Clinically, the anterolateral abdominal wall has been divided into 9 regions created by 2

horizontal and 2 vertical lines

The 2 horizontal lines:

1. The upper line is placed at the level of the 9th costal cartilages
2. Lower at the top of the iliac crests.

The 2 vertical lines:

1. Extend upward from the middle of the inguinal (Poupart's) ligament to the cartilage of the
8th rib.

The 9 regions thus constructed are:

3 upper regions-left hypochondriac, epigastric and right hypochondriac

3 middle regions-left lumbar, umbilical and right lumbar

3 lower regions-left iliac, hypogastric and right iliac.

Identifying the regions in this way aids in the description and the location of the viscera
and the abdominal masses.

The small intestine (small bowel) lies between the stomach and the large intestine (large
bowel) and its major divisions are: duodenum, jejunum, and ileum. The small intestine is so
called because its lumen diameter is smaller than that of the large intestine, although it is longer
in length than the large intestine.

The small intestine (duodenum, jejunum and ileum) has an average length of 22 feet, the
extremes being 30 and 15 feet. The division into jejunum and ileum is arbitrary, since there is no
one point at which it may be said that the jejunum ends and the ileum begins.

The lumen of the small intestine is widest in the duodenum and narrowest near the
ileocecal valve; for this reason a foreign body tends to become impacted in the region of the
latter (and may be the cause of appendicitis.)

Take note: No small intestines occupy the fetal pelvis, but in the adult pelvis the amount depends
on the state of distention of the bladder and the rectum and upon the position of the pelvic colon.

The duodenum continues into the jejunum at the duodenojejunal junction or flexure, which lies
to the left of L2 vertebra and is fixed to the retroperitoneum by a suspensory ligament of Treitz.
The inferior mesenteric vein (IMV) lies to its left. There are several peritoneal fossae around the
flexure, which may be the sites of an internal herniation of the small bowel. The rest of the small
intestine is a 4-6-m long convoluted tube occupying the center of the abdomen and the pelvis,
surrounded on 2 sides and above by the colon (a part of the large intestine). The ileum continues
into the large intestine at the ileocecal junction
Duodenum

The duodenum has 4 parts: superior, descending, horizontal, and ascending.

A. The first (superior) part, or bulb (5 cm), is connected to the undersurface of the liver
(porta hepatis) by the hepatoduodenal ligament (HDL), which contains the proper hepatic
artery, portal vein, and common bile duct (CBD); the quadrate lobe of the liver and
gallbladder are in front, and the CBD), portal vein, and gastroduodenal artery (GDA) are
behind.
B. The second (descending) part, or C loop (10 cm), which has an upper and a lower genu
(flexure), is composed of the transverse mesocolon and colon in front and the right
kidney and inferior vena cava (IVC) behind; the head of the pancreas lies in the concavity
of the C.

C. The third (horizontal) part (7.5 cm) runs from right to left in front of the inferior vena
cava (IVC) and aorta, with superior mesenteric vessels (the vein on the right and the
artery on the left) in front.

D. The fourth (ascending) part (2.5 cm) continues as the jejunum. The duodenum continues
into the jejunum at the duodenojejunal flexure.

Jejunum

The jejunum constitutes about two fifths of the small intestine and the ileum about three fifths.
The jejunum has a thicker wall and a wider lumen than the ileum and mainly occupies the left
upper and central abdomen.

Ileum

The ileum constitutes about three fifths of the small intestine and the jejunum about two
fifths. The ileum has a thinner wall and a smaller lumen than the jejunum and mainly occupies
the central and right lower abdomen and pelvis. Mesenteric fat is abundant in the mesentery of
the ileum, and vessels in the mesentery are, therefore, not well seen. (In cystic fibrosis, the
jejunum is where the mesentery vessels are well seen because much less mesenteric fat is present
in the jejunum than in the ileum.)

Mesentery

The mesentery is a double fold of peritoneum attached to the posterior abdominal wall. It is fan-
shaped with a root of about 15 cm extending obliquely from the left L2 transverse process level
to the right sacroiliac joint and crossing a third part of the duodenum, aorta and inferior vena
cava (IVC) right ureter, and a 4- to 6-m periphery, which covers the entire length of the jejunum
and ileum. Between the 2 leaves of the mesentery are the mesenteric vessels and lymph nodes.
Blood supply

The superior mesenteric artery (SMA) is the artery of the midgut and, therefore, of the small
intestine; it comes off as the second branch (the inferior mesenteric artery is its third branch)
from the anterior surface of the abdominal aorta about 1 cm below the origin of the celiac trunk,
at the level of L1 behind the neck of the pancreas. From there, it descends in front of the uncinate
process of the pancreas and the third (horizontal) part of the duodenum to enter the small
intestine mesentery.

