GIT DEVELOPMENT- PART 2

Objectives:
To understand and list the derivatives of midgut and hindgut and the events involved in their formation. To understand the developmental errors occurring during the process.

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Midgut:
Part lying caudal to the liver bud and that extends up to the junction of right 2/3 and left 1/3 of adult transverse colon In the adult the commencement is distal to the entrance of bile duct into the duodenum. At the 5th week it is suspended from the dorsal body wall by a short mesentery. Communicates with the yolk sac through vitelline duct. Derivatives of midgut are, - Duodenum distal to the opening of the bile duct. - Jejunum and ileum. - Cecum, appendix, ascending colon and right 2/3 of the transverse colon. Supplied by the superior mesenteric artery.
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 Elongation of midgut results in the formation of primary intestinal loop. Superior mesenteric artery forms the axis of this loop. Primary loop has 2 parts, -Cephalic limb (pre-arterial) which develops in to distal part of duodenum, jejunum & part of ileum. -Caudal limb (post-arterial) which develops into lower part of ileum, appendix, cecum, ascending colon & right (proximal) 2/3 of transverse colon. At the apex the loop remains in open connection with yolk sac through narrow vitelline duct.

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Caudal limb of primary intestinal loop

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Physiological umbilical herniation: Projection of intestinal loop into the extra embryonic cavity in the umbilical cord. It occurs at the 6th week due to, Rapid elongation of primary intestinal loop particularly the cephalic limb. Rapid growth and expansion of liver. Lack of room in the abdominal cavity to accommodate all the intestinal loops.

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Rotation of the midgut:

Concomitant with growth in length and physiological herniation there is rotation of primary intestinal loop around an axis formed by superior mesenteric artery. When viewed from front there is counterclockwise rotation of total 270 degrees on completion. First 90 rotation occur at the herniation, which brings the cephalic limb of the loop to the right and the caudal limb of the loop to the left. The loop lies out side the body cavity.
6th week 8th week
Cephalic limbto right

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Caudal limb to left

 Remaining 180 rotation occur during the return (10th week) of herniated intestinal loop back into the abdominal cavity. Even during rotation elongation of intestinal loop continues particularly of the cephalic limb which forms the coils of jejunum and ileum. Caudal limb elongates slightly.

10th week

11th week

Cecal bud Cecum

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Cephalic limb elongates forming coils of jejunum & ileum & also being retracted back to abdominal cavity.

Return of midgut loop to Abdominal cavity:

During the 10th week herniated intestinal loop begins to return to the abdominal cavity due to, Expansion of the abdominal cavity with the growth of embryo. Reduced growth of liver. Regression of mesonephric kidney. Proximal portion of jejunum (cephalic limb) returns first and comes to lie on the left side of abdominal cavity. Remaining coils of the cephalic limb (distal part of jejunum & ileum) returns gradually and occupies more towards the right side. Cecal bud which is a conical dilation of caudal limb of primary intestinal loop is the last part of the gut to return to abdominal cavity and temporarily occupies the right upper quadrant just below the right lobe of liver. Later the cecal bud descends to its adult position of right iliac fossa thus pulling the caudal limb downwards forming the ascending colon and hepatic flexure of colon. Remaining part of the caudal limb forms the right 2/3 of transverse colon.
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Cecum and appendix: Primordium of cecum and appendix is cecal bud. Appears at the 6th week as an elevation on the anti-mesenteric border of caudal limb of primary intestinal loop. Distal end (apex) of cecal bud forms a narrow diverticulum called appendix which increases rapidly in length. After birth the lateral wall of the cecum grows more than the medial wall so that the appendix comes to open on its medial side. Position of appendix varies frequently being posterior to cecum (retrocecal) or colon (retrocolic).

Caudal limb

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Fixation of the intestine:

Attachment of dorsal mesentery to the posterior abdominal wall is modified as loops of intestine return to the abdominal cavity. As the intestine enlarge, lengthen and assume their final position, their mesenteries are pressed against the peritoneum of posterior abdominal wall and get fused. Enlarged colon presses the duodenum and pancreas against posterior abdominal wall that causes absorption of duodenal mesentery. Hence except for the first part the duodenum has no mesentery and lies retroperitoneally. Consequently, the ascending and descending colons are permanently anchored in a retro-peritoneal position. Transverse mesocolon fuses with the posterior wall of greater omentum and maintains its mobility. The line of attachment extends from hepatic flexure to splenic flexure of colon. Jejunoileal loop retain their mesentery with a new line of attachment extending from duodenojejunal junction to the ileocecal junction. Appendix, lower end of cecum and sigmoid colon also retain their mesenteries.
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Hindgut:
Part extending from the left 1/3 of transverse colon to the cloacal membrane. Derivatives of hindgut in GIT are, Left 1/3 of transverse colon. Descending and sigmoid colon. Rectum and superior part of anal canal. Derivatives of hindgut in other system are, Internal lining of urinary bladder and urethra. Supplied by inferior mesenteric artery.

