The Stomach, Pancreas and Spleen

Dr. Michael L. Capulong

MD, FPCS, FPSGS
The Stomach
Expanded portion of GIT
Major organ of the GIT
Connects the esophagus to the intestines
Located in the epigastric and left upper quadrant of the
abdomen
Occupies T10-L3
Approximate content: 1.5 L
Crescent-shaped
4 Regions of the Stomach:
Cardia - just distal to the GE junction
Fundus - above and to the left of GE junction
Corpus (body) - 75-80% of the stomach, site of
breakdown of food
Antrum - pyloro-antral area, tapering portion of the
stomach as it goes to the pylorus
*pylorus - Grossly palpable as a hard structure
distal to the stomach due to the pyloric sphincter
which prevents back flow of contents from the
duodenum to the stomach
*GE junction prevents back flow of gas and gastric
contents
*GERD - gastro esophageal reflux disease incomplete contraction of the GE junction
More commonly known as heart burn
Curvatures of the Stomach:
Lesser curvature - smaller and more medial curvature,
attaches to portions of the omentum (gastrohepatic
ligament)
Greater curvature - larger and more lateral curvature,
attaches to infoldings of the omentum (gastrosplenic
ligament and gastrocolic ligament)
Other Markers:
Cardiac notch - indentation between the cardia and the
fundus, this signifies the start of the fundus and the
greater curvature of the stomach
Angular notch - angulation found at the lesser curvature
of the stomach, this will divide the body and the antrum
of the stomach (end of body and start of antrum)
Pre-pyloric vein of Mayo - a very small vein that signifies
the area of the pylorus
Anatomy:
The stomach is fixed at two points:
Proximal - at the GE junction
Distal - at the retroperitoneal duodenum (2nd part
of the duodenum)
Anterior - in contact with left hemi-diaphragm, left low
and anterior segment of right lobe of the liver and the
anterior parietal surface of the abdominal wall
Posterior - left diaphragm, left kidney, left adrenal gland,
and neck, tail, and body of pancreas
The greater curvature is near the transverse colon and
transverse colon mesentery
The concavity of the spleen contacts the left lateral
portion of the stomach

Blood Supply:
Derived from the celiac artery
3 branches
Left gastric artery - supplies the cardia of the stomach
and distal esophagus; runs along the lesser
curvature and anastomose with the right
gastric artery
Splenic artery - gives rise to 2 branches which help
supply the greater curvature of the stomach
Left gastroepiploic - supplies greater curvature and
greater omentum, anastomoses with
right gastroepiploic artery
Short gastric arteries - several, supply the fundus
of the stomach and also anastomose
with the left gastroepiploic artery and
left gastric artery
Common hepatic or proper hepatic artery - 2 major
branches
Right gastric artery - supplies a portion of the
lesser curvature
Gastroduodenal artery - gives rise to right
gastroepiploic artery and helps supply
greater curvature in conjunction with
left gastroepiploic artery
Venous Drainage:
Follows the arterial system, concomitant veins
Lymphatic Drainage:
Lymph from the proximal portion of the stomach drains
along the lesser curvature first drains into superior
gastric lymph nodes surrounding the left gastric artery
Distal portion of the lesser curvature drains through the
suprapyloric nodes
Proximal portion of the greater curvature is supplied by
the lymphatic vessels that traverse the
pancreaticosplenic nodes (posterior portion of the
stomach LUQ)
Antral portion of the greater curvature drains into the
subpyloric and omental nodal groups
"Gastric cancer malignancies are very difficult to control due to
the abundance of lymph nodes and the Japanese are the
world's leader in gastric surgery"
Nerve supply:
Parasympathetic innervation of stomach - vagus nerve
(parasympathetic response: increase acid secretion)
Sympathetic innervation of stomach - splanchnic nerve
Anatomy of the vagus nerve:
Left anterior vagus nerve
Left of the esophagus
Branches
Hepatic branch
Supplies liver and biliary tract
Anterior gastric or anterior nerve of Latarget
(terminal branches) - surgically, when a
gastric surgery is done for ulcers or acid
production is needed to be decreased, you
ligate the terminal branches of the vagus
nerve (nerve of Latarget)
Right posterior vagus nerve
Right of the esophagus
Branches
Celiac
Posterior Latarget
(also called crow-feet / crow-foot nerves)
Innervates posterior gastric wall

The Pancreas
Retroperitoneal organ (devoid of any peritoneal covering or
refection) lies transversely and slightly obliquely at L1-L2
level
Transverse mesocolon attached to anterior margin
Exocrine (production of pancreatic enzymes) and endocrine
functions (hormonal production: glucagon and insulin as
well as somatostatin)
Head, neck, body and tail of the pancreas
Relations:
Head
Lies in curvature of duodenum
Tumours in the pancreas have early
manifestations because of compression
Vomiting, jaundice
Anterior to IVC, aorta, right renal vessels and left
renal vein
Uncinate process (curving portion of the
pancreatic head to the superior mesenteric
vessels) projects posteriorly and to the left and lies
posterior to superior mesenteric vessels
Common bile duct passes posteriorly in a groove
or embedded within
Neck
Anterior to the union of the splenic vein and
superior mesenteric vein to form the portal vein
"The critical point of surgery in stomach and
pancreas is the involvement of the great vessels,
do not attempt to operate when the great vessels
are involved because this will be very catastrophic
due to its vulnerability to rupture"
Body
Curves over vertebrae and great vessels
Anterior to the aorta and lies between the celiac
trunk and the superior mesenteric artery
Splenic vein passes posteriorly
Tail
Lies in the splenorenal ligament
Usually contacts the hilum of the spleen
The pancreatic ducts:
Two pancreatic ducts
Main or chief pancreatic duct (Wirsung)
Runs the length of the pancreas from the
entire tail and body and from the
postero-inferior part of the head, including
the uncinate process
Formed by junction of small dust of lobules
from the tail through the body to the neck
Leaves the head piercing the duodenum
and ends by an orifice common to it and the
common bike duct at the summit of the
major duodenal papilla of Vater
Accessory pancreatic duct (Santorini)
If present, drains the antero-superior part of
the head and empties independently into
the 2nd portion of the duodenum
Blood supply:
Arterial supply:
Head: superior pancreaticoduodenal artery (from
gastroduodenal artery) and inferior
pancreaticoduodenal artery (from SMA)
Body and tail: branches from splenic artery
Venous drainage:
Mostly splenic vein but also portal vein and SMV

The Spleen
Large soft vascular lymphatic organ in the left upper
quadrant
Up to 12 cm with one axis in line with 10th rib
Arises from mass of mesenchymal cells located between
layers of dorsal mesogastrium
Normally, the spleen is not palpable but during
splenomegaly, the inferior part of the spleen
becomes palpable
Borders of the spleen:
Anterior and superior borders
Sharp and often notched
Separate the diaphragmatic surface from the
gastric surface
Posterior border
More rounded and blunter than the anterior
Separates renal from diaphragmatic surface
Inferior border
Separates diaphragmatic from colic surface
Can be palpated during splenomegaly as it goes
down during respiration
Relations:
Posterior to stomach
Connected to greater curvature by gastrosplenic
ligament
Anterior to superior part of the left kidney
Connected by splenolenal ligament
Laterally: diaphragm, 9-11th left ribs
Tail of pancreas lies at the hilum of the spleen
Blood supply:
Arterial supply
Splenic artery divides into end arteries as it enters
the spleen
No anastomoses, hence obstruction of one end
artery resulting in area of splenic infarction
Venous drainage
Splenic vein
Lymphatic drainage
Pancreaticosplenic lymph nodes

Prepared by: Paolo Warren (Med-IA)