SMALL INTESTINES Primary site for absorption of nutrients from ingested materials.

. Consists of the duodenum, jejunum and ileum. Extends from the pylorus to the iliocecal junction where the ileum joins the cecum. The pylorus empties the contents of the stomach into the duodenum o Almost entirely supported by a mesentery except majority of the duodenum, which is mainly a retroperitoneal organ. I. CONNECTIVE TISSUE Gastrohepatic ligament + hepatoduodenal ligament = lesser omentum Greater omentum or gastrocolic ligament attaches the stomach to the transverse colon. Duodenocolic ligament = attaches transverse colon to the superior part of the duodenum. II. LAYERS Serosa Subserosa Loose CT where veins, arteries and nerves traverse and penetrate deeply into the wall of the intestine. Muscularis Externa (ICOL) OuterLongitudinal Myenteric/Auerbachs Plexus o Regulates movement in the intestinal tract (i.e. peristalsis, propulsion, circular contractions.) Inner Circular Submucosa Submucosal/MeissnersPlexus Muscularis Mucosae (ICOL) Outer Longitudinal Inner Circular Lamina Propria Mucosa A. DUODENUM The first and shortest part of the small intestine. Also the widest and most fixed part. Pursues a C-shaped course around the head of the pancreas. As food enters the duodenum, more fluids are added bile, proteases, amylases for digesting fat, carbohydrates respectively. Begins at the pylorus on the right side and ends at the duodenojejunal flexure at the level of L2. Can be divided into four parts. I. SUPERIOR PART a. The first part and a short part (approximately 5cm) b. Inner mucosal lining: simple columnar epithelium. c. Also contains duodenal glands/Brunners glands, which secrete substances that neutralize acid from the stomach. d. Covered by peritoneum at its anterior aspect; is bare of peritoneum posteriorly. i. First 2 cm immediately after the pylorus (the ampulla or duodenal cap) is intraperitoneal and mobile. ii. Distal 3 cm have no mesentery and are immobile because they are retroperitoneal e. Proximal part has the hepatoduodenal ligament of the lesser omentum attached superiorly. i. The bile duct, portal vein and hepatic artery traverse this ligament. f. Greater omentum is attached inferiorly. II. DESCENDING PART a. 7-10cm in length. b. Plays the greatest role in digestion. c. Where digestive juices enter into the bowel through the posteromedial wall of the upper half. d. Major Duodenal Papilla i. Located posteromedially. ii. Hepatopancreatic ampulla or ampulla of Vater = common bile duct (bile from the liver and gall bladder) + pancreatic duct (duct of Wirsung.) iii. Hepatopancreatic sphincter or Sphincter of Oddi = formed by the longitudinal muscle of the duodenal wall e. Minor Duodenal Papilla/Duct of Santorini

III.

IV.

i. Only present in 60-70% of people. ii. Located 2cm proximal to the major papilla. f. The peritoneum reflects from its middle third to form the double layered mesentery of the transverse colon (transverse mesocolon) g. Features circular folds or plicae circularis or valves of Kerckring. INFERIOR (HORIZONTAL PART) a. 6-8cm long b. Runs transversely to the left. ASCENDING PART a. Short (5cm) b. Relationships with other organs: i. Begins at the left of L3 vertebra ii. Rises superiorly as far as the superior border of the L2 vertebra iii. Runs along the left side of the aorta to reach the inferior iv. border of the body of the pancreas. c. Curves anteriorly to join the jejunum at the duodonojejunal flexure, which takes the form of an acute angle. Duodojejunal flexure is supported by the suspensory muscle/ligament of Treitz. d. Ligament of Treitz = Slip of skeletal muscle from the diaphragm + fibromuscular band of smooth muscle

B. JEJUNUM Begins at DJ (duodenojejunal) Flexure 2/5 length of intraperitoneal section. Occupies LUQ Distinct Plicae Circulares Thicker/ Wider Long Vasa Recta C. ILEUM Ends at Ileocecal Junction 3/5 length of intraperitoneal section Occupies RLQ PC gradually thins out & disappears Paler/ More fatty Many Short Arcades Many lymph nodes (Peyers Patches) 1. Together, jejunum and ileum are 6-7m long. 2. The jejunum mostly occupies the left upper quadrant while the ileum mostly occupies the right lower quadrant. 3. There is no clear line demarcation between jejunum and ileum MESSENTERY Fan-shaped fold of peritoneum Root of the mesentery, directed obliquely, inferiorly and to the right, crosses the ascending and inferior parts of the duodenal aorta,IVC,right ureter, right psoas major and right testicular or ovarian vessels. The average length of the mesentery from its root to the intestinal border is 20cm. Attaches the jejunum and the ileum to the posterior abdominal wall Extends from the duodenojejunal junction on the left side of L2 vertebra to the ileocolic junction and the right sacroiliac joint. Two layers of mesentery containing superior mesenteric vessels, lymph nodes, a variable amount of fat, and autonomic nerves. LARGE INTESTINES Water is absorbed from the indigestible residues of the liquid chyme converting it into semi solid stool or feces. Consists of cecum; appendix; ascending, transverse, descending and sigmoid colon;rectum and anal canal The L.I. can be distinguished from the S.I. by: o Omental appendices: small, fatty omentum like projections o Teniae Coli: Thickened bands of smooth muscle representing most of the longitudinal coat o Haustra: sacculations of the wall of colon b/w the teniae.

