathologies. Study not only disease pathophysiology,
but also its specific findings, so that you can differentiate between
two similar diseases. For example, what specifically makes ulcerative
colitis different from Crohn disease? Also, be comfortable with basic
interpretation of abdominal x-rays, CT scans, and endoscopic images.

367
 370 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Pancreas and spleen Pancreas—derived from foregut. Ventral pancreatic bud contributes to uncinate process and main
embryology pancreatic duct. The dorsal pancreatic bud alone becomes the body, tail, isthmus, and accessory
A
pancreatic duct. Both the ventral and dorsal buds contribute to pancreatic head.
Annular pancreas—abnormal rotation of ventral pancreatic bud forms a ring of pancreatic tissue
Ž encircles 2nd part of duodenum; may cause duodenal narrowing (arrows in A ) and vomiting.
Pancreas divisum—ventral and dorsal parts fail to fuse at 7 weeks of development. Common
stomach anomaly; mostly asymptomatic, but may cause chronic abdominal pain and/or pancreatitis.
Spleen—arises in mesentery of stomach (hence is mesodermal) but has foregut supply (celiac trunk
Ž splenic artery).
Gallbladder

Accessory
pancreatic duct
Minor papilla
Major papilla

Dorsal
pancreatic bud
Uncinate process
Main pancreatic duct
Ventral
pancreatic bud

GASTROINTESTINAL—ANATOMY
``

Retroperitoneal Retroperitoneal structures A are posterior to SAD PUCKER:

structures (and outside of) the peritoneal cavity. Injuries Suprarenal (adrenal) glands [not shown]
to retroperitoneal structures can cause blood Aorta and IVC
or gas accumulation in retroperitoneal space. Duodenum (2nd through 4th parts)
Pancreas (except tail)
Ureters [not shown]
Colon (descending and ascending)
Kidneys
Esophagus (thoracic portion) [not shown]
Duodenum Duodenum/jejunum Rectum (partially) [not shown]
Ascending Peritoneum Descending
colon colon A
Right Left
Pancreas

Asc Desc
Liver Colon Colon
IVC Kidney
Aorta
IVC Ao

Kid Kid

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 371

Important gastrointestinal ligaments

Falciform Diaphragm
ligament Liver
Liver
Hepatogastric
ligament Stomach
Stomach
Hepatoduodenal Spleen
Portal triad ligament

Spleen Gastrosplenic
ligament Transverse
colon
Kidney
Splenorenal
ligament
Gastrocolic
ligament

LIGAMENT CONNECTS STRUCTURES CONTAINED NOTES

Falciform ligament Liver to anterior abdominal Ligamentum teres hepatis Derivative of ventral mesentery
wall (derivative of fetal umbilical
vein), patent paraumbilical
veins
Hepatoduodenal Liver to duodenum Portal triad: proper hepatic Derivative of ventral mesentery
ligament artery, portal vein, common Pringle maneuver—ligament is
bile duct compressed manually or with
a vascular clamp in omental
foramen to control bleeding
from hepatic inflow source
Borders the omental foramen,
which connects the greater
and lesser sacs
Part of lesser omentum
Hepatogastric Liver to lesser curvature of Gastric vessels Derivative of ventral mesentery
ligament stomach Separates greater and lesser sacs
on the right
May be cut during surgery to
access lesser sac
Part of lesser omentum
Gastrocolic ligament Greater curvature and Gastroepiploic arteries Derivative of dorsal mesentery
transverse colon Part of greater omentum
Gastrosplenic Greater curvature and spleen Short gastrics, left Derivative of dorsal mesentery
ligament gastroepiploic vessels Separates greater and lesser sacs
on the left
Part of greater omentum
Splenorenal ligament Spleen to left pararenal space Splenic artery and vein, tail of Derivative of dorsal mesentery
pancreas

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 372 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Digestive tract Layers of gut wall A (inside to outside—MSMS):

anatomy ƒƒ Mucosa—epithelium, lamina propria, muscularis mucosa
ƒƒ Submucosa—includes submucosal nerve plexus (Meissner), secretes fluid
ƒƒ Muscularis externa—includes myenteric nerve plexus (Auerbach), motility
ƒƒ Serosa (when intraperitoneal), adventitia (when retroperitoneal)
Ulcers can extend into submucosa, inner or outer muscular layer. Erosions are in mucosa only.
Frequency of basal electric rhythm (slow waves), which originate in the interstitial cells of Cajal:
duodenum > ileum > stomach.
A
Mucosa
Epithelium
Lamina propria Tunica mucosa
Muscularis mucosa
Mesentery
Tunica submucosa
Submucosa
Vein Submucosal gland
Artery
Lymph vessel

