ANATOMY

REVIEW COURSE 2009

GASTROINTESTINAL TRACT

ALFONSO C. DANAC, MD, FPCS, FPSGS, FPALES

Chairman & Associate Professor, Department of Anatomy
Angeles University Foundation School of Medicine
 Organ Systems of the Body

• Digestive system
– Composed of the oral cavity, esophagus, stomach,
small intestine, large intestine, rectum, anus, and
liver
– Breaks down food into absorbable units that enter
the blood
– Eliminates indigestible foodstuffs as feces
 Body Cavities
• The abdominopelvic cavity is separated from the
superior thoracic cavity by the dome-shaped
diaphragm
• It is composed of two subdivisions
– Abdominal cavity – contains the stomach,
intestines, spleen, liver, and other organs
– Pelvic cavity – lies within the pelvis and contains
the bladder, reproductive organs, and rectum
 Abdominopelvic Regions
• Umbilical
• Epigastric
• Hypogastric
• Right and left iliac or
inguinal
• Right and left lumbar
• Right and left
hypochondriac

Figure 1.11a
Abdominopelvic Regions

Figure 1.11b
 Abdominopelvic Quadrants

• Right upper
• Left upper
• Right lower
• Left lower

Figure 1.12
 Digestive System: Overview
• The alimentary canal or gastrointestinal (GI) tract
digests and absorbs food

• Alimentary canal – mouth, pharynx, esophagus,

stomach, small intestine, and large intestine

• Accessory digestive organs – teeth, tongue,

gallbladder, salivary glands, liver, and pancreas
Digestive System: Overview

Figure 24.1
 Digestive Process

• The GI tract is a “disassembly” line

– Nutrients become more available to the body
in each step
 Digestive Process
• There are six
essential activities:

– ingestion,
propulsion, and
mechanical
digestion
– chemical
digestion,
absorption, and
defecation

Figure 24.2
 Essential Activities of Digestion

• Ingestion – taking food into the digestive tract

• Propulsion – swallowing and peristalsis

Peristalsis – waves of contraction and relaxation of
muscles in the organ walls

• Mechanical digestion – chewing, mixing and churning food

 Essential Activities of Digestion
• Chemical digestion -
catabolic breakdown
of food
• Absorption -
movement of nutrients
from the GI
tract to the
blood or
lymph
• Defecation - elimination of
indigestible solid
wastes
Figure 24.2
Figure 24.2
 Digestive System Organs and Peritoneum
• Peritoneum –
serous
membrane of the
abdominal
cavity
– Visceral – covers
external surface
of most digestive
organs
– Parietal – lines
the body wall

Figure 24.5a
Digestive System Organs and Peritoneum
• Peritoneal cavity
– Lubricates
digestive organs
– Allows them to
slide across one
another

Figure 24.5a
 Digestive System Organs and Peritoneum
• Mesentery -
double layer of peritoneum that
provides:
Vascular and nerve
supplies to the viscera
A means to hold digestive
organs in place and
store fat
• Retroperitoneal organs -
organs outside the peritoneum
• Peritoneal organs
(intraperitoneal) -
organs surrounded by peritoneum

Figure 24.5b
 Blood Supply: Splanchnic Circulation

• Arteries and the organs they serve include

– The celiac trunk (hepatic, splenic, and left gastric):
spleen, liver, and stomach
– Inferior and superior mesenteric: small and large
intestines
• Hepatic portal circulation:
– Collects nutrient-rich venous blood from the digestive
viscera
– Delivers it to the liver for metabolic processing and
storage
 Mouth
• Oral or buccal cavity:
– Is bounded by lips, cheeks, palate, and tongue
– Has the oral orifice as its anterior opening
– Is continuous with the oropharynx posteriorly
• To withstand abrasions:
– The mouth is lined with stratified squamous epithelium
– The gums, hard palate, and dorsum of the tongue are
slightly keratinized
Mouth

Figure 24.7a
 Lips and Cheeks
• Have a core of skeletal muscles
– Lips: orbicularis oris
– Cheeks: buccinators
• Vestibule – bounded by the lips and cheeks externally and
teeth and gums internally
• Oral cavity proper– area that lies within the teeth and
gums
• Labial frenulum – median fold that joins the internal
aspect of each lip to the gum

