Gross anatomy

Overview

 Function:
o Digests food via acid, enzymes, and commensals
o Absorbs nutrients and water
o Waste products are excreted in feces
 Includes:
o Oral cavity
o Esophagus
o Stomach
o Small intestine
o Large intestine
o Liver
o Gallbladder
o Pancreas
 The gastrointestinal tract can also be divided according to its major blood-supplying
arteries:
o Foregut → supplied by the celiac trunk
o Midgut → supplied by the superior mesenteric artery (SMA)
o Hindgut → supplied by the inferior mesenteric artery (IMA)

Peritoneum and retroperitoneum

Layers of peritoneum

 Parietal peritoneum

 Lines the abdominal cavity

 Covers retroperitoneal organs on the ventral surface
 Innervated by the phrenic nerve, lower intercostal and subcostal nerves, ilioinguinal
nerves, and iliohypogastric nerves

 Visceral peritoneum

 Covers the surface of intraperitoneal organs

  Mesentery: a contiguous double-layered fold of visceral peritoneum that contains
intestinal vessels, lymphatics, and nerves and anchors the bowel to the posterior
abdominal wall
o It is formed by the visceral peritoneum folding onto itself in two layers
o The mesentery of the small intestine is known as mesentery
o The mesentery of other organs are named according to the organ they attach to
(e.g., mesocolon, transverse mesocolon, mesoappendix)
o The ascending colon, descending colon, rectum, and anal canal do not have a
mesentery as they are retroperitoneal organs


o

o Peritoneal ligaments are mesenteric folds that connect organs to each other or to
the abdominal wall
o The omentum is the visceral peritoneum extending from the stomach and
proximal duodenum to other abdominal organs
 Greater omentum
 Extends from the greater curvature; covers the intestines
 Contains
 Gastrosplenic ligament → connects the stomach and
spleen; contains the short gastric arteries
 Gastrophrenic ligament → connects the stomach and
diaphragm
 Gastrocolic ligament → connects the stomach with the
transverse colon; contains the gastroepiploic arteries
 Lesser omentum
 Extends from the lesser curvature to liver
 Contains
 Hepatogastric ligament → connects stomach to liver;
contains gastric arteries
 Hepatoduodenal ligament → contains common bile duct,
portal vein, hepatic artery proper

Peritoneal cavity

 Space (potential) between the parietal and visceral peritoneum

 Divided into
o Greater sac: the main peritoneal cavity
 Extends from the diaphragm to the floor of the pelvis; envelops all
intraperitoneal organs
 o Lesser sac (omental bursa): An intraperitoneal recess that lies posterior to the
stomach and lesser omentum
 Boundaries:
 Anterior: lesser omentum (gastrohepatic ligament and
hepatoduodenal ligament), posterior wall of the stomach,
gastrocolic ligament
 Posterior: Pancreas, left adrenal gland, left kidney
 Inferior: Transverse mesocolon
 Left lateral: splenic hilum, gastrosplenic ligament, splenorenal
ligament
 Right lateral: communicates with greater sac through the epiploic
foramen
 Significance:
 Entry into omental bursa is required for pancreatic surgeries and to
drain lesser sac collections


o

 Common site of free fluid collection in patients with intra-
abdominal bleeding, acute pancreatitis

Epiploic foramen (foramen of Winslow)

 Connects the lesser and greater sac

 Anatomy
o Superior: caudate lobe of the liver
o Inferior: first part of the duodenum
o Anterior: hepatoduodenal ligament and the hepatic portal vein
o Posterior: inferior vena cava

Organs of the peritoneal cavity

 Intraperitoneal organs
o Covered by the visceral peritoneum
o Suspended by mesentery
 Retroperitoneal organs
o Covered by parietal peritoneum
o Not suspended by mesentery
 Secondary retroperitoneal organs
o Organs suspended by mesentery during the embryonic period
o Fusion of the visceral and parietal peritoneum fixes organs to the abdominal wall.
Intraperitoneal organs Secondary retroperitoneal organs Retroperitoneal organs
Stomach Duodenum (2nd and 3rd part) Kidneys
Duodenum (1st part) Ascending colon Adrenal glands
Jejunum Descending colon Ureters
Ileum Upper rectum Aorta
Cecum/ appendix Pancreas (head, neck, body) Inferior vena cava
Transverse colon Lower rectum
Sigmoid colon Anal canal
Liver and gallbladder
Spleen
Pancreas (tail)
Bladder
Genital organs

Vasculature
The abdominal aorta is the direct continuation of the descending thoracic aorta and gives rise to
all the vessels that supply the organs of the abdominal cavity.

