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[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 1 of 18
Figure 2. Layers of the Small Intestine
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 2 of 18
4th Part (Ascending Part)
● Runs superiorly and left of the aorta, to reach the inferior
border of the body of the pancreas
● Curves anteriorly to join jejunum at the duodenojejunal
flexure / junction
● Supported by the Ligament of Treitz
➝ aka Suspensory Muscle of the Duodenum
➝ Composed of skeletal muscle from the R crus of the
diaphragm and a fibromuscular band of smooth
muscle from the 3rd and 4th part of duodenum
➝ Contraction of muscle widens the angle of the
duodenojejunal flexure, thus facilitating movements of
the intestinal contents
C. JEJUNUM & ILEUM
Figure 4. Magnified image of Ampulla of Vater Table 1. Jejunum vs. Ileum
Figure 5. (A) Pancreas at 6th week of dev’t. Ventral and dorsal pancreatic duct in Plicae Present, more Thins out, disappears
close contact. (B) Fusion of pancreatic duct --- main pancreatic duct + bile duct Circulares distinct, tall, closely
enters duodenum at the major papilla. The accessory pancreatic duct (when packed
present) enters duodenum at the minor papilla (Langman’s Embryology)
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 3 of 18
→ Contents: Superior Mesenteric arteries and veins,
- Presence of plicae circulares explains why the jejunum is lymphatics
thicker and wider (in order to receive large bulks of food) → Lymphatics:
▪ Lacteals within the villi absorb fats into plexuses
Peyer’s Patches in the walls
- High density of MALT in the GIT ▪ Course: Lacteals → Juxta-intestinal →
- Function: filters bacteria and toxins in the lymph Mesenteric and Superior Central Nodes → Aorta
- Found at the distal 1/3 of ileum (terminal ileum), where
the greatest amount of absorption occurs ● Root of mesentery
→ Length: 15 cm
Increased absorption in ileum → Need for greater blood → Oblique from duodenojejunal junction (L of L2) to
supply → more arcades, shorter vasa recta ileocolic junction (R of sacroiliac joint)
● Mesentery vs Omentum
→ Mesentery = suspends organ from the posterior
abdominal wall
→ Omentum (aka ligaments) = organ to organ connection
▪ Greater omentum
- gastrocolic ligament
▪ Lesser omentum
- gastrohepatic ligament
- hepatoduodenal ligament
Figure 6. Lower Left: Mucosa of the Ileum; Upper Right: Mucosa of the Jejunum
● Mesentery Proper
→ inferior to the duodenum, suspending the small intestine
or bowel loops
● Transverse Mesocolon
→ has a mesentery, crosses the 2nd part of duodenum
Figure 7. Jejunum vs Ileum
As a general rule, draw an imaginary line across the R costal
angle and L ASIS.
Everything Above: Jejunum
Everything Below: Ileum
D. MESENTERY
● Mesentery
→ Fan shaped fold of peritoneum
→ Function: tethers the entire gut from the posterior
abdominal wall
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 4 of 18
Mesentery of the Small Intestine Embryology: (Source: GIT Embryology 2021B, Langman’s Embryology, Dr. Zorba
Bautista’s PPT on GIT Embryology, and this lecture)
Figure 11. (Modified image) Primitive dorsal and ventral mesenteries (encircled:
liver bud)
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 5 of 18
- The small bowel grows faster than the colonic
segment.
- Because it's growing faster, it will now flip over and
the small bowel segment will drop
● Meckel's Diverticulum ● The small intestine or midgut develops outside for about
- Abnormal lining of gastric epithelium producing three weeks, and is set to return, due to the abdominal
acidic secretions (instead of the normal intestinal wall growing and eventually closing in the midline.
epithelium), ● Proximal portion of Jejunum
- First sign of Meckel’s Diverticulum = - First part to reenter the abdominal cavity
Unexplainable hemorrhage from lower GIT - Its mesentery is not long enough for it to go straight
➔ Location: 20-30 cm proximal from ileocecal down to the pelvis at the right side.
junction, where there are no Brunner’s glands - It cannot go to RUQ because the liver is there.
