1. CBL –STOMACH & DUODENUM
BY
Dr. Abdul Waheed Ansari
Chairperson & Prof. Anatomy,
RAKCOMS.
12/18/2014 1

2. The learning out comes for the CBL are:-
• 1. Identifying the gross features and microscopic picture of stomach
and relate it to the clinical cases.
• 2. Relate the relations of stomach and its blood supply, nerve supply
and lymphatic drainage with the clinical scenarios.
• 3. Correlate the gross features of duodenum and histological
differences with other segments of GIT.
• 4. The blood supply, lymphatic drainage and its nerve supply.
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3. A case of upper gastrointestinal bleeding
• A 68-year-old male was admitted to the hospital with a chief complaint of
emesis of bright red blood.
• The patient reported that he was shopping when he began throwing up
blood at the store.
• He denied any associated pain, melena (passing of black tarry stools),
hematochezia (passing of fresh blood from anus), liver disease, or prior
episodes.
• The patient reported some lightheadedness with standing, but denied
chest pain, shortness of breath, and visual disturbances.
• He was on Indomethacin for his gout problem since one month.
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4. The gross anatomy of stomach
• It is the most dilated part of digestive system. It is a
reservoir of food, it produces acid and enzymes for the
food to be digested and mixed with the bile for fat
metabolism in the duodenum.
• Stomach is continuous above with the esophagus and
below with the first part of small intestine- duodenum.
• Stomach is covered by peritoneum and hanging folds are
the omenta- greater and lesser omenta.
• Stomach is anchored to the undersurface of diaphragm
by gastro phrenic & gastro colic ligaments.
• The wall of stomach is made up of serosa, muscularis
externa, submucosa , muscularis interna and mucosa.
• It is supplied by branches from coeliac artery.
• The nerve supply comes from vagus nerve and coeliac
ganglion.
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5. The blood supply of stomach
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6. The following groups of lymph nodes are associated
with stomach:-
• The lymphatic drainage is very important because
the cancer can spread to the various part of the
body through lymphatic system and the staging of
the stomach cancer involves regional lymph
nodes.
• The lymph nodes surrounding the lesser curvature
of the stomach drained directly into the celiac
nodes.
• The lymph nodes surrounding the greater
curvature and the fundus drained into the splenic
nodes which then drained into the celiac nodes.
• 1. Splenic group
• 2. Cardiac group
• 3. Coeliac group
• 4. Duodenal group
• 5. Hepatic group12/18/2014 6

7. The vagal innervation of stomach carries
parasympathetic supply to acid producing gastric
mucosa • The truncal vagotomy is performed to cut off the acid secretion fibers.
• As a result there will be stasis in the stomach and gall bladder leading to
formation of ileus and cholelithiasis.
• Peptic ulcers are defects in the gastric or duodenal mucosa that extend
through the muscularis mucosa.
• The epithelial cells of the stomach and duodenum secrete mucus in
response to irritation of the epithelial lining and as a result of cholinergic
stimulation.
• The superficial portion of the gastric and duodenal mucosa exists in the
form of a gel layer, which is impermeable to acid and pepsin.
• Other gastric and duodenal cells secrete bicarbonate, which aids in
buffering acid that lies near the mucosa.
• Prostaglandins of the E type (PGE) have an important protective role,
because PGE increases the production of both bicarbonate and the
mucous layer.
• The study of H pylori has revealed that it is a major part of the triad,
which includes acid and pepsin, that contributes to primary peptic ulcer
disease. When H pylori colonizes the gastric mucosa, inflammation
usually results.
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8. The histology of stomach
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9. • Mucous secreting cells (goblet cells)- Line the luminal surface of the stomach and
gastric pits and gastric glands. Produce mucus and bicarbonate.
• Mucous neck cells- Present in the neck of the gland. Produce mucin.
• Parietal cells (oxyntic cells)- Distributed throughout the length of the gland, but
numerous in the middle portion. Large, rounded cells with eosinophilic cytoplasm and
centrally located nucleus. Produce gastric acid.
• Chief cells (peptic or zymogenic cells)- Clustered at the base of the gland. Identified by
basally located nuclei and strongly basophilic granular cytoplasm. Produce pepsinogen,
digests protein.
Types of cells present in the stomach:
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10. A case of perforation of gastric ulcer
• A 42-year-old person was admitted to the hospital after visiting the emergency room
complaining of severe epigastric pain and pain over her right shoulder.
• She had a history of gastric ulcer which had been treated previously with medication,
but on questioning, she admitted that she had been so busy recently that she had
forgotten to refill her prescription and had not taken her medication in time.
• As a result of the history and physical findings, the physician suspected that she was
suffering from a perforated gastric ulcer.
• Gastroscopy was performed which confirmed the diagnosis.
• When the surgeon examined the patient's stomach during the surgery, she found a
small perforation on the posterior aspect of the body of the stomach near the lesser
curvature.
• The perforation was repaired and, in addition, a vagotomy was performed.
• During the vagotomy, the surgeon found it necessary to cut the left gastric artery and
ligate it.12/18/2014 10

11. The stomach bed and its relations
• The structure located posterior to the
stomach could be damaged by gastric
juices leaking from a perforated ulcer
on the posterior wall of the stomach.
• These organs would include the
pancreas, the left suprarenal gland,
the upper part of the left kidney, the
diaphragm, the splenic artery, and its
branches, and maybe the spleen.
• Erosion of the wall of the splenic
artery is of particular concern because
it could lead to severe internal
hemorrhage and rapid exsanguination.12/18/2014 11