Lumen
Submucosal nerve
plexus (Meissner)
Muscularis
Inner circular layer
Myenteric nerve plexus Tunica muscularis
(Auerbach)
Outer longitudinal layer Tunica serosa
Serosa (peritoneum)

Digestive tract histology

Esophagus Nonkeratinized stratified squamous epithelium. Upper 1/3, striated muscle; middle and lower 2/3
smooth muscle, with some overlap at the transition.
Stomach Gastric glands A . Parietal cells are eosinophilic (pink, red arrow in B ), chief cells are basophilic
(black arrow in B ).
Duodenum Villi and microvilli  absorptive surface. Brunner glands (bicarbonate-secreting cells of submucosa)
and crypts of Lieberkühn (contain stem cells that replace enterocytes/goblet cells and Paneth cells
that secrete defensins, lysozyme, and TNF).
Jejunum Villi C , crypts of Lieberkühn, and plicae circulares (also present in distal duodenum).
Ileum Villi, Peyer patches (arrow in D ; lymphoid aggregates in lamina propria, submucosa), plicae
circulares (proximal ileum), and crypts of Lieberkühn. Largest number of goblet cells in the small
intestine.
Colon Crypts of Lieberkühn with abundant goblet cells, but no villi E .
A B C D E

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 373

Abdominal aorta and branches

IVC AORTA Arteries supplying GI structures are single and
Right Left branch anteriorly.
Inferior phrenic Arteries supplying non-GI structures are paired
T12
Superior suprarenal and branch laterally and posteriorly.
Celiac
Two areas of the colon have dual blood supply
Middle suprarenal
from distal arterial branches (“watershed
regions”) Ž susceptible in colonic ischemia:
SM A
ƒƒ Splenic flexure—SMA and IMA
L1
Inferior suprarenal ƒƒ Rectosigmoid junction—the last sigmoid
arterial branch from the IMA and superior
Renal
rectal artery
Gonadal
L2 Nutcracker syndrome—compression of left
renal vein between superior mesenteric artery
and aorta. May cause abdominal (flank) pain,
gross hematuria (from rupture of thin-walled
IM A
L3 renal varicosities), left-sided varicocele.
Superior mesenteric artery syndrome—
characterized by intermittent intestinal
obstruction symptoms (primarily postprandial
L4 pain) when SMA and aorta compress
transverse (third) portion of duodenum.
“Bifourcation” at L4
Typically occurs in conditions associated
Right
common iliac Left common iliac
with diminished mesenteric fat (eg, low body
L5
weight/malnutrition).

Median sacral
Duodenum
Aorta
Right external Right internal Left internal Left external
iliac iliac iliac iliac

SMA

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 374 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Gastrointestinal blood supply and innervation

EMBRYONIC PARASYMPATHETIC VERTEBRAL
GUT REGION ARTERY INNERVATION LEVEL STRUCTURES SUPPLIED
Foregut Celiac Vagus T12/L1 Pharynx (vagus nerve only) and lower esophagus
(celiac artery only) to proximal duodenum;
liver, gallbladder, pancreas, spleen (mesoderm)
Midgut SMA Vagus L1 Distal duodenum to proximal 2/3 of transverse
colon
Hindgut IMA Pelvic L3 Distal 1/3 of transverse colon to upper portion of
anal canal

Celiac trunk Branches of celiac trunk: common hepatic, splenic, and left gastric. These constitute the main
blood supply of the foregut.
Strong anastomoses exist between:
ƒƒ Left and right gastroepiploics
ƒƒ Left and right gastrics

Abdominal aorta
Celiac trunk Esophageal branches
Left hepatic
Left gastric
Short gastric

Right hepatic Splenic

Cystic
Left gastroepiploic

Proper hepatic

Common hepatic
“Anastomosis”
Gastroduodenal
Anterior superior pancreaticoduodenal Areas supplied by:
Posterior superior pancreaticoduodenal
Left gastric artery
Splenic artery
Right gastric
Right gastroepiploic Common hepatic artery

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 375

Portosystemic
anastomoses

Azygos vein Pathologic blood in portal HTN

Esophageal vein Flow through TIPS, re-establishing
normal flow direction
IVC Q
Normal venous drainage

Shunt
Systemic venous system
Left gastric vein
Portal venous system
Portal vein
Splenic vein
Paraumbilical vein
Superior mesenteric vein
Inferior mesenteric vein
R
Umbilicus
Colon