➔ Prone to bleeding and ulceration - Only space available is the LUQ, and pulls the rest
➔ Massive hemorrhage coming out the anus as of the contents there
melena (black tarry stools) or hematochezia
(fresh bloody red stools)
➔ Outpouching is difficult to see on x-ray and
scope
➔ Cause of disorder is unknown
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 6 of 18
● Hindgut
-Composed of: rectum, sigmoid colon, descending
colon, part of transverse colon
- Intra abdominal and doesn't go out
➔ When the jejunum returns, it goes to the left and
drags in everything until the terminal ileum
➔ Cecum
- connects terminal ileum to ascending colon
- cecal bud is the last to re-enter
- Will end up in the RLQ because the jejunum
pushed the colon to the L
- The jejunum fills LUQ and the descending
colon is forced to go to the left
➔ Rectum stays in the midline because it’s attached
to the sacrum
- The ileum can no longer occupy both the LUQ
due to the jejunum and the LLQ because of
the sigmoid colon
Mesenteries of Intestinal Loops
● Dorsal mesenteries or posterior mesenteries : found in Figure 17. Anterior view of the large intestine
all structures
● Ventral mesentery : found only in the foregut A. ILEOCECAL JUNCTION
● The mesenteries of the duodenum (the distal part) Ileocecal Valve
attaches to the posterior wall, such that the duodenum is
● Main purpose is to prevent the fecal material of going
now retroperitoneal
back to the small bowel/intestine
● The jejunum which was first to re-enter will retain its
dorsal mesentery all the way until the ileocecal junction. ● It is not actually a sphincter, but rather multiple rings
That’s why it’s called mesentery proper. of muscle particularly three. Comprised of the following:
● The dorsal mesentery of the ascending colon is pushed ➔ Inner circular muscle of the ileum
to the right gutter and fuses with the posterior wall. Such ➔ Circular muscle of the colon
that the ascending colon is now partially retroperitoneal ➔ Longitudinal muscle of the tenia coli
● The transverse mesocolon now lies anterior to the
duodenum. The gap in the 2nd part of the duodenum is
where the transverse mesocolon is.
● The mesocolon of the descending colon gets pushed to
the gutter and fuses posteriorly to become retroperitoneal
● Sigmoid colon, lower end of cecum and the appendix
remain as free mesenteries
● Pancreas becomes retroperitoneal
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 7 of 18
Efferent lymphatic vessels pass to the superior ● Nerve supply: superior mesenteric plexus
mesenteric lymph nodes ● Lymphatic drainage:
● Only segment of the colon that will have a complete ➔ Epicolic and paracolic lymph nodes → ileocolic and
covering of longitudinal muscle. Taenia coli will converge intermediate right colic lymph nodes → superior
at the base and completely envelop by the longitudinal mesenteric lymph nodes
muscle Transverse Colon
Appendicitis ● Description:
● inflammation of the appendix ➔ Third part of the large intestine
● caused by obstruction to the appendiceal orifice of the ➔ Most mobile, since it is not attached to the posterior
small lumen of the appendix commonly by a fecal matter abdominal wall, and longest part of the large
if the patient is highly constipated. Bacteria will proliferate intestines
and its fluid secretion that leads to swelling of the well ➔ Crosses the abdomen from the right colic flexure to
and occluding the blood supply. the left colic flexure
➔ Left colic flexure is also called as splenic flexure; It
C. COLON is usually more superior, more acute but less
● Encircles the small intestine; the ascending colon lies mobile than the right colic flexure
to the right, transverse colon superior and/or anterior, ➔ It has a mesentery called transverse mesocolon,
descending colon to the left, and the sigmoid colon which fuses with the posterior wall of the omental
inferior to it. bursa
● Comprised of five different parts: ➔ The root of the mesentery lies along the border of
➔ Cecum the pancreas and posteriorly continuous with the
➔ Ascending colon parietal peritoneum
➔ Transverse colon ● Arterial supply: Mainly middle colic artery, branch of