Figure 24.7b
Lips and Cheeks

Figure 24.7b
 Palate
• Hard palate – underlain by palatine bones and palatine
processes of the maxillae
– Assists the tongue in chewing
– Slightly corrugated on either side of the raphe (midline
ridge)
• Soft palate – mobile fold formed mostly of skeletal muscle
– Closes off the nasopharynx during swallowing
– Uvula projects downward from its free edge
• Palatoglossal and palatopharyngeal arches form the
borders of the fauces
 Tongue
• Occupies the floor of the mouth and fills the oral cavity
when mouth is closed
• Functions include:
– Gripping and repositioning food during chewing
– Mixing food with saliva and forming the bolus
– Initiation of swallowing, and speech
• Intrinsic muscles change the shape of the tongue
• Extrinsic muscles alter the tongue’s position
• Lingual frenulum secures the tongue to the floor of the
mouth
 Tongue
• Superior surface bears three types of papillae
– Filiform – give the tongue roughness and provide
friction
– Fungiform – scattered widely over the tongue and give
it a reddish hue
– Circumvallate – V-shaped row in back of tongue
• Sulcus terminalis – groove that separates the tongue into
two areas:
– Anterior 2/3 residing in the oral cavity
– Posterior third residing in the oropharynx
Tongue

Figure 24.8a
 Salivary Glands
• Produce and secrete saliva that:
– Cleanses the mouth
– Moistens and dissolves food chemicals
– Aids in bolus formation
– Contains enzymes that breakdown starch
• Three pairs of extrinsic glands – parotid,
submandibular, and sublingual
• Intrinsic salivary glands (buccal glands) –
scattered throughout the oral mucosa
 Salivary Glands
• Parotid – lies anterior to the ear between the
masseter muscle and skin
– Parotid duct – opens into the vestibule next to the
second upper molar
• Submandibular – lies along the medial aspect of
the mandibular body
– Its ducts open at the base of the lingual frenulum
• Sublingual – lies anterior to the submandibular
gland under the tongue
– It opens via 10-12 ducts into the floor of the mouth
Salivary Glands II

Figure 24.9a
 Teeth
• Primary and permanent dentitions have formed
by age 21
• Primary – 20 deciduous teeth that erupt at
intervals between 6 and 24 months
• Permanent – enlarge and develop causing the
root of deciduous teeth to be resorbed and fall
out between the ages of 6 and 12 years
– All but the third molars have erupted by the end of
adolescence
– There are usually 32 permanent teeth
Teeth

Figure 24.10.1
Teeth

Figure 24.10.2
 Classification of Teeth
• Teeth are classified according to their shape
and function
– Incisors – chisel-shaped teeth adapted for cutting or
nipping
– Canines – conical or fanglike teeth that tear or pierce
– Premolars (bicuspids) and molars – have broad
crowns with rounded tips and are best suited for
grinding or crushing
• During chewing, upper and lower molars lock
together generating crushing force
 Dental Formula
• A shorthand way of indicating the number and
relative position of teeth
– Written as ratio of upper to lower teeth for the mouth
– Primary: 2I (incisors), 1C (canine), 2M (molars)
– Permanent: 2I, 1C, 2PM (premolars), 3M

2I 1C 2PM 3M

X 2 (32 teeth)
2I 1C 2PM 3M
 Tooth Structure
• Two main regions – crown and the root
• Crown – exposed part of the tooth above the gingiva
(gum)
• Enamel – acelluar, brittle material composed of
calcium salts and hydroxyapatite crystals is the
hardest substance in the body
– Encapsules the crown of the tooth
• Root – portion of the tooth embedded in the jawbone
 Tooth Structure
• Neck – constriction where the crown and root
come together
• Cementum – calcified connective tissue
– Covers the root
– Attaches it to the periodontal ligament
• Periodontal ligament
– Anchors the tooth in the alveolus of the jaw
– Forms the fibrous joint called a gomaphosis
• Gingival sulcus – depression where the
gingival borders the tooth
 Tooth Structure
• Dentin – bonelike material deep to the enamel cap
that forms the bulk of the tooth
• Pulp cavity – cavity surrounded by dentin that
contains pulp
• Pulp – connective tissue, blood vessels, and nerves
• Root canal – portion of the pulp cavity that extends
into the root
• Apical foramen – proximal opening to the root canal
• Odontoblasts – secrete and maintain dentin
throughout life
Tooth Structure