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 Cloaca is an expanded endoderm lined terminal part of the hindgut. It is in contact with surface ectoderm at the cloacal membrane. Cloacal membrane is composed of endoderm of cloaca and ectoderm of proctodeum or anal pit. The cloaca receives the allantois ventrally.
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cloaca

 Cloaca is divided into dorsal and ventral parts by a urorectal septum (layer of mesoderm) that develops in angle between allantois & hindgut. Dorsal part forms the rectum and upper part of anal canal. Ventral part forms the urogenital sinus. Urorectal septum grows towards the cloacal membrane and fuses with it by the 7th week, dividing it into dorsal anal membrane and ventral urogenital membrane. Between the two membranes, the tip of urorectal septum forms the perineal body.

proctodeum

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 Mesenchymal proliferation produces elevation of the surface ectoderm around the anal membrane. Anal membrane ruptures at the end of 8th week creating the anal opening. Anal canal: Superior 2/3(endoderm)- from hindgut (dorsal part of cloaca). Inferior 1/3(ectoderm)- from proctodeum. The junction of the two is indicated by the pectinate line. This line indicate the former site of anal membrane.

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Developmental Anomalies:
Congenital Omphalocele: Herniation of abdominal viscera through an enlarged umbilical ring. May include liver, small & large intestine, stomach, spleen and gallbladder. Covered by amnion. Umbilical Hernia: Herniation through an imperfectly closed umbilicus. Usually greater omentum & part of small intestine. Covered by subcutaneous tissue and skin.
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 Gastroschisis: Herniation of abdominal contents through the body wall directly into the amniotic cavity. Occurs lateral to the umbilicus, usually on the right side. Viscera not covered by peritoneum or amnion.

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Vitelline Duct Abnormality:

Meckels diverticulum: Occurs in about 2% of children Lies about 2 feet from ileo-cecal valve. Contain 2 types of ectopic mucosa- gastric or pancreatic Length is about 2 inches. Vitelline Cyst. Vitelline Fistula.
Meckels diverticulum

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Defects In Gut Rotation: Malrotation: Usual 270 counterclockwise rotation is not complete. Occasionally may rotate only 90. Colon & cecum are first to return to abdomen & lie on the left side. Reversed Rotation: Primary intestinal loop rotates 90 clockwise. Transverse colon lies behind the duodenum & superior mesenteric artery. May result in volvulus & compromise of blood supply resulting in gangrene of the intestine.
Malrotation Reversed Rotation

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 Subhepatic cecum & appendix: Results due to the anomalies of midgut rotation. Mobile cecum: Results from incomplete fixation of ascending colon due to the persistence of portion of mesocolon. Internal hernia: Portion of small intestine passes into the mesentery and entrapped in it. Stenosis and Atresia of the intestine: Results due to failure of formation of adequate number of vacuoles during recanalization.
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Abnormalities Of Hindgut:
Congenital megacolon or Hirschsprungs disease: Due to absence of parasympathetic ganglia in the bowel wall.

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 Imperforate anus: No anal opening because thin layer of anal membrane separates the anal canal from the exterior. Results due to failure of rupture of anal membrane at the end of 8th week.

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 Anorectal atresia & fistula: Result of incomplete separation of the cloaca by the urorectal septum. Rectourethral fistula or Urorectal fistula. Rectovaginal fistula.

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Summary: The gut tube develops from endoderm, including in part the yolk sac. Ectodermal derivatives of the gut are the stomodeum and the proctodeum. The boundaries between the three sections of the gut are indicated by the margins of distribution of the primary arteries of the three sections The tube forms by extensive elongation resulting in folding and rotation. The tube develops through a stage in which the lumen is obliterated and subsequently recanalized. Where layers of peritoneum become applied to one another due to folding, the deep layers are reabsorbed. Abnormalities of the system are related to the major events of 14 August 2013 elongation, recanalization, rotation and septation.