Celiac trunk

 Anterior branch of the abdominal aorta that arises at the level of the 12th thoracic vertebra
(T12)
 Left gastric artery

 Esophageal branch to the distal esophagus (abdominal)

 Lesser curvature of the stomach

 Splenic artery


o Retroperitoneal until it enters the splenorenal ligament to reach the splenic hilum
o Branches to the spleen
o Branches to the neck, body, and tail of the pancreas
o Left gastroepiploic artery (supplies greater curvature of the stomach)
o Short gastric arteries (supply the fundus of the stomach)
 Common hepatic artery
o Proper hepatic artery
 Travels in the hepatoduodenal ligament
 Branches into the right and left hepatic arteries, and right gastric artery
 Cystic artery branches from the right hepatic artery
o Gastroduodenal artery
  Posterior to the first part of the duodenum
 Right gastroepiploic artery (gastro-omental)
 Superior pancreaticoduodenal artery
 Supplies the head of the pancreas
 Anastomosis with the inferior pancreaticoduodenal artery

Superior mesentery artery (SMA)

 Anterior branch of the abdominal aorta that arises at the level of the first lumbar vertebra
(L1)
 SMA passes anterior to the third segment of the duodenum
 Inferior pancreaticoduodenal artery
o Anastomosis with the superior pancreaticoduodenal artery
o Supplies the head of the pancreas
 Intestinal arteries (form vascular arcades and vasa rectae): supply the jejunum and ileum
 Ileocolic artery: supplies the distal ileum, the cecum, and appendix
 Right colic artery: supplies the ascending colon
 Middle colic artery: supplies the proximal two-thirds of the transverse colon

Inferior mesentery artery (IMA)

 Anterior branch of the abdominal aorta that arises at the level of the 3rd lumbar vertebra
(L3)
 Left colic artery: supplies the distal third of the transverse colon and descending colon
 Sigmoid artery: supplies the sigmoid colon
 Superior rectal artery: supplies the superior part of the rectum and anal canal

Colonic anastomosis

 Marginal artery (of Drummond): anastomosis between the superior and inferior
mesentery artery. It is a continuous artery that travels along the mesenteric side of the
colon.
 Central anastomotic mesenteric artery (arc of Riolan): anastomosis between the middle
colic artery and the left colic artery
 Cannon point: area where the innervation of the colon changes from the vagus nerve to
the pelvic splanchnic nerves
o Proximal: innervation mediated by the vagus nerve
o Distal: innervation mediated by pelvic splanchnic nerves
The splenic flexure and the rectosigmoid junction are watershed areas, which are most
vulnerable to bowel ischemia.

Venous drainage of the GI tract

 Inferior vena cava (systemic)

o Formed by anastomosis of the two common iliac veins (at the L5 level)
o Passes through the vena cava opening of the diaphragm (at the T8 level)
o Only drains the lower rectum and anal canal (from the GI tract)
 Portal system
o Drains blood from abdominal viscera (above the pectinate line) → to the liver
(hepatic portal vein) → liver sinusoids → hepatic veins → inferior vena cava →
right atrium
o Hepatic portal vein
 Formed by anastomosis of the superior mesentery vein and the splenic
vein (posterior to the neck of the pancreas)
 The inferior mesentery vein drains into the splenic vein.

Portocaval anastomoses

 Esophageal
o Portal circulation: left gastric vein
o Systemic circulation: thoracic esophageal veins (drain into the azygos system)
o Clinical significance: esophageal varices (in portal hypertension)
 Paraumbilical
o Portal circulation: paraumbilical veins
o Systemic circulation: veins in the anterior abdominal wall
o Clinical significance: caput medusae (in portal hypertension)
 Rectal
o Portal circulation: superior rectal veins (from the inferior mesentery vein)
o Systemic circulation: inferior rectal veins (from the internal iliac vein)
o Clinical significance: internal hemorrhoids (in portal hypertension)
 Other veins that form part of the portal system (can be involved in portal hypertension)
o Drain into the splenic vein: short gastrics (results in gastric varices), left
gastroepiploic, pancreatic, and inferior mesenteric vein (drain the superior rectal
and left colic veins)
o Drain into the superior mesenteric vein: right gastroepiploic, jejunal, ileal,
pancreaticoduodenal, right colic, middle colic, ileocolic (appendicular veins)
o Drain into the hepatic portal vein: left gastric, esophageal, right gastric,
paraumbilical, and cystic veins
References:[1]

Microscopic anatomy
Overview

The gastrointestinal tract is composed of four main layers. Although variations exist between
each part of the gut, the general structure remains similar. The 4 layers are as follow:

 Mucosa
o Epithelium: contains glands that aid in digestion
o Lamina propria: attachment site for epithelial cells
o Muscularis mucosae
 Submucosa: contains the Meissner plexus (submucous)
o Provides parasympathetic innervation to glands
o Responsible for the secretomotor activity of the GIT
 Muscularis externa: contains the Auerbach plexus (myenteric)
o Contains ganglion cells
 Ganglion cells are absent in Hirschsprung disease
 Due to failure of neural crest cells to migrate caudally
 Located between the longitudinal and circular muscular layers
 Provide sympathetic and parasympathetic innervation
 Provide motor innervation to the smooth muscle of the GIT
 Serosa or adventitia: composed of the visceral peritoneum

Regional characteristics

Mucosal cells and Notable

Structure Epithelium Functions
glands features
Oral  Stratified   Lubrication of
cavity squamous food
epithelium  Antibacterial
protection
 Mucosal cells and Notable
Structure Epithelium Functions
glands features
 IgA secretion

 Transmits the
bolus of food
from the pharynx
to the stomach
 Skeletal
 The lower
 Nonkeratiniz muscle in
esophageal
ed stratified upper
sphincter
squamous third
Esophagu  prevents
epithelium  Smooth
s regurgitation of
 Transition muscle in
food from the
zone lower
stomach back
third
into the
esophagus
(failure to do so
causes GERD).

 Secretion
 Body and o Hydrochl
fundus: oric (HCl)
shallow
 Mucus cells acid
pits, deep
 Simple  Chief cells o Pepsinoge
glands
columnar  Parietal cells n
Stomach  Pylorus:
epithelium  Enteroendocr o Intrinsic
deep pits,
ine (EE) cells factor
shallow,
o Peptide
branched
glands hormones
o Gastrin

 Simple  Brunner
 Villi
columnar glands
 Plicae
epithelium  Goblet cells
Duodenu  Crypts of  Brunner glands
with villi  Paneth cells
m Lieberkü
and  Enteroendocr
hn
microvilli ine (EE) cells


o Secret
e
bicarb
onate,
amyla
 se,
maltas
e
o Brunn
er
gland
hyper
plasia
occurs
aroun
da
duode
nal
ulcer
 Goblet cells:
secrete mucin
 Paneth cells:
secrete
lysozyme,
defensins, and
TNF-α
 Enteroendocri
ne (EE) cells:
secrete
gastrin,
cholecystokin
in (CCK),
gastric
inhibitory
peptide (GIP),
secretin,
serotonin, and
substance P

 Simpl
e  Villi
colum  Goblet  Secretions
 Plicae o Lysozym
nar cells
circular
epithel  Paneth e
es
ium cells o Cholecyst
Jejunum  Crypts
with  Enteroendo okinin
of
villi crine (EE) (CCK)
Lieber
and cells o Secretin
kühn
micro
villi
  Simpl
e
colum
nar
 Peyer's
epithel
patches
ium
Ileum  Goblet
with
cells
villi
and
micro
villi

 M cells
 Endocyt
found
osis of
over
antigens
lympha
and
tic
transport
nodule
to
s and
lymphoi
Peyer's
d tissue
patches

 Active
transport
of Na+
 Simple  No villi and
columna  Crypts passive
r  of reabsorpt
Colon
epitheliu Lieberk ion of
m ühn water
from the
intestinal
lumen

Rectum and  Simple  Pectinate line divides  Contain  Voluntar

anal canal columna the anal canal s inner y and
r o Above circular involunta
epitheliu  Develo and ry
m with pment: outer control
goblet endoder circular of
cells m muscle defecatio
 Epitheli layers n
um:
column
ar
epitheli
 um
 Blood
supply:
superior
rectal
artery
 Innervat
ion:
inferior
hypogas
tric
plexus
 Lympha
tics:
internal
iliac
nodes
o Below
 Develo
pment:
ectoder
m
 Epitheli
um
 Blood
supply:
middle
and
inferior
rectal
arteries
 Innervat
ion:
inferior
rectal
nerves
 Lympha
tics:
superfic
ial
inguinal
nodes

Intestinal stem cells are located in the crypts of Lieberkuhn. These divide to replace all of the
cells of the intestinal epithelium every 5 days.
Gastrointestinal function and regulators
Molecule Source Action Regulation
 ↑ Contraction
of the
gallbladder
 ↑ Secretion of  Postprandial: ↑
 I cells pancreatic fatty acids and
o Duodenum enzymes amino acids
Cholecystokinin
o Jejunum  ↑ Relaxation of entering small
the sphincter of intestine
Oddi
 ↓ Gastric
emptying

 ↑ Secretion of
bile acids
 ↑ Pancreatic  ↑ Gastric acid
 S cells: duodenum secretion of and fatty acids in
Secretin
bicarbonate the duodenum
 ↓ Secretion of
gastric acid