Left side of SMA

1. Multiple jejunal branches

2. Ileal branches arise from the left side of the SMA.

They anastomose with each other to form a series of loops or arcades from which arise the
terminal (end) branches, called vasa recta, which supply the jejunum and ileum and lie between
the 2 leaves of the small intestine mesentery. Jejunum has fewer (2-3) series of arcades, and the
vasa recta are longer. The ileum has more (4-5) series of arcades, and the vasa recta are shorter.

From the right side of the SMA arise ileocolic, right colic, and middle colic arteries. The
ileocolic artery or one of its branches gives off the appendicular artery. The ileal branch of the
ileocolic artery anastomoses with the terminal ileal branch of the SMA. The left branch of the
middle colic artery anastomoses with the ascending branch of the left colic artery (which in itself
is a branch of the inferior mesenteric artery). The arc of Riolan connects the middle colic artery
(or its left branch) to the left colic artery (or its ascending branch).

Jejunal, ileal, ileocolic, right colic, and middle colic arteries are accompanied by the same named
veins, which drain into the SMV.

The superior mesenteric vein (SMV) lies to the right of the SMA in front of the uncinate process
of the pancreas and the third part of the duodenum. Union of the vertical SMV and the horizontal
splenic vein forms the portal vein (PV) behind the neck of the pancreas. The inferior mesenteric
vein (IMV) lies to the immediate left of the duodenojejunal (DJ) flexure and joins the junction of
the splenic vein (SV) and SMV. The PV runs up (superiorly) behind the first part of the
duodenum in the hepatoduodenal ligament (HDL) behind (posterior to) the bile duct on the right
and the proper hepatic artery (HA) on the left. The portal venous system (SV, SMV, and PV) has
no valves.

Microscopic Anatomy

The small intestine contains the standard 4 layers present in most parts of the gastrointestinal
tract: the mucosa, submucosa, muscularis propria, and serosa.
The mucosa includes a columnar epithelium with glands called crypts of Lieberkuhn; mucus-
secreting goblet cells; Paneth cells, which secrete lysozymes; enteroendocrine cells, which
secrete hormones; fingerlike (leaflike) projections called villi, which increase its absorptive
surface area several times; lamina propria (connective tissue); and muscularis mucosa.

The ileum has subepithelial aggregates of lymphoid tissue along the antimesenteric border; these
are called Peyer patches. Mucosa is much thicker in the jejunum than in the ileum and is
arranged in spiral folds called plicae circulares, which appear as valvulae conniventes on plain
abdominal radiographs.

The submucosa contains the blood vessels and the Meissner nerve plexus; the muscularis propria
contains inner circular and outer longitudinal muscles and myenteric (Auerbach) nerve plexus;
and the serosa covering the organs of the peritoneal cavity is called the visceral peritoneum.

Physiologic Anatomy

From the point of view of absorption of important nutrients, the proximal jejunum and distal
ileum are more important; the distal jejunum and proximal ileum (mid-small bowel) can be more
easily sacrificed without much disturbance of absorption. Massive resection of small bowel (eg,
in mesenteric vascular disease) or repeated resections (eg, in Crohn disease) may result in short
bowel syndrome.

Pathophysiological Variants

The vitellointestinal duct may persist as the following:

A patent duct: This is small bowel communicating with the umbilicus.

Meckel diverticulum: This is present in about 2% of people and is a true
(containing all layers) diverticulum, from the antimesenteric border of the
distal ileum (about 2 ft proximal to the ileocecal junction). It is a remnant of
the intestinal end of the vitelline duct. The mucosa of the diverticulum may
contain ectopic gastric tissue, which may secrete acid and cause ulceration in
the adjacent intestinal mucosa. The tip of the diverticulum may be attached
to the umbilicus by a band around which volvulus (rotation) of ileum may
occur, causing intestinal obstruction and strangulation.

Vitelline sinus at the umbilicus: This presents as a raspberry tumor or

adenoma.

Fibrous band between ileum and umbilicus, around which torsion of a small
bowel loop may occur

Malrotation

Malrotation of the gut results in the location of the small intestine on the right side and the large
intestine on the left side of the abdomen. The duodenojejunal flexure comes to lie to the right
(instead of the normal left) of the midline and cecum in epigastrium or right hypochondrium
(instead of the normal right iliac fossa); a band (of Ladd) runs across the duodenum from right to
left, and the narrow base of the small bowel mesentery predisposes it to volvulus.

Atresia

Atresia (duodenal, jejunal, and ileal), narrowing, or even complete obliteration of the lumen
resulting in neonatal intestinal obstruction may be present; it may even cause polyhydramnios
(excessive amniotic fluid) in utero.

Duplication cysts can occur in any part of the small intestine.

15 minutes

GI Tract: Oral to Rectum (short discussion)

Zoom in to stomach (discuss)

Zoom in to Small intestine

Physiology of Digestion

Single Sentence Causes for Intestinal Surgery