12. The pain felt at shoulder is a referred pain
• The shoulder pain was likely referred pain that occurred due to
irritation of the diaphragm by gastric juices.
• The diaphragm is innervated by the phrenic nerves which arise from
cervical nerves 3, 4, and 5.
• These cervical nerves also contain nerves that innervate the shoulder
region; thus, the shoulder is a common location for referred pain
from the diaphragm.
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13. The collateral circulation around the stomach
• If the left gastric artery is occluded due to
surgical ligation, collateral circulation
from the right gastric artery, right
gastroomental artery (a branch of the
gastro duodenal artery), and the left
gastroomental and short gastric arteries
(branches of the splenic artery) is usually
adequate to compensate for loss of flow
through the left gastric artery.
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14. A case of carcinoma of head of pancreas
• M.S., a generally healthy 74-year-old woman, visited her physician with the following
complaints: progressive jaundice over the last week or so, frequent bowel movements
with pale, greasy feces, a lack of energy, weight loss, and back pain.
• The physician ordered a series of tests, which suggested that the jaundice was of an
obstructive, not metabolic, nature.
• Abdominal ultrasound demonstrated the presence of a growth on the head of the
pancreas, and further tests indicated that the lesion was a pancreatic carcinoma .
• After consultation with a surgeon, M.S. elected to have a cholecystojejunostomy
performed to correct the obstruction and prevent the discomfort and pruritis that
usually accompany obstructive jaundice.
• The pancreatic tumor was deemed inoperable.
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15. The first segment of small intestine is duodenum
• The duodenum is the first part of the small
intestine, followed by the jejunum and ileum
(in that order); it is also the widest and
shortest (25 cm) part.
• The duodenum is a C-shaped or horseshoe-
shaped structure that lies in the upper
abdomen near the midline.
• The first (superior) part, or duodenal bulb (5
cm), which is connected to the undersurface
of the liver (porta hepatis) by the
hepatoduodenal ligament, containing the
proper hepatic artery, portal vein, and
common bile duct (CBD); the quadrate lobe
(segment IV) of the liver and the gallbladder
are in front, whereas the CBD, the portal
vein (PV), and the gastroduodenal artery
(GDA) are behind it.
• The second (descending) part (7.5 cm), which has
an upper and a lower genu (flexure); the transverse
mesocolon and transverse colon are in front, and
the right kidney and inferior vena cava (IVC) are
behind it; the head of the pancreas lies in the
concavity of the duodenal C. The major duodenal
papilla opens in the posterior wall of 2nd part of
duodenum draining the bile and pancreatic juices.
• The third (horizontal) part (10 cm) runs from right to
left in front of the IVC and aorta, with the superior
mesenteric vessels (the vein on the right and the
artery on the left) in front of it.
• The fourth (ascending) part (2.5 cm) continues as
the jejunum.
• Except for its first part, the duodenum is largely
retroperitoneal and therefore fixed; it has no
mesentery and is covered by peritoneum only on its
anterior surface.12/18/2014 15

16. The blood supply, innervation
and lymphatic drainage of
duodenum
• The gastroduodenal artery arises from
coeliac trunk.
• The supraduodenal artery is a branch
from gastroduodenal artery.
• The superior and inferior
pancreaticoduodenal arterial arches are
from both coeliac and superior
mesenteric arteries.
• The corresponding veins drain into
superior mesenteric vein.
• Innervation to duodenum is derived from
coeliac ganglion and vagi nerves.
• The lymphatic drainage is to the
gastroduodenal group,
pancreaticoduodenal and hepatic group
of lymph nodes.
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17. The histology of duodenum
• The wall of the duodenum contains
the same 4 layers that are seen in the
remainder of the small bowel--
namely, the mucosa (lined with
columnar epithelium, containing
lamina propria and muscularis
mucosa), the submucosa, the
muscularis propria (with inner circular
and outer longitudinal layers), and the
serosa (only on its anterior surface).
• The duodenal mucosa is characterized
by the presence of Brunner’s glands,
which secrete mucus.
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18. A case of duodenal ulcer • A 40 year-old male with a long history
of duodenal ulcer problems was
brought in for emergency surgery to
control severe hemorrhage into the
peritoneal cavity.
• The surgeons found that erosion by
the ulcer of a vessel passing behind
the first part of the duodenum was
the source of the hemorrhage.
• Which of the following vessels passes
behind the first part of the
duodenum and would need to be
clamped off to control the bleeding?
• It is gastroduodenal artery bleeding
from a perforated duodenal ulcer.
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19. References:- Essential Clinical Anatomy-4th edition-
Keith Moore (pages143-152)
• http://teachmeanatomy.info/abdome
n/viscera/stomach/blood-supply-to-
the-stomach-arteries/
• http://emedicine.medscape.com/articl
e/181753-overview#aw2aab6b2b2aa
• http://library.med.utah.edu/WebPath/
GIHTML/GI421.html
• http://www.cytochemistry.net/microa
natomy/digestive/stomach.htm
• http://www.colorado.edu/intphys/iph
y3415/histology/#digestive
• http://www.udel.edu/biology/Wags/
histopage/illuspage/igi/intestinesppt.
htm
• http://web.uni-
plovdiv.bg/stu1104541018/docs/res/s
kandalakis'%20surgical%20anatomy%
20-
%202004/Chapter%2016_%20Small%
20Intestine.htm
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