TENIAE COLI 3 distinct longitudinal bands of smooth muscles. o Mesocolic tenia: transverse and sigmoid mesocolon attach. o Omental tenia:omental appendice attach to. o Free tenia: no attachment For most of the bowels, the teniae coli are formed by longitudinal muscles. The appendix, terminal part of the sigmoid colon and early part of the rectum are comprised mainly of longitudinal muscle. The rest of the bowels are composed mainly of circular muscle with an extremely thin longitudinal muscle. Begin at the base of the appendix as the thick longitudinal layer of the appendix. Run the length of the large intestine, abruptly broadening and merging with each other again at the rectosigmoid junction into a continuous longitudinal layer around the rectum. Semilunar folds = muscular thickenings between teniae coli. Shortens the part of the wall with which they are associated. Colon becomes sacculated or baggy between the teniae, forming the haustra. CECUM 1st part of Large intestine Continuous with the ascending colon Blind intestinal pouch, approx.7.5cm in length and breadth. Lies in the iliac fossa of right lower quadrant of the abdomen;usually lies within 2.5cm of the inguinal ligament. While typically found in the right lower quadrant of the abdomen,it is known to vary in some individuals. If distended with feces or gas, may be palpable through the anterolateral abdominal wall. Almost entirely enveloped by peritoneum. No mesentery Bound to the lateral abdominal wall via one or more cecal folds of peritoneum. Terminal ileum enters the cecum obliquely and partly invaginates into its wall. o Ileocecal junction is located here. Superior to it is the superior ileocecal recess. o The recesses are formed by the ileocecal folds/bloodless folds of Treves. Cut to expose the appendix at the back cecum No vessels in this area. o Longitudinal muscle act as sphincters. Prevent reflex from the cecum to the ileum when they tighten. Ureter is located behind the cecum as well as the iliac vessels. This area is known as ileocecal recess. At most proximal part appendix is located. In dissection,the ileal orifice enters the cecum between ileocolic lips, folds that meet laterally. Form ridges, frenula of ileal orifice.

APPENDIX Blind intestinal diverticulum Contains masses of lymphoid tissues. 6-10cm in length Arises from the posteromedial aspect of cecum inferior to the ileocecal junction. Short triangular mesentery,the mesoappendix. Appendix position is variable,but usually retrocecal. Retrocecal appendix=appendix is retroperitoneal and attach to the cecum. Inner circular outer longitudinal (ICOL)layer: muscularis layer In submucosa, mostly lymphatic tissue

COLON Has four parts: ascending, transverse, descending and sigmoid. Only the transverse colon and sigmoid colon have mesentery. All vessels for the ascending and descending colon are retroperitoneal. A. ASCENDING COLON a. Extends superiorly from the cecum to the right colic flexure, near the liver (right lobe), where it turns to the left.