➔ Descending colon the SMA, also may receive from the right and left colic
➔ Sigmoid colon arteries via anastomoses. Its anastomoses collectively
● Plicae circulares becomes semilunar folds form the marginal artery (of Drummond, juxtacolic artery)
● Generally 800 cm only ● Venous drainage: Superior mesenteric artery
Cecum ● Lymphatic drainage: middle colic artery → superior
● Description: mesenteric lymph nodes
➔ First part of the large intestine ● Nerve supply: superior mesenteric nerve plexus via
➔ It is the area where the fecal material enters from the periarterial plexuses of the right and middle colic
the small bowel arteries
➔ Lies in the right lower quadrant and the iliac fossa
Descending Colon
➔ Cecum has no mesentery, makes it prone to
displacement from the iliac fossa ● Description:
➔ Occupies a secondarily retroperitoneal position
● Arterial supply: ileocolic artery, part of the superior
although has a short mesentery approximately 33%
mesenteric artery
of people
● Venous drainage: ileocolic vein, tributary of the SMV ➔ The short mesentery is not enough to induce
● Lymphatic drainage: volvulus/twisting of the colon
➔ passes through the lymph nodes of the ➔ It has a paracolic gutter on its lateral aspect the
mesoappendix and to the ileocolic lymph nodes. same as with the ascending colon
➔ Efferent lymphatic vessels pass to the superior ➔ As it descend, it passes to the anterior border of the
mesenteric lymph nodes left kidney
● Nerve supply: Sympathetic (lower thoracic part) and ● Arterial supply: left colic and sigmoid arteries,
parasympathetic (vagus) nerves from the superior branches of the inferior mesenteric artery
mesenteric plexus ➔ It forms a part of the marginal artery via the
Ascending Colon anastomosis of the superior branch of the most
● Description: superior sigmoid artery and the descending branch
➔ Second part of the large intestine of the left colic artery
➔ Generally narrower than the cecum ● Venous drainage: IMV, to the splenic vein and to the
➔ Secondarily retroperitoneal along the right side of hepatic portal vein
the posterior abdominal wall ● Nerve supply:
➔ Forms the right paracolic gutter, deep vertical ➔ Sympathetic nerves: lumbar part of the sympathetic
groove lined with parietal peritoneum trunk via lumbar splanchnic nerves
➔ Parietal peritoneum covers the ascending colon ➔ Parasympathetic nerves: pelvic splanchnic nerves
anteriorly and its side via the inferior hypogastric/pelvic plexus and nerves
➔ Usually have no mesentery but 25% of people do
● Lymphatic drainage: epicolic and paracolic nodes →
have short mesentery
intermediate colic lymph nodes → inferior mesenteric
➔ Passes superiorly to the right lobe of the liver which
lymph nodes that lie around IMA
turns to left at the right colic flexure or hepatic
➔ Lymph from the left colic flexure may drain to the
flexure
superior mesenteric lymph nodes
● ranch
Arterial supply: Ileocolic and right colic arteries, b
of SMA
● Venous drainage: Ileocolic and right colic veins,
tributaries of SMV
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 8 of 18
Sigmoid Colon ➔ Parasympathetic nerves: S2-S4 spinal cord level
● Description: via the pelvic splanchnic nerves and left and right
➔ Usually has a long mesentery, the sigmoid inferior hypogastric plexuses to the pelvic plexus
mesocolon
E. ANAL CANAL
➔ Omental appendices are long and disappears when
the sigmoid mesentery terminates
➔ Once the distal colon tinea starts fanning out and
become one whole entire wall or loop of
longitudinal smooth muscle,externally, marks the
demarcation of the rectum and the rectosigmoid
junction
● Its arterial supply, venous drainage, lymphatic drainage,
and nerve supply are the same with the descending
colon
● Usually the first one to expands compared to
transverse colon
D. RECTUM
● Description
➔ Follows the curvature of the sacral and coccyx
forming the sacral flexure of the rectum
➔ Ends antero-inferior to the tip of the coccyx,
immediately before a sharp posterior-inferior angle,
the anorectal flexure
➔ Retroperitoneal and subperitoneal part of the large
bowels
➔ Complete layer of muscularis externa
➔ Tenia coli already fanned out leading to no division