Figure 24.11
 Pharynx
• From the mouth, the oro- and laryngopharynx
allow passage of:
– Food and fluids to the esophagus
– Air to the trachea
• Lined with stratified squamous epithelium and
mucus glands
• Has two skeletal muscle layers
– Inner longitudinal
– Outer pharyngeal constrictors
 Esophagus
• Muscular tube going from the
laryngopharynx to the stomach
• Travels through the mediastinum and
pierces the diaphragm
• Joins the stomach at the cardiac orifice
 Deglutition (Swallowing)
• Involves the coordinated activity of the tongue,
soft palate, pharynx, esophagus and 22 separate
muscle groups
• Buccal phase – bolus is forced into the
oropharynx
• Pharyngeal-esophageal phase – controlled by the
medulla and lower pons
– All routes except into the digestive tract are sealed off
• Peristalsis moves food through the pharynx to the
esophagus
Deglutition (Swallowing)

Figure 24.13a-c
Deglutition (Swallowing)

Figure 24.13d, e
 Stomach
• Chemical breakdown of proteins begins and food is
converted to chyme
• Cardiac region – surrounds the cardiac orifice
• Fundus – dome-shaped region beneath the diaphragm
• Body – midportion of the stomach
• Pyloric region – made up of the antrum and canal
which terminates at the pylorus
• The pylorus is continuous with the duodenum through
the pyloric sphincter
Stomach

Figure 24.14a
 Stomach
• Greater curvature – entire extent of the convex
lateral surface
• Lesser curvature – concave medial surface
• Lesser omentum – runs from the liver to the lesser
curvature
• Greater omentum – drapes inferiorly from the
greater curvature to the small intestine
• Nerve supply – sympathetic and parasympathetic
fibers of the autonomic nervous system
• Blood supply – celiac trunk, and corresponding
veins (part of the hepatic portal system)
Small Intestine: Gross Anatomy
• Runs from pyloric sphincter to the ileocecal valve
• Has three subdivisions: duodenum, jejunum, and ileum
• The bile duct and main pancreatic duct:
– Join the duodenum at the hepatopancreatic ampulla
– Are controlled by the sphincter of Oddi
• The jejunum extends from the duodenum to the ileum
• The ileum joins the large intestine at the ileocecal
valve
 Liver
• The largest gland in the body
• Superficially has four lobes – right, left,
caudate, and quadrate
• The falciform ligament:
– Separates the right and left lobes anteriorly
– Suspends the liver from the diaphragm and
anterior abdominal wall
• The ligamentum teres:
– Is a remnant of the fetal umbilical vein
– Runs along the free edge of the falciform ligament
 Liver: Associated Structures
• The lesser omentum anchors the liver to the stomach
• The hepatic blood vessels enter the liver at the porta
hepatis
• The gallbladder rests in a recess on the inferior surface
of the right lobe
• Bile leaves the liver via
– Bile ducts which fuse into the common hepatic duct
– The common hepatic duct fuses with the cystic duct
– These two ducts form the bile duct
Liver: Associated Structures

Figure 24.20
 The Gallbladder
• Thin-walled, green muscular sac on the ventral
surface of the liver
• Stores and concentrates bile by absorbing its water
and ions
• Releases bile via the cystic duct which flows into
the bile duct
 Pancreas
• Location
– Lies deep to the greater curvature of the stomach
– The head is encircled by the duodenum and the tail
abuts the spleen
• Exocrine function
– Secretes pancreatic juice which breaks down all
categories of foodstuff
– Acini (clusters of secretory cells) contain zymogen
granules with digestive enzymes
• The pancreas also has an endocrine function –
release of insulin and glucagon
 Large Intestine
• Has three unique features:
– Teniae coli – three bands of longitudinal smooth
muscle in its muscularis
– Haustra – pocketlike sacs caused by the tone of
the teniae coli
– Epiploic appendages – fat-filled pouches of
visceral peritoneum
• Is subdivided into the cecum, appendix, colon,
rectum, and anal canal
• The saclike cecum:
– Lies below the ileocecal valve in the right iliac
fossa
– Contains a wormlike vermiform appendix
Large Intestine