Superior rectal vein

(superior hemorrhoidal vein)
Epigastric veins
Middle rectal vein
Inferior rectal vein
S
Anus

SITE OF ANASTOMOSIS CLINICAL SIGN PORTAL ↔ SYSTEMIC

Esophagus Esophageal varices Left gastric ↔ esophageal
(drains into azygos)
Umbilicus Caput medusae Paraumbilical ↔ small
epigastric veins of the anterior
abdominal wall.
Rectum Anorectal varices Superior rectal ↔ middle and
inferior rectal
Varices of gut, butt, and caput (medusae) are commonly seen with portal hypertension.
 reatment with a Transjugular Intrahepatic Portosystemic Shunt (TIPS) between the portal
T
vein and hepatic vein relieves portal hypertension by shunting blood to the systemic circulation,
bypassing the liver. TIPS can precipitate hepatic encephalopathy due to  clearance of ammonia
from shunting.

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 376 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Pectinate line Also called dentate line. Formed where endoderm (hindgut) meets ectoderm.
Nerves Arteries Veins Lymphatics Above pectinate line: internal hemorrhoids,
Visceral innervation Superior rectal Superior rectal vein Drain to internal adenocarcinoma.
artery (branch → IMV → splenic iliac LN
of IMA) vein → portal vein Internal hemorrhoids receive visceral
innervation and are therefore not painful.

Pectinate line
Below pectinate line: external hemorrhoids,
anal fissures, squamous cell carcinoma.
External hemorrhoids receive somatic
innervation (inferior rectal branch of
pudendal nerve) and are therefore painful if
thrombosed.
Anal fissure—tear in anoderm below
Inferior rectal vein pectinate line. Pain while pooping; blood
Somatic innervation Inferior rectal artery → internal pudendal
(pudendal nerve (branch of internal vein → internal iliac
Drain to superficial on toilet paper. Located in the posterior
inguinal LN
[S2-4]) pudendal artery) vein → common iliac midline because this area is poorly
vein → IVC perfused. Associated with low-fiber diets and
constipation.

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 377

Liver tissue The functional unit of the liver is made up of Zone I—periportal zone:
architecture hexagonally arranged lobules surrounding the ƒƒ Affected 1st by viral hepatitis
A
central vein with portal triads on the edges ƒƒ Best oxygenated, most resistant to circulatory
(consisting of a portal vein, hepatic artery, bile compromise
ducts, as well as lymphatics) A . ƒƒ Ingested toxins (eg, cocaine)
Apical surface of hepatocytes faces bile Zone II—intermediate zone:
canaliculi. Basolateral surface faces sinusoids. ƒƒ Yellow fever
Kupffer cells (specialized macrophages) located Zone III—pericentral (centrilobular) zone:
in sinusoids (black arrows in B ; yellow arrows ƒƒ Affected 1st by ischemia (least oxygenated)
show central vein) clear bacteria and damaged ƒƒ High concentration of cytochrome P-450
B or senescent RBCs. ƒƒ Most sensitive to metabolic toxins (eg,
Hepatic stellate (Ito) cells in space of Disse ethanol, CCl4, halothane, rifampin,
store vitamin A (when quiescent) and produce acetaminophen)
extracellular matrix (when activated). ƒƒ Site of alcoholic hepatitis
Responsible for hepatic fibrosis.

Central vein (drains

into hepatic vein)

Sinusoids

Stellate cell

Space of Disse

Kupffer cell

Blood flow

Zone 1 Branch of
hepatic artery Bile flow
Zone 2
Branch of
Zone 3 portal vein
Bile ductule

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 378 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Biliary structures Cholangiography shows filling defects in gallbladder (blue arrow in A ) and cystic duct (red arrow
A
in A ).
Gallstones that reach the confluence of the common bile and pancreatic ducts at the ampulla of
e Vater can block both the common bile and pancreatic ducts (double duct sign), causing both
CHD cholangitis and pancreatitis, respectively.
op
sc
do

Tumors that arise in head of pancreas (usually ductal adenocarcinoma) can cause obstruction of
En

ct
du
tic
Pa
nc
rea
common bile duct Ž enlarged gallbladder with painless jaundice (Courvoisier sign).

Cystic duct
Liver
Gallbladder
Common hepatic duct

Common bile duct

Tail
Accessory Neck Body
pancreatic duct
Pancreas
Head
Sphincter of Oddi
Ampulla of Vater
Main pancreatic duct
Duodenum

Femoral region
ORGANIZATION Lateral to medial: nerve-artery-vein-lymphatics. You go from lateral to medial to find your
navel.
Femoral triangle Contains femoral nerve, artery, vein. Venous near the penis.
Femoral sheath Fascial tube 3–4 cm below inguinal ligament.
Contains femoral vein, artery, and canal (deep
inguinal lymph nodes) but not femoral nerve.