into three sections
➔ Has transverse rectal folds or valves of
Houston to slow down peristaltic rush
■ Two on the left - Superior and Inferior
■ One on the right - Middle
➔ Ampulla of the rectum
Figure 19. Anterior and Internal view of the rectum and anal canal
■ Receives and holds the fecal matter until it is
expelled
Anal Canal
■ It has the ability to dilate for it to
● Terminal part of the large intestine and of the entire
accommodate the fecal matter that is
digestive canal
essential for maintaining fecal continence
● Begins at the point where the rectal ampulla narrows at
➔ Peritoneum covers the anterior and lateral
the level of the U-shaped sling formed by the
surfaces of the superior third of the rectum, only
puborectalis
the anterior of the middle third, and none on the
muscle
inferior third due to its nature being subperitoneal
● 2.5-3.5cm long
➔ Peritoneal reflections form the floor of the pouches:
● Ends at the Anal Verge
■ For males: Rectovesical pouch
Anatomical Anal Canal
■ For females: Anterior to the uterus,
● Extends from the dentate or pectinate line to the anal
Vesicouterine pouch, while posterior to the
verge
uterus, rectouterine pouch or Pouch of
Surgical Anal Canal
Douglas
● Begins at the anorectal junction
● Arterial supply: ● Terminates at the anal verge
➔ Proximal part: Superior rectal artery, IMA
➔ Middle and Inferior: Right and left middle rectal Other Parts
arteries, anterior division of the internal iliac arteries Anus
➔ Anorectal junction and anal canal: Inferior rectal ● Is the external outlet of alimentary tract
arteries, from the internal pudendal arteries in the ● Descends posteroinferiorly between anococcygeal
perineum ligament and perineal body
● Surrounded by internal and external anal sphincters
● Venous drainage: Superior, middle, and inferior
Internal Sphincter
rectal veins
● Involuntary sphincter surrounding superior 2/3 of the anal
➔ Superior drains to portal venous system
canal
➔ Middle and inferior drains to the systemic system
● Thickening of the circular muscle layer
● Nerve supply: ● Contraction (tonus) - stimulated and maintained by
➔ Sympathetic nerves: lumbar spinal cord, conveyed sympathetic fibers from the superior rectal (peri-arterial
via lumbar splanchnic nerves and the and hypogastric plexuses; inhibited by parasympathetic
hypogastric/pelvic plexuses, and through the fiber stimulation, both intrinsically in relation to peristalsis
periarterial plexus of the inferior mesenteric and and extrinsically by fibers conveyed by the pelvic
superior rectal arteries splanchnic nerves
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 9 of 18
● Tonically contracted most of the time to prevent leakage Anorectal Sphincter Tone can be assessed during digital rectal
of fluid and flatus exam (DRE) when the patient is asked to squeeze the examining
External Sphincter finger.
● Large voluntary sphincter that forms a broad band on
each side of the inferior 2/3 of the anal canal Embryology: (end of 7th week)
● Supplied mainly by S4 through the inferior rectal nerve Upper ⅔ of the Anal Canal:
● With subcutaneous, superficial, and deep parts; these ● is derived from the endoderm of the hindgut
are zones rather than muscle bellies and are often ● It is lined by simple columnar epithelium
indistinct. ● Supplied by the superior rectal artery ( branches from the
Anorectal Junction inferior mesenteric artery)
● Where the rectum joins the anal canal Lower ⅓ of the Anal Canal:
● Where the rectal ampulla narrows abruptly as it traverses ● Derived from the ectoderm around the proctodeum
pelvic diaphragm ● Supplied by inferior rectal arteries ( branches from the
● Indicated by superior ends of anal columns internal pudendal arteries)
Anal Columns of Morgagni ● Lined by stratified squamous epithelium
● infolding of the mucosa
● Acts as cushion upon defecation
● Series of longitudinal ridges found at the superior half of IV.ARTERIAL BLOOD SUPPLY
the mucous membrane NOTE: All underlined arteries are the ones that Dr. Bautista actually
● Contains terminal branches of superior rectal artery and mentioned in class; the others weren’t, but for the sake of completeness,
we also put it here.