Figure 24.29a
 Colon
• Has distinct regions: ascending colon, hepatic
flexure, transverse colon, splenic flexure,
descending colon, and sigmoid colon
• The transverse and sigmoid portions are anchored
via mesenteries called mesocolons
• The sigmoid colon joins the rectum
• The anal canal, the last segment of the large
intestine, opens to the exterior at the anus
 Valves and Sphincters of the
Rectum and Anus
• Three valves of the rectum stop feces from being
passed with gas
• The anus has two sphincters:
– Internal anal sphincter composed of smooth muscle
– External anal sphincter composed of skeletal muscle
• These sphincters are closed except during defecation
 Histology of the Alimentary Canal

• From esophagus to the anal canal the walls of the GI

tract have the same four tunics
– From the lumen outward they are the mucosa, submucosa,
muscularis externa, and serosa

• Each tunic has a predominant tissue type and specific

digestive function
Histology of the Alimentary Canal

Figure 24.6
 Mucosa
• Moist epithelial layer that lines the lumen of the alimentary
canal

• Its three major functions are:

– Secretion of mucus
– Absorption of the end products of digestion
– Protection against infectious disease

• Consists of three layers: a lining epithelium, lamina propria,

and muscularis mucosae
 Mucosa: Epithelial Lining
• Consists of simple columnar epithelium and
mucus-secreting goblet cells
• The mucus secretions:
– Protect digestive organs from digesting themselves
– Ease food along the tract
• Stomach and small intestine mucosa contain:
– Enzyme-secreting cells and
– Hormone-secreting cells (making them endocrine
and digestive organs)
 Mucosa: Lamina Propria and
Muscularis Mucosae
• Lamina Propria
– Loose areolar and reticular connective tissue
– Nourish the epithelium and absorb nutrients
– Contains lymph nodes (part of MALT) important in
defense against bacteria

• Muscularis mucosae – smooth

muscle cells that produce local movements of mucosa
 Mucosa: Other Sublayers
• Submucosa – dense connective tissue containing
elastic fibers, blood and lymphatic vessels, lymph
nodes, and nerves
• Muscularis externa – responsible for segmentation
and peristalsis
• Serosa -
the protective visceral peritoneum
- replaced by the fibrous adventitia in the esophagus
- retroperitoneal organs have both an adventitia
and serosa
 Enteric Nervous System
• Composed of two major intrinsic nerve plexuses
– Submucosal nerve plexus – regulates glands and
smooth muscle in the mucosa
– Myenteric nerve plexus:
• Major nerve supply that controls GI tract mobility
• Segmentation and peristalsis are largely automatic
involving local reflex arcs
• Linked to the CNS via long autonomic reflex arc
 Esophageal Characteristics
• Esophageal mucosa – nonkeratinized stratified
squamous epithelium
• The empty esophagus is folded longitudinally and
flattens when food is present
• Glands secrete mucus as a bolus moves through
the esophagus
• Muscularis changes from skeletal (superiorly) to
smooth muscle (inferiorly)
 Microscopic Anatomy of the Stomach
• Muscularis – has an additional oblique layer that
– Allows the stomach to churn, mix and pummel food
physically
– Breaks down food into smaller fragments
• Epithelial lining is composed of:
– Goblet cells that produce a coat of alkaline mucus
• Gastric pits containing gastric glands that
secrete:
– Gastric juice
– Mucus
– Gastrin
 Glands of the Stomach: Fundus and Body
• Gastric glands of the fundus and body have
a variety of secretory cells
– Mucous neck cells – secrete acid mucus
– Parietal (oxyntic) cells – secrete HCl and intrinsic
factor
– Chief (zymogenic) cells – produce pepsinogen
• Pepsinogen is activated to pepsin by:
– HCl in the stomach
– Pepsin itself by a positive feedback mechanism
– Enteroendocrine cells – secrete gastrin, histamine,
endorphins, serotonin, cholecystokinin (CCK), and
somatostatin into the lamina propria
 Stomach Lining
• The stomach is exposed to the harshest
conditions in the digestive tract
• To keep from digesting itself, the stomach has
a mucosal barrier with:
– A thick coat of bicarbonate-rich mucus on the
stomach wall
– Epithelial cells that are joined by tight junctions
– Gastric glands that have cells impermeable to HCl
• Damaged epithelial cells are quickly replaced
 Microscopic Anatomy of the Small Intestine