Narrower than the cecum. The anterior and its sides are usually covered by peritoneum while it is considered retroperitoneal along the right side of the posterior abdominal wall d. Separated from the anterolateral abdominal wall by the greater omentum. e. A deep vertical groove lined with parietal peritoneum (right paracolic gutter) lies between the lateral aspect of the ascending colon and the adjacent abdominal wall. f. Ends where it turns medially. B. TRANSVERSE COLON a. The third, longest and most mobile part of the large intestines b. Crosses the abdomen from the right colic flexure to the left colic flexure near the spleen, where colon turns inferiorly. c. Its mesentery is the transverse mesocolon. d. Variable in position, usually hanging to L3. e. Has a renocolic ligament attaching it to the right kidney. f. Distal portion of the transverse colon ends at the spleen where it is attached with a splenocolic ligament g. attaches to diaphragm through phrenocolic ligament h. Right Colic Flexure i. Hepaticflexure ii. lies deep to the 9th and 10th ribs and is overlapped by inferior part of the liver i. Left Colic Flexure i. splenic flexure ii. lies anterior to the inferior part of kidney iii. more superior, acute, less mobile than right colic flexure C. DESCENDING COLON a. extends from the left colic flexure to the pelvis, where it becomes the sigmoid colon. b. Anterior part of the descending colon is attached retroperitoneally. c. As it descends, the colon passes anterior to the lateral border of the left kidney. d. Has a paracolic gutter (left) on its lateral aspect. e. Ends when it starts to become completely intraperitoneal. D. SIGMOID COLON a. forms an S-shaped tube that extends medially and then inferiorly into the pelvic cavity and ends at the rectum. b. Links the descending colon and the rectum. c. Extends from the iliac fossa to S3, where it joins the rectum. d. Usually has a long mesentery (sigmoid mesocolon) and therefore has considerable freedom of movement, especially its middle part e. Root of the sigmoid mesocolon i. extends first medially and superiorly along the external iliac vessels ii. Then, medially and inferiorly from the bifurcation of the common iliac vessels to the anterior aspect of the sacrum f. Left ureter and the division of the left common iliac artery lie retroperitoneally, posterior to the apex of the root of the sigmoid colon g. Omental appendices of the sigmoid colon are long, disappears when sigmoid colon terminates h. Teniae coli also disappear as the longitudinal muscle in the wall of the colon broadens to form a complete layer in the rectum ** the mucosal lining of the colon contains numerous straight tubular glands called CRYPTS, which contain many mucus producing goblet cells. The longitudinal smooth muscles layer of the colon does not completely envelope the intestinal wall but form three bands called TENIAE COLI. RECTUM Straight tube (although is only erect anteroposteriorly.) Sagittal view: Follows the curvature of the sacrum. Muscular tunic is smooth muscle and it is relatively thick in rectum compared with the rest of the digestive tract. o A fixed terminal part of the large intestines that is 5 in. (13cm) long. o Hardly any absorption occurs here. o Primarily retroperitoneal and subperitoneal o Posterior Peritoneal Reflection at the L5-S1 area. o Anteriorly Peritoneal Reflection area of S3-S4. Peritoneum covers the anterior and lateral surfaces of the upper 1/3 of the rectum and only the anterior surface of the middle 1/3. The lower 1/3 devoid of peritoneum (it is therefore subperitoneal.)

b. c.

Has NO mesentery, sacculations, taenia coli or appendices. Extends from S3 up to the area where it pierces the levator ani muscle. Continuous with sigmoid colon (level of S3 vertebra) superiorly and with the anal canal inferiorly. o Lies posteriorly against the inferior three sacral vertebrae and the coccyx, anococcygeal ligament, median sacral vessels, inferior ends of the sympathetic trunks and sacral plexuses. o Rectal ampulla = distal dilated portion above the levator ani muscle; NOT covered by peritoneum. A collecting area until one is ready to defecate. Defecation is controlled by the sphincter muscles and anal canal is curved posteriorly over the edge of coccyx forming an acute angle. In males: the peritoneum that covers the rectum goes down and covers the posterior aspect of the urinary bladder forming the floor of rectovesical pouch. Related anteriorly to: o Fundus of the urinary bladder o Terminal parts of the ureters o Ductus deferentes o Seminal glands o Prostate In females: the peritoneum that covers the proximal 2/3 of the rectum covers the posterior fornix of the vagina to form the rectouterine pouch (Pouch of Douglas). women do not have rectovesical pouches. Pararectal fossae o Bilateral and formed in the lateral reflections of the peritoneum from the superior third of the rectum in both sexes. o Permit the rectum to distend as it fills with feces. o Follows the curve of the sacrum and coccyx forming the sacral flexure of the rectum. o Ends anteroinferior to the tip of the coccyx that perforates the pelvic diaphragm, immediately before the sharp posteroinferior angle of the anorectal flexure of the anal canal (an important mechanism for fecal continence.) Transverse rectal folds (valves of Houston.) o Overlie thickened parts of the circular muscle layer of the rectal wall. o Support the weight of fecal matter to prevent its urging toward the anus. o Superior to and supported by the pelvic diaphragm (levator ani) and anococcygeal ligament. o Receives and holds fecal mass until it is expelled during defecation. o Ability to relax to accommodate initial and subsequent arrival of fecal material is important in maintaining fecal continence