 ↑ Insulin
 K cells  ↑ Fatty acids
secretion
Gastric inhibitory o Duodenum  ↑ Oral glucose
 ↓ Secretion of
polypeptide (GIP) o Jejunum  ↑ Amino acids
gastric acid

 ↑ Intestinal
motility
 Small intestine (migratory  ↑ During fasting
Motilin
motor
complexes)

Vasoactive  Small intestine  ↑ Secretion of  ↑ Distention of

intestinal peptide  Gallbladder water and the stomach
(VIP) electrolytes  ↑ Vagal
 Molecule Source Action Regulation
 Parasympathetic stimulation
 ↑ Relaxation of
neurons in  ↓ Sympathetic
sphincters
sphincters activity

 ↑ Relaxation of
smooth muscle

Nitric oxide (NO) and sphincters
(e.g., LES)

 VIPoma
o Tumor of pancreatic cells (non-alpha, non-beta cells)
o Secretes excess VIP
o Clinical features
 WDHA syndrome
 Watery diarrhea
 Hypokalemia
 Achlorhydria

Embryology
Embryology of the gastrointestinal tract

The gastrointestinal tract (GIT) is derived from the primitive gut tube, which is divided into
foregut, midgut, and hindgut. The epithelium arises from endoderm, which also gives rise to the
parenchyma of the liver and pancreas. Although the spleen is in the peritoneal cavity, it is
derived from mesoderm rather than endoderm.

 Foregut
o 4th week
o Derived from the respiratory diverticulum.
o The tracheopharyngeal septum divides the trachea and the esophagus.
o Forms the esophagus, stomach, duodenum (1st and 2nd part), liver, pancreas,
biliary apparatus, and gallbladder
o Blood supply from the celiac artery
 Midgut
o 4th week
o Starts below the 2nd portion of the duodenum (3rd and 4th part)
 o Forms the distal part of the duodenum, jejunum, ileum, cecum, appendix,
ascending colon, and proximal transverse colon
o Blood supply from the superior mesentery artery
o Rotates 270° counterclockwise around the superior mesenteric artery (SMA)
outside of abdominal cavity in the 10th week
 Hindgut
o 4th week
o Connects with the allantois ventrally and the cloaca caudally
o Forms the distal transverse colon; up to the splenic flexure, descending colon,
sigmoid colon, rectum, and the anal canal above the pectinate line
o Blood supply from the inferior mesentery artery
 The gut is composed of three germ layers:
o Endoderm: forms the epithelial lining
o Mesoderm: forms smooth muscle layer
o Ectoderm: includes enteric nervous system

The midgut herniates through the umbilical ring during the 6th week and returns to the abdominal
cavity on the 10th week.

Clinical significance
Oral cavity

 Diseases of the salivary glands

Esophagus

 Achalasia
 Boerhaave syndrome
 Mallory-Weiss syndrome
 Plummer-Vinson syndrome
 Eosinophilic esophagitis
 Gastroesophageal reflux disease
 Barrett's esophagus
 Esophageal cancer
 Esophageal diverticula
 Esophageal atresia
 Esophageal varices

Stomach

 Hypertrophic pyloric stenosis

  Hiatal hernia
 Congenital diaphragmatic hernias
 Atrophic gastritis
 Peptic ulcer disease (PUD)
 Vitamin B12 deficiency (Pernicious anemia)
 Gastrinoma (Zollinger-Ellison syndrome)
 Ménétrier disease
 Gastric cancer
 MALT lymphoma

Small intestine

 Celiac disease
 Lactose intolerance
 Tropical sprue
 Whipple disease
 Duodenal atresia and stenosis
 Volvulus and intestinal malrotation
 Malabsorption
 Superior mesenteric artery syndrome

Large intestine

 Irritable bowel syndrome

 Crohn disease
 Ulcerative colitis
 Diverticular disease
 Acute appendicitis
 Meckel diverticulum
 Hirschsprung disease
 Megacolon
 Intussusception
 Intestinal ischemia
 Bowel obstruction
 Angiodysplasia
 Meconium ileus
 Necrotizing enterocolitis
 Colorectal cancer

Liver, gallbladder, and pancreas

 Portal hypertension
 Cirrhosis
 Ascites
 Spontaneous bacterial peritonitis
 Alcoholic liver disease
 Hepatic encephalopathy
 Hepatocellular carcinoma
 Benign liver tumors and hepatic cysts
 Budd-Chiari syndrome
 α1-antitrypsin deficiency
 Jaundice and cholestasis
 Inherited hyperbilirubinemia
 Neonatal jaundice
 Wilson disease
 Hemochromatosis
 Primary sclerosing cholangitis
 Primary biliary cholangitis
 Cholelithiasis and cholecystitis
 Acute cholangitis
 Acute pancreatitis
 Chronic pancreatitis
 Pancreatic cancer