• Structural modifications of the small intestine

wall increase surface area
– Plicae circulares: deep circular folds of the mucosa
and submucosa
– Villi: fingerlike extensions of the mucosa
– Microvilli: tiny projections of absorptive mucosal
cells’ plasma membranes
Microscopic Anatomy of the Small Intestine

Figure 24.21a-c
Small Intestine: Histology of the Wall
• The epithelium of the mucosa is made up of:
– Absorptive cells and goblet cells
– Interspersed T cells (intraepithelial lymphocytes),
and
– Enteroendocrine cells
• Intestinal crypts cells secrete intestinal juice
• Peyer’s patches are found in the submucosa
• Brunner’s glands in the duodenum secrete
alkaline mucus
 Large Intestine: Microscopic Anatomy
• Colon mucosa is simple columnar epithelium
except in the anal canal
• Has numerous deep crypts lined with goblet cells
• Anal canal mucosa is stratified squamous
epithelium
• Anal sinuses exude mucus and compress feces
• Superficial venous plexuses are associated with the
anal canal
• Inflammation of these veins results in itchy
varicosities called hemorrhoids
Large Intestine: Microscopic Anatomy

Figure 24.29b
Large Intestine
• receive fluid waste
products and store
until released from
body.
• excess water
absorbed
• feces, stools
• defecation, or bowel
movement
 Functions of the Large Intestine
• Other than digestion of enteric bacteria, no further
digestion takes place
• Vitamins, water, and electrolytes are reclaimed
• Its major function is propulsion of fecal
material toward the anus
• Though essential for comfort, the colon is not
essential for life
Mesenteries of Digestive Organs

Figure 24.30b
Mesenteries of Digestive Organs

Figure 24.30c
Mesenteries of Digestive Organs

Figure 24.30d
 Embryonic Development of the
Digestive System
• 3rd week – endoderm has folded and foregut and
hindgut have formed
• The midgut is open and continuous with the yolk sac
• Mouth and anal openings are nearly formed
• 8th week – accessory organs are budding from
endoderm
Embryonic Development of the
Digestive System

Figure 24.37
EMBRYOLOGY OF THE GASTROINTESTINAL TRACT

GIT – represented as a straight tube of uniform caliber

suspended in the midline of the abdominal cavity by
a ventral and dorsal mesentery
- lies between 2 layers of mesentery thus has right and
left surfaces

Dorsal mesentery – extends along entire length of the tube

subdivided as mesogastrium, mesoduodenum,
mesojejunum, mesoileum, and mesocolon

Ventral mesentery – extends as far as first inch of duodenum

(or umbilicus) referred to as ventral mesogastrium
DIVISIONS OF THE GIT
- based on the 3 branches of the aorta supplying the GIT

1. FOREGUT - stomach to second portion of duodenum

(entrance of the bile ducts); supplied by
celiac axis

2. MIDGUT - entrance of the bile ducts up to junction of

middle and distal third of the transverse colon;
supplied by superior mesenteric artery

3. HINDGUT - from distal third of transverse colon to rectum;

supplied by inferior mesenteric artery
DEVELOPMENT, ROTATION AND FIXATION
initial short segment becomes the abdominal esophagus
- distal to this segment, foregut bulges to form the stomach
- lower foregut and entire midgut lengthen to form the
redundant umbilical loop which has a descending proximal
and ascending distal limb
> small intestines develop from descending limb and
half of ascending limb
> remaining ascending limb bulges to form the cecal bud
- elongation of initial colic segment (midgut) forms the
ascending colon and proximal 2/3 of transverse colon
- terminal colic segment (hindgut) forms the remaining 1/3
of transverse colon, descending, sigmoid and pelvic portions
of colon
- rectum develops from the primitive cloaca
DEVELOPMENT, ROTATION AND FIXATION

- upper end of hindgut is fixed to posterior abdominal wall by

the mesentery of teminal colic segment
- colic angle is formed where the initial colic segment and
terminal colic segment meets
- extremities of the midgut as anchored by the fixed upper
duodenum above and and the fixed “colic angle”
*fixed points are close together and the mesentery filled
space is known as “duodenocolic isthmus”
- part of umbilical loop (descending limb and first half of
ascending limb) grows rapidly making the embryonic
peritoneal cavity unable to contain it
*part of the loops grows into the umbilical cord (extra-
embryonic celom) resulting in a temporary and
physiologic umbilical hernia
DEVELOPMENT, ROTATION AND FIXATION