o o o

ANAL CANAL the last 2.5-3.5 cm of the digestive tract begins at inferior end of the rectum and ends at the anus (external outlet of the alimentary/ external GI tract opening.) Usually collapsed except during passage of feces or defecation Lateral walls are kept in apposition by the levator ani muscles and the anal sphincters except during defecation. the smooth muscle layer of analcanal is even thicker than that of the rectum and the internal and external anal sphincter. Internal Anal Sphincter o Involuntary muscle o Superior 2/3 of the canal. A thickening of the circular muscle layer. Stimulated by the sympathetic fibers from the superior rectal (periarterial) and hypogastric plexuses. Inhibited by parasympathetic fibers. o Relaxes temporarily in response to distention of the rectal ampulla o Continuous until distention is relieved o Voluntary contraction of external anal sphincter and puborectalis will prevent defecation or flatulence. External Anal Sphincter Large voluntary muscle. Forms broad band on each sides of the inferior 1/3 of the canal. Attached anteriorly to perineal body and posteriorly to the coccyx by the Anococcygeal Ligament. Blends superiorly with puborectalis.

 Has 3 zones: o Subcutaneous - small ring under the skin of the anus. o Superficial - sling of muscle from perineal body to coccyx. o Deep Innervated by S4 thru Inferior rectal nerve. o Except for the deep part which is supplied by fibers from the nerve to the levator ani. Anal columns - series of longitudinal ridges Superior half of the canals mucous membrane. Contain the terminal branches of the superior rectal arteries and veins (hemorrhoidal vessels.) Perianal Glands- secrete oily substance which lubricates the feces; can be blocked especially during constipation leading to formation of abscesses. In the submucosa of the proximal third of anus, the internal venous plexuses are found. Superior end of anal column corresponds to the anorectal line (where the lining epithelium from simple columnar epithelium with goblet cells of the rectum changes to stratified squamous epithelium in the anal canal.) Anorectal Junction - indicated by the superior ends of the anal column. o Where rectum joins anal canal. Anal Valves - inferior ends of the column. Anal Sinuses- are small recess superior to the valves. o When compressed, release mucus which aids in evacuation of feces. Anal Crypts - spaces or depressions superior to anal valves into which the secretions of the perianal glands are emptied. White Line of Hilton- corresponds to the area where the conjoined longitudinal muscle attaches to the mucous membrane of the anal canal. Anal pecten the transitional zone between the skin and the mucous membrane; between the pectinate line and the anal verge. Surgical anal canal where the levator ani is. Anatomical anal canal portion from dendate line (pectinate line/anatomic anorectal line) down to the anal verge. Pectinate/ Dendate line - inferior comb shaped limits of the valves. o Demarcates the junction of the superior (visceral: embryonic hindgut) and inferior (somatic: embryonic proctodeum) part of the anal canal. o Important landmark; determines the arterial supply, innervation, venous and lymphatic drainage of the superior and inferior anal canal. BLOOD SUPPLY, VEINS LYMPHATIC DRAINAGE & NERVE SUPPLY A.Duodenum Arteries Celiac Trunk o Via gastroduodenal artery and its branch superior pancreaticoduodenal artery supplies duodenum proximal to the entry of the bile duct into the descending part of duodenum Superior Mesenteric Artery (arises from abdominal aorta at the level of L1 vertebra, 1cm inferior to celiac trunk) o Branch: inferior pancreaticoduodenal artery supplies duodenum distal to the entry of the bile duct Veins o Follow the arteries and some directly drain into hepatic portal vein o Others indirectly to superior mesenteric and splenic veins Lymphatic drainage o Anterior lymphatic vessels Pancreaticodudodenal lymph nodes (along superior and inferior pancreaticoduodenal arteries) Pyloric lymph nodes (along gastroduodenal artery) o Posterior Lymphatic vessels Superior mesenteric lymph nodes Celiac lymph nodes Nervesupply o Vagal trunks and greater and lesser splanchnic nerves celiac and superior mesenteric plexuses periarterial plexus B. Jejunum and Ileum Arteries o Superior Mesenteric Artery

 Veins o

Jejunal and ileal arteries Forms 15-18 branches to jejunum and ileum Arterial arcades loops or arches formed from the union of arteries then gives rise to vasa recta (straight arteries)