vein
● Contains vascular structures of hemorrhoidal vessels Table 12. Summary
Anal valves
Origin Arterial Supply Part it supplies
● Found at the inferior ends of the column
● Join the inferior ends of anal columns
Anal crypts DUODENUM
● Depressions superior to anal valves
● Secretions of the perianal glands are emptied Celiac 1. gastroduodenal a., and its part proximal to the
Anal sinuses trunk branch, entry of the bile duct
● Exude mucus upon compression that aids in defecation 2. superior into the descending
● Small recess superior to – valves pancreaticoduodenal a. part of the duodenum
Anorectal Ring
● Marks the junction between rectum and anal canal SMA inferior pancreaticoduodenal part distal to the entry
● Formed by joining of puborectalis muscle, Deep external a. of the bile duct (2nd,
sphincter, Conjoined longitudinal muscle, highest part of
the internal sphincter 3rd, and 4th parts)
Perianal glands
● Provide lubrication Pancreaticoduodenal arteries —> supply both the duodenum
● Oil secretion during defecation and pancreas
Perianal abscess
● Formed when there is inflammation of perianal glands JEJUNUM and ILEUM
Levator Ani Muscle
● Start of surgical anal canal SMA 1. Jejunal a. jejunum and ileum,
● 5 cm from the anal verge 2. Ileal a. respectively
● A part of the pelvic diaphragm
Puborectalis These arteries unite to form loops or arches called a rterial
● U - shaped, medial most located levator ani Muscle
arcades, which gives rise to straight arteries called the vasa
● Pulls anorectal junction anteriorly, forming the anorectal
angle recta.
TRANSVERSE COLON*
Figure 2.. Lateral view of puborectalis muscle
SMA 1. Middle colic a. 1. proximal ⅔
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 10 of 18
2. Left colic a. 2. distal ⅓ Doc said to remember these three branches also because it’s
easy to ask in exams:
DESCENDING and SIGMOID COLON* ● Right & Left Inferior Phrenic Arteries – will go to the esophagus
● Superior Phrenic Arteries – will also supply the lower part of the
IMA 1. left colic a. both arteries supply esophagus
2. sigmoid a. the descending and
sigmoid colon
*The structures of the colon may also receive blood flow from
other arteries in the Marginal Artery of Drummond.
RECTUM
A. CELIAC TRUNK
“I will not expect you to know all the names of the structures kasi,
it’s immaterial, even to us, surgeons; it’s not really that important.
You get the main structures, you’re fine.” – Dr. Baustista
● Supplies the abdominal part of the foregut (distal 1/3 of Figure 21. Celiac Trunk and its branches
esophagus, stomach, 1st & 2nd parts of duodenum,
B. SUPERIOR MESENTERIC ARTERY
pancreas, spleen, liver, biliary system)
● Mainly supplies the midgut
● Arises from abdominal aorta (at level of aortic hiatus)
● Arises from abdominal aorta (at L1 level)
Major Branches - Found along the inferior border of the pancreas,
● Left gastric artery – supplies: lesser curvature of within the folds of the mesentery proper
stomach & distal (abdominal) esophagus Main Branches of SMA
→ Esophageal branch ● Ileocolic Artery – supplies: cecum, ileocecal junction,
● Splenic artery – supplies: spleen, greater curvature & and (to an extent) ascending colon
posterior body of stomach, pancreas → Terminal branch of SMA
→ Posterior gastric a. – supplies: posterior wall & → Anastomoses with right colic a.
fundus of stomach → Divides into ileal and colic branches
→ Left gastroepiploic (gastro-omental) a. – supplies: ● Right Colic Artery – supplies: ascending colon & right
left side of greater curvature of stomach colic flexure
→ Short gastric a. – supplies: fundus of stomach ● Middle Colic Artery – supplies: proximal 2/3 of
● Hepatic Artery transverse colon
→ Common Hepatic a. → Last branch in terms of chronology
▪ Gastroduodenal a. – supplies: stomach, ● Inferior pancreaticoduodenal artery – supplies: 2nd,
pancreas, 1st part of duodenum, distal part of 3rd, and 4th parts of the duodenum (distal to entry of bile
bile duct duct)
− Superior pancreaticoduodenal a. – ● Jejunal & Ileal arteries – supplies jejunum and ileum
supplies: head of pancreas & proximal
duodenum
− Right gastroepiploic a. – right side of
greater curvature of stomach
▪ Right gastric a. – supplies: right portion of
lesser curvature of stomach
→ Hepatic artery proper
▪ Right hepatic a.