- SMA supplies the umbilical loop (midgut) which starts as a

branch of the abdominal aorta that passes through the
duodenocolic isthmus, sends branches to the umbilical
loop and ends as the the vitelline artery which supplies
the vitello-intestinal duct (omphalomesenteric duct)*
*communication between the midgut and yolk sac
which normally disappears before birth
> may persist as a Meckel’s diverticulum

- SMA runs in the mesentery of the umbilical loop and sends

branches upward to the descending limb (prearterial limb
and prearterial mesentery) and downward to the
ascending limb of the loop (postarterial limb and
postarterial mesentery)
DEVELOPMENT, ROTATION AND FIXATION

5th week: rotation takes place

- starts while midgut loop is still in the umbilical cord
*growth of right lobe of liver starts rotation by pressing
on prearterial segment pushing it to the right and
downward; postarterial segment is pushed to the left
and upward
*liver growth rotates umbilical loop 90° counterclockwise
>primitive left surface of mesentery now faces upward,
primitive right surface faces downward
>arrest of rotation: appendix and cecum is found on
on the left side of the body
DEVELOPMENT, ROTATION AND FIXATION
10th week: umbilical loop returns to abdominal cavity in
definite and orderly manner
- starts with proximal part of prearterial segment
*SMA is fixed firmly from its origin at the aorta to its
termination at the umbilicus forming a taut cord
- return of the small gut starts to the right of the SMA but
since the intra-abdominal space to the right is small, coils
that were reduced first are pushed to the left and behind the
artery
*as coils pass to the left, they encounter the dorsal mesentery
of the hindgut which occupies the midline which is also
pushed to the left ahead of the small intestines
> descending colon now occupies left flank and “colic
angle” is pushed upward and to the left to form the
splenic flexure; cecum and right half of colon follows
crossing in front of origin of the SMA
DEVELOPMENT, ROTATION AND FIXATION

- outcome:
1.Duodenum lies behind the SMA
2. Transverse colon is in front of SMA
3. Small gut travels from the left upper to the right lower
quadrant of the abdomen
4. Descending colon is pushed to the left
5. Cecum and appendix are under the liver
6. No ascending colon

- as rotation continues, descent of cecum occurs until it

reaches the right iliac fossa and fixation of the gut to the
posterior abdominal wall takes place
*ascending colon is now formed
DEVELOPMENT, FIXATION AND ROTATION
- ascending, transverse and descending colon has now reached
its final position forming an inverted U which embraces
the jejunum and ileum
- cecum, ascending colon and ascending mesocolon
(postarterial) fuses with the right parietal peritoneum
- upper limit of ascending mesocolon overlies a part of a loop
of duodenum and pancreatic head, which aids in fixing
these structures to the posterior abdominal wall
- transverse colon and mesocolon hangs free
- two transverse “colic angles” (hepatic and splenic flexure)
are fixed
- jejunal and ileal loops hang free by a common jejuno-ileal
mesentery which passes obliquely from the duodeno-
jejunal flexure to the ileocecal angle
DEVELOPMENT, ROTATION AND FIXATION
- descending colon and mesocolon fuses with left parietal
peritoneum
- sigmoid colon does not fuse and forms an intersigmoid
recess or fossa of variable depth
- layers are not firmly fixed; with no vessels, nerves or other
vital structures passing between them
*may be restored to embryologic state during dissection
through these cleavage planes
-lateral fixation occurs in the git
*to restore to embryologic state, incise lateral to the segment
and dissect in medial direction thus preserving the
primitive dorsal mesentery
- fusion and fixations are variable
FETAL CIRCULATION
- fetus receives oxygenated blood from the placenta through
the umbilical vein
> vein passes through the liver and enters the IVC
through the ductus venosus
> some blood circulate through the liver and enter
IVC through the hepatic veins
- some of the blood from the pulmonary artery that is
pumped into the aorta flows through the hypogastric
arteries to the umbilical arteries and out to the
placenta for removal of waste products and oxygenation