Superior mesenteric vein lies anterior to the right of the SMA in the root of mesentery Unites with the splenic vein forming hepatic portal vein Lymphatic Drainage o Lacteals specialized lymphatic vessels in the intestinal villi that absorb fat - Empty their milk-like fluid into the lymphatic plexuses in the walls of the jejunum and ileum, in between layers of mesentery and through the three groups of lymph nodes Juxta-intestinal lymph nodes close to intestinal wall Mesenteric lymph nodes among arterial arcades, drain into superior mesenteric lymph nodes Superior central nodes proximal part of the SMA o Ileocolic lymph nodes from the terminal ileum following the ileocolic artery Nerve supply o Periarterial nerve plexus supplies nerve supply to the parts of the intestine that surrounds SMA and its branches o Sympathetic originate in the T8-T10 of spinal cord pass through sympathetic trunks and abdominopelvic splanchnic nerves to the superior mesenteric nerve plexus Celiac and Superior mesenteric ganglia where presynaptic and postsynaptic sympathetic neurons synapse Reduces peristaltic and secretory activity of the intestine, vasoconstrictor, reducing or stopping digestion and making blood o Parasympathetic From posterior vagal trunks myenteric and submucosal plexuses where presynaptic and postsynaptic parasympathetic neurons synapse increases peristaltic and secretory activity of the intestine has sensory (visceral afferent) fibers insensitive to most pain stimuli (cutting, burning), sensitive to distention (colic-spasmodic abdominal pains or intestinal cramps) C. Large Intestines Arteries o Ileocolic artery terminal branch of the SMA, supplies cecum o Appendicular artery - branch of ileocolic artery (supplies appendix) Veins o Ileocolic vein tributary of SMV, from cecum and appendix Lymphatic drainage o Ileocolic lymph nodes lie along ileocolic artery, pass to the superior mesenteric lymph nodes NerveSupply o Superior mesenteric plexus (cecum and appendix) where sympathetic and parasympathetic nerves are derived (sympathetic lower thoracic part of spinal cord, parasympathetic vagus nerves) D. Colon (Ascending Colon and Right Colic Flexure) Arteries o Ileocolic and Right colic arteries branches of SMA anastomose with right branch of middle colic artery, continued by left colic and sigmoid arteries, forming marginal artery (juxtacolic artery) Veins o Ileocolic and right colic veins Lymphatic Drainage o Epicolic and paracolic lymph nodesileocolic and right colic lymph nodessuperior mesenteric lymph nodes Nerve Supply o Superior mesenteric plexus (Transverse Colon) Arteries o Middle colic artery also a branch of SMA o Right and left colic arteries part of marginal artery (juxtacolic artery)

 Veins o Superior Mesenteric Vein Lymphatic Drainage o Middle colic lymph nodes superior mesenteric lymph nodes Nerve Supply o Periarterial plexuses of right and middle colic arteries superior mesenteric nerve plexus (Descending and Sigmoid colon) Arteries o Left colic and sigmoid arteries branches of Inferior mesenteric artery SMA supplying blood to the part orad (proximal) to the flexure or right colic flexure (derived from embryonic midgut) IMA supplying blood to the part aborad (distal) to the flexure or left colic flexure (derived from embryonic hindgut) Sigmoid arteries anastosmose with descending branch of left colic artery (part of marginal artery) Veins o Inferior mesenteric vein splenic vein hepatic portal vein Lymphatic Drainage o Epicolic and paracolic lymph nodes inferior mesenteric lymph nodes (left colic flexure may also drain to superior mesenteric lymph nodes) Nerve Supply o Sympathetic from lumbar part of sympathetic trunk via abdominopelvic splanchnic nerves o Parasympathetic from pelvic splanchnic nerves via inferior hypogastric (pelvic) plexus Orad to middle of sigmoid colon visceral afferents pass retrogradely with sympathetic fibers to thoracolumbar spinal sensory ganglia whereas reflex information travel with parasympathetic fibers to vagal sensory ganglia Aborad to middle of sigmoid colon visceral afferents follow parasympathetic fibers retrogradely to the sensory ganglia of spinal nerves S2-S4 E. Rectum and Anal Canal Arteries o Superior rectal artery branch of inferior mesenteric artery supplies proximal part of rectum o Right and Left Middle Rectal arteries - from internal iliac arteries, supplies middle and inferior parts of rectum o Inferior rectal arteries from internal pudendal arteries, supply anorectal junction Collateral circulation anastomoses bet. Superior and inferior rectal arteries Veins o Superior (drains into portal venous system), middle and inferior rectal veins (drains into systemic system) o Rectal venous plexus Internal rectal venous plexus- deep to the mucosa of anorectal junction External venous plexus external to the muscular wall of the rectum Nervesupply Sympathetic lumbar splanchnic nerves hypogastric/pelvic plexus o periarterial plexus of inferior and superior rectal arteries Parasympathetic S2-S4 spinal nerves, pelvic splanchnic nervesinferior hypogastric plexus rectal (pelvic) plexus