▪ Left hepatic a.
▪ Cystic a.
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 11 of 18
Figure 23. Inferior Mesenteric Artery
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 12 of 18
Figure 24. Inferior Mesenteric Artery and its branches
E. RECTUM
● Superior Rectal Artery (from IMA)
→ supplies are above the surgical anal canal
→ Supplies: area superior to pectinate line, superior
muscles, and perianal skin
● Middle Rectal Artery (direct branch of internal iliac
artery)
→ Has right and left branches
→ Supply the area above the levator ani muscle
→ Supplies: middle and inferior parts of rectum
● Inferior Rectal Artery (from internal pudendal artery, a
branch of the internal iliac artery)
→ Supply the area below the levator ani muscle
→ Supplies: anorectal junction and anal canal
→ Contributes to renal vasculature, making it a
contributor of hemorrhoids
● Occasionally, you will also find the Median Sacral Artery Figure 25. Arterial Supply, Rectum
(direct branch of Aorta)
→ Lies along the curvature of the sacrum just before the
bifurcation of the common iliac artery
→ It will send down an artery to the posterior part of the
rectum
“Does this mean walang mesentery ang rectum?”
● No. “Along the sacrum, the arteries, veins, and
lymphatics will all be encased in a mesentery-like
structure, which you can actually pull off from the
sacrum. There will be a potential plane that you can
actually separate in the live individuals. Madali siyang
tanggalin. You just have to know where. That’s why when
we do complete rectal incision because of a cancer, we
have to remove even that mesentery because all of the
lymphatics are there.”
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 13 of 18
V. VENOUS DRAINAGE
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 14 of 18
Tributaries of the Splenic Vein Superior rectal vein
● Inferior mesenteric veins - drains left colic, sigmoid, ● drains into the portal circulation via inferior mesenteric
superior rectal and descending colon vein.
➔ Pancreatic vein Middle rectal vein
➔ Left gastroepiploic vein ● drains into the internal iliac vein (systemic drainage)
➔ Short gastric vein Inferior rectal vein
● drains into the internal pudendal vein then internal iliac
vein (systemic drainage)
Middle rectal vein and inferior rectal vein are exceptions
because it drains back to the systemic circulation instead of the
portal circulation.
The median sacral vein (or middle sacral veins) accompanies
the corresponding artery along the front of the sacrum, and
joins to form a single vein, which ends in the left common iliac
vein; sometimes in the angle of junction of the two iliac veins.
The blood in the gut does not go directly into the IVC
because it has to go to the liver first.
rectum is another area where you have venous collaterals
meaning part of the GIT drain onto these vessels.
In cases of portal hypertension, the blood flow to the portal
Figure 29. Veins of the Stomach, Duodenum, Pancreas and
vein is not good, the blood that needs to return to the systemic
Spleen
circulation drains into the rectal veins. This makes the unions
of the superior with the middle and inferior rectal veins
Veins Directly Draining into the Portal Vein
important portal- systemic anastomoses.
● Cystic vein – drains the gallbladder
● Superior pancreaticoduodenal
● Left and right gastric veins C. PORTOSYSTEMIC ANASTOMOSIS
[ANA] 4.04 Group 6: Banaga, Banzon, Baraero, Barrios, Baratang | Editor: Catral 15 of 18
● Portosystemic/ Portocaval anastomosis are accessory A. SMALL INTESTINE
drainages. ● Duodenum
● Done in order to reduce portal hypertension by diverting ➔ derive from the vagus and greater and lesser
blood from the portal venous system to the systemic (abdominopelvic) splanchnic nerves by way of the
venous system celiac and superior mesenteric plexuses.