Umbilical vein – becomes ligamentum teres

Hypogastric arteries – becomes the lateral umbilical ligaments
surface ectoderm
•buccopharyngeal membrane
membrane breaks down, creating opening.
•anal pit
anal canal (caudal part)
anal membrane perforates
primitive endoderm
•foregut diverticulum (pocket)
opharyngeal region of foregut
olaryngo-tracheal groove
oesophageal region of foregut
oesophagus
ostomach
oglandular/proventricular/pyloric stenosis
ofundus/pyloric antrum
opyloric sphincter
odorsal mesogastrium
olieno-renal ligament
osplenic primordium
ospleen
ogastro-splenic ligament
oduodenum (rostral half)
•foregut-midgut junction
oseptum transversum
ohepatic diverticulum
ocystic primordium
ogall bladder
ocommon bile duct
ohepatic ducts
oliver/gall bladder
ohepatic primordium
ohepatic parenchyma
ohepatic sinusoids
olobes of liver
oliver/gall bladder
opancreatic primordium
oleft & right lobes
obody/tail uncinate process
opancreas
•midgut region
oduodenum (candal half)
ojejunum
omidgut
ophysiological umbilical hernia
omidgut loop returns to peritoneal cavity
•hindgut diverticulum (pocket)
ohindgut
odistal hindgut (+urorectal septum)
orectum (+perineal body)
oanal canal (rostral part)
(+anal sphincter (external & internal))
oano-rectal junction
ocloaca (surface ectoderm?)
ocloacal membrane
ourogenital sinus
obladder (+perineal body)
bladder
SUMMARIES
The gastrointestinal tract (GIT) extending from the
pharyngeal membrane to the cloacal membrane arises
from the endoderm of the trilaminar embryo (week 2, 3).

During the 4th week, the 3 distinct portions (fore-, mid-

and hind-gut) extend the length of the embryo and will
contribute different components of the GIT.

The large mid-gut is generated by lateral embryonic

folding which "pinches off" a pocket of the yolk sac, the 2
compartments continue to communicate through the
vitelline duct.
The oral cavity (mouth) is formed following breakdown of the
buccopharyngeal membrane (=oropharyngeal) and contributed
to mainly by the pharynx lying within the pharyngeal arches.

The opening of the GIT means that it contains amniotic fluid,

which is also swallowed later in development.

The hepatic diverticulum (liver bud) lies under the septum

transversum and is the earliest associated GIT organ that has
differentiated, and will occupy a substantial region of the
abdomen during development.
Much of the midgut is herniated at the umbilicus external to
the abdomen through development. A key step in development
is the rotation of this midgut that must occur to place the GIT
in the correct abdominal position with its associated
mesentery.

The GIT itself differentiates to form significantly different

structures along its length: esophagus, stomach, duodenum,
jejunum, ileum (small intestine), colon (large intestine).
The mesenteries of the GIT are generated from the common
dorsal mesentery, with the ventral mesentery contributing to
the lesser omentum and falciform ligament.

The pancreas arises from 2 sources: the hepatic diverticulum

(ventral) and the duodenum (dorsal). The pancreas must also
differentiate to establish specific cells for endocrine and
exocrine function.

The spleen arises in week 5 within the dorsal mesogastrium as

proliferating mesenchyme. Cells required for its hemopoietic
function arise from the yolk sac wall. The spleen generates
both red and white cells in the 2nd trimester. Note that
embryonic RBCs remain nucleated.
ESOPHAGUS