Transversalis
fascia
Inguinal
ligament
Lymphatics
Sartorius
muscle Femoral ring—site of
femoral hernia
Femoral
Nerve
Femoral
Artery
Femoral Femoral
Vein sheath

Adductor longus
muscle

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 379

Inguinal canal
Abdominal wall
Deep (internal)
Inferior epigastric site of protrusion of
inguinal ring
vessels direct hernia
site of protrusion of
Parietal peritoneum indirect hernia Medial umbilical ligament

Extraperitoneal tissue Median umbilical ligament

Transversalis fascia Rectus abdominis muscle

Pyramidalis muscle
Transversus abdominis muscle
Conjoint tendon
Linea alba
Internal oblique muscle
Spermatic cord (ICE tie)

Aponeurosis of external
oblique muscle
Superficial (external)
Inguinal ligament inguinal ring

Internal spermatic fascia Cremasteric muscle and fascia External spermatic fascia
(transversalis fascia) (internal oblique) (external oblique)

Abdominal wall
Anterior superior iliac spine
Posterior rectus sheath Transversus abdominis muscle
Transversalis fascia
Evagination of transversalis fascia Inferior epigastric vessels
Arcuate line Internal (deep) inguinal ring Rectus abdominis
Ductus (vas) deferens
Inferior epigastric vessels Genital branch of genitofemoral Inguinal ligament
Rectus abdominis nerve
Inguinal (Hesselbach) triangle
Internal spermatic vessels
Inguinal ligament
Iliacus muscle
Inguinal (Hesselbach) triangle Femoral nerve
External iliac vessels
Femoral vessels
Pubic tubercle Femoral triangle
Lacunar ligament

Anterior abdominal wall Anterior abdominal wall

(viewed from inside) (viewed from outside)

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 380 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Hernias Protrusion of peritoneum through an opening, usually at a site of weakness. Contents may be at
risk for incarceration (not reducible back into abdomen/pelvis) and strangulation (ischemia and
necrosis). Complicated hernias can present with tenderness, erythema, fever.
Diaphragmatic hernia Abdominal structures enter the thorax. Most common causes:
A
ƒƒ Infants—congenital defect of pleuroperitoneal membrane Ž left-sided herniation (right
hemidiaphragm is relatively protected by liver) A .
ƒƒ Adults—laxity/defect of phrenoesophageal membrane Ž hiatal hernia (herniation of stomach
through esophageal hiatus).
Sliding hiatal hernia—gastroesophageal
junction is displaced upward as gastric cardia Herniated
gastric cardia Herniated
slides into hiatus; “hourglass stomach.” Most gastric fundus
common type. Associated with GERD.
Paraesophageal hiatal hernia—
gastroesophageal junction is usually normal
but gastric fundus protrudes into the thorax.
Sliding hiatal hernia Paraesophageal hiatal hernia

Indirect inguinal Goes through the internal (deep) inguinal

hernia ring, external (superficial) inguinal ring, and Peritoneum

B
into the groin. Enters internal inguinal ring Deep
inguinal ring
lateral to inferior epigastric vessels. Caused Inguinal canal
by failure of processus vaginalis to close (can Superficial
form hydrocele). May be noticed in infants or inguinal ring
discovered in adulthood. Much more common Intestinal loop
within spermatic
in males B . cord
Follows the pathway of testicular descent.
Testis
Covered by all 3 layers of spermatic fascia.

Direct inguinal hernia Protrudes through inguinal (Hesselbach) Peritoneum

triangle. Bulges directly through parietal Deep
Intestinal inguinal
peritoneum medial to the inferior epigastric loop ring
vessels but lateral to the rectus abdominis.
Superficial
Goes through external (superficial) inguinal inguinal ring
ring only. Covered by external spermatic
fascia. Usually occurs in older males due to Spermatic cord
acquired weakness of transversalis fascia.
MDs don’t lie:
Testis
Medial to inferior epigastric vessels =
Direct hernia.
Lateral to inferior epigastric vessels = indirect
hernia.
Femoral hernia Protrudes below inguinal ligament through
femoral canal below and lateral to pubic
tubercle. More common in females, but
overall inguinal hernias are the most common.
More likely to present with incarceration or
strangulation (vs inguinal hernia). Intestinal loop
beneath inguinal
ligament

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 412 SEC TION III GASTROINTESTINAL

NOTES
``

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