● In the esophagus, there are venous plexuses that ➔ conveyed to the duodenum via peri-arterial plexuses
anastomose with the esophageal vessels that drains up extending to the pancreaticoduodenal arteries
your thorax into the hemiazygos system. ● Jejunum and Ileum
○ This is why in conditions that cause portal ➔ The SMA and its branches are surrounded by a
hypertension, you will find your esophageal varices periarterial nerve plexus through which the nerves are
or varicosities in your esophageal veins. conducted to the parts of the intestine supplied by this
artery
➔ Sympathetic fibers originate in the T8–T10 segments of
VI. NERVE SUPPLY
the spinal cord, reach the superior mesenteric nerve
plexus through the sympathetic trunks and thoracic
abdominopelvic (greater, lesser, and least) splanchnic
nerves
➔ Presynaptic sympathetic fibers synapse on cell bodies
of postsynaptic sympathetic neurons in the celiac and
superior mesenteric (prevertebral) ganglia
➔ Parasympathetic fibers derived from the posterior vagal
trunks. The presynaptic parasympathetic fibers
synapse with postsynaptic parasympathetic neurons in
the myenteric and submucosal plexuses in the
intestinal wall
➔ Sympathetic stimulation reduces peristaltic and
secretory activity of the intestine and acts as a
vasoconstrictor, reducing or stopping digestion and
making blood (and energy) available for “fleeing or
fighting.”
➔ Parasympathetic stimulation increases peristaltic and
secretory activity of the intestine, restoring the digestion
process following a sympathetic reaction. The small
intestine also has sensory (visceral afferent) fibers. The
intestine is insensitive to most pain stimuli, including
cutting and burning; however, it is sensitive to
distension that is perceived as colic (spasmodic
abdominal pains or “intestinal cramps”).
B. LARGE INTESTINE
● Cecum and Appendix
➔ derives from the sympathetic and parasympathetic
nerves from the superior mesenteric plexus
We only name the main ganglia which are located along the main ➔ Sympathetic nerve fibers originate in the lower thoracic
trunks, and the ones closer to the main trunks
part of the spinal cord, and the parasympathetic nerve
Figure 32. Nerves of Stomach and Duodenum with stomach reflected
fibers derive from the vagus nerves
➔ Afferent nerve fibers from the appendix accompany the
● Sympathetic stimulation comes from the sympathetic
sympathetic nerves to the T10 segment of the spinal
trunk and it causes: Decreased bowel motility, Decreased
cord
bowel secretion, Vasoconstriction (to shunt blood to other
● Colon
parts of the body therefore inhibiting digestion)
➔ Ascending Colon
● Parasympathetic stimulation comes from the vagus nerve
- derived from Superior Mesenteric Plexus
and sacral plexus: Increased bowel motility, Increased bowel
➔ Transverse Colon
secretion, Vasodilation
- derived from Superior Mesenteric Plexus
● All nerves will end up at the main trunks. Major ganglionic
➔ Descending and Sigmoid Colon
areas found at the bases of arterial trunks are the celiac
- sympathetic supply- from the lumbar part of the
plexus, superior and inferior mesenteric plexus
sympathetic trunk via lumbar (abdominopelvic)
● Both the sympathetic and parasympathetic plexuses are
splanchnic nerves, the superior mesenteric
insensitive to pain due to lack of nociceptive receptors and
plexus, and the peri-arterial plexuses following
are sensitive to distention due to the stretch receptors
the inferior mesenteric artery and its branches
● Clinical Correlation: - parasympathetic nerve supply- from the pelvic
➔ Celiac plexus – if a patient has a pancreatic tumor that splanchnic nerves via the inferior hypogastric
is inoperable, the sensory innervations of the celiac (pelvic) plexus and nerves, which ascend
plexus will be ablated with ethyl alcohol instead to retroperitoneally from the plexus, independent of
reduce pain caused by the tumor. the arterial supply to this part of the
gastrointestinal tract
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C, RECTUM ● Jejunum and Ileum
● Sympathetic supply is from the lumbar spinal cord, ➔ Lacteals
conveyed via lumbar splanchnic nerves and the - specialized lymphatic vessels in the intestinal villi
hypogastric/pelvic plexuses, and through the peri-arterial (tiny projections of the mucous membrane) that
plexus of the inferior mesenteric and superior rectal arteries absorb fat; empty their milk-like fluid into the
● Parasympathetic supply is from the S2–S4 spinal cord lymphatic plexus in the walls of jejunum and ileum
level, passing via the pelvic splanchnic nerves and the left - lacteals drain in turn into lymphatic vessels
and right inferior hypogastric plexuses to the rectal (pelvic) between the layers of the mesentery
plexus. - within the mesentery, lymph passes sequentially
➔ Because the rectum is inferior (distal) to the pelvic through three groups of lymph nodes:
pain line, all visceral afferent fibers follow the ● Juxta-intestinal lymph nodes: located close
parasympathetic fibers retrogradely to the S2–S4 to the intestinal wall
spinal sensory ganglia ● Mesenteric lymph nodes: scattered among
the arterial arcades
● Superior central nodes: located along the
proximal part of the SMA
➔ Efferent lymphatic vessels from the mesenteric lymph
nodes drain to the superior mesenteric lymph nodes;
Lymphatic vessels from the terminal ileum follow the
ileal branch of the ileocolic artery to the ileocolic lymph
nodes
VII. LYMPHATICS
● Bowel wall → intramural nodes → juxtaintestinal nodes
(along the border of the bowels) → mesenteric nodes →
superior mesenteric nodes → para-aortic area → lymphatic
trunk → thoracic duct Figure 34. Mesenteric lymph nodes
● Lymphatic vessels follow the arterial vessels and drain into
the lymphatic node roots which include the superior and B. LARGE INTESTINE
inferior mesenteric nodes and celiac nodes forming the
● Cecum and Appendix
mesenteric trunk
➔ passes to lymph nodes in the meso-appendix and to
➔ Celiac Nodes – drain the gastric and duodenal nodes
the ileocolic lymph nodes
➔ Superior Mesenteric Nodes – drains the cecum,
➔ Efferent lymphatic vessels pass to the superior
appendix, ascending colon and middle colic lymph nodes
mesenteric lymph nodes
of transverse colon
➔ Inferior Mesenteric Nodes – drains the epicolic and ● Colon
paracolic nodes of transverse colon ➔ Ascending Colon
- passes first to epicolic and paracolic lymph nodes
A. SMALL INTESTINE
→ ileocolic and intermediate right colic lymph
● Duodenum
nodes→ superior mesenteric lymph nodes
➔ lymphatic vessels follow the arteries.
➔ Transverse Colon
➔ Anterior lymphatic vessels→ pancreaticoduodenal lymph
- middle colic lymph nodes→ superior mesenteric
nodes→ pyloric lymph nodes
lymph nodes
➔ Posterior lymphatic vessels→ superior mesenteric lymph
➔ Descending Colon and Sigmoid Colon
nodes.
- conducted through vessels passing to the epicolic
➔ both lymphatic vessels drain into Efferent lymphatic
and paracolic nodes→ intermediate colic lymph
vessels(from duodenal lymph nodes)→ celiac lymph
nodes along the → inferior mesenteric lymph
nodes
nodes. However, lymph from the left colic flexure
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may also drain to the superior mesenteric lymph
- Stomach - Appendix - Rectum
nodes - Liver - Ascending Colon - Upper anal canal
- Gallbladder & Bile - Proximal ⅔ of - Urogenital sinus
ducts transverse colon
- Pancreas
- Upper duodenum
C. RECTUM
● Rectum and Anal Canal
➔ Superior to the pectinate line, the lymphatic
vessels→ internal iliac lymph nodes→ common iliac
and lumbar lymph nodes
➔ Inferior to the pectinate line, the lymphatic vessels
superficially→ superficial inguinal lymph nodes, as
does most of the perineum
VIII. REFERENCES
● https://upload.wikimedia.org/wikipedia/commons/thumb/3/31/Layers_of_the_
GI_Tract_english.svg/1200px-Layers_of_the_GI_Tract_english.svg.png
● The gastrointestinal system. Retrieved from:
https://i.pinimg.com/originals/e3/c6/e8/e3c6e8cf6b6975ff2102324c82054539.j
pg
● https://image.slidesharecdn.com/163ch16lecturepresentation-130815125309-
phpapp01/95/163-ch-16lecturepresentation-43-638.jpg?cb=1376617245
● https://www.sciencedirect.com/topics/medicine-and-dentistry/anal-canal
● http://medcell.med.yale.edu/histology/gi_tract_lab/meissners_plexus.php
● https://web.duke.edu/anatomy/embryology/gi/gi.html
IX. APPENDIX
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