- stomach is separated from the primitive pharynx by a

constriction which is the future esophagus
> arises from the common tubular structure of the trachea
and esophagus which becomes divided by the growth
of two lateral septa which fuse and form the trachea
anteriorly and esophagus posteriorly
*lack of fusion of septa leads to development of
tracheo-esophageal fistula
> due to development of the lungs, constriction is lengthened
> esophagus is converted into a solid cord of cells, losing its
tubular structure
>> becomes canalized later to form the tube again
*imperfect canalization leads to congenital stricture
STOMACH
- developed from that part of the foregut which is situated
between the esophagus and the pharynx in front and the
liver bud and yolk sac behind
*4th week: stomach is located at the neck
> heart, lungs and stomach lie near the exit of the
vagal fibers from the CNS
*6th-7th week: growth of lung bud causes elongation of
esophagus and backward migration of the stomach
(from cervical structure goes down to lower thorax)
>embryologic position: long axis is in the median plane
and greater curvature is facing dorsally
*changes its position during development becoming
almost transversely placed with the greater
curvature facing downward and to the left and
the lesser curvature facing upward and to the
right
STOMACH
- change is due to the combined axial rotation along the long
axis of the stomach and anteroposterior axis
> first rotation (longitudinal axis) swings through an arc
of 90°
*primitive left gastric surface is directed forward, primitive
right gastric surface, backward; greater curvature and
dorsal mesogastrium to the left and lesser curvature and
ventral mesogastrium to the right
- lesser peritoneal cavity (omental bursa) forms retrogastric
pouch; spleen and splenic artery to the left; and
meso-esophagus becomes shortened making esophagus
lie against the posterior wall
- second rotation (anteroposterior axis) draws the pyloric end
to the right and cardiac end to the left
-opening of lesser sac is formed (epiploic foramen or Foramen
of Winslow)
DUODENUM
- rotation of intestines to their ultimate abdominal positions
is produced by drawing the initial colic segment to the
right so that the duodeno-jejunal junction and the small
intestines lie toward the left
*duodenojejunal angle is placed against mesentery of
terminal small intestines, with which it fuses
*degree of fusion accounts for fossae and peritoneal folds
>deficient fixation increases depth and capacity of fossae
(leading to internal herniation)
>hyperfixation of duodenojejunal angle may cause
obstruction
*descending duodenum and part of tranverse duodenum
fuses with primitive right parietal peritoneum
*remaining transverse and ascending duodenum fuses
with descending mesocolon
*duodenojejunal angle fuses with transverse mesocolon
CONGENITAL ANOMALIES

Malrotation

Midgut Volvulus

Duodenal Webs

Meckel’s Diverticulum

Intestinal Atresia

Duplications
COLON
- 10 weeks AOG, abdominal cavity increases sufficiently to
permit return of intestines
>because of cecal swelling, large intestine is the last to
leave the umbilical cord and re-enter the abdominal
cavity
*cecum, ascending and proximal 2/3 of transverse colon is
derived from the midgut
*rest is derived from the hindgut
>cecum becomes fixed on the right side close to the iliac crest
>> colon passes obliquely upward to the left of the stomach,
where it curves sharply to form the splenic flexure and
continues as the future descending colon
>> as liver decreases in size, hepatic flexure appears in the
originally oblique proximal colon
*flexure demarcates ascending from transverse colon
COLON
- posterior peritoneal fixations of the colon take place so that
ascending mesocolon and colon fuse with the right parietal
peritoneum and anterior surface of the descending
duodenum and its mesentery;
- descending colon fuses with left parietal peritoneum
- mesentery to the rest of small bowel remains free and unfused
- transverse colon and mesocolon remain free and suspended
from anterior abdominal wall and remain fixed at the two
colic angles
-redundant sigmoid loop does not fuse with the left pelvic
peritoneum
-upper boundary of mesosigmoid is rectosigmoid or
intersigmoid recess (fossa)
-rectum is the only part of the GIT which maintains its
primitive sagittal position and has no mesentery
RECTUM

- developing hindgut is terminated by the cloaca

*6th week - cloaca is partitioned by the anorectal septum
into ventral urogenital sinus and dorsal rectum

8th week - anal canal is completely formed when the thin

anal membrane ruptures
>dentate line in the lower anal canal marks the
transition from endodermal hindgut to
ectodermal tissue

CONGENITAL ANOMALIES
Hirschsprung’s Disease
Imperforate Anus
ANTERIOR ABDOMINAL WALL

Boundaries:
Superior - costal margins (7th-10th rib) and xiphoid process
Inferior - iliac crest, inguinal ligament, pubic crest and
upper end of symphysis pubis

Surface Anatomy
Skin – loosely attached except in the umbilicus
Linea alba – xiphoid to symphysis pubis; divided into
supraumbilical and infraumbilical part
- fibrous raphe formed by the decussation of
3 lateral abdominal muscles
Umbilicus – navel; puckered scar marking site of umbilical
cord
DIVISIONS OF THE ANTERIOR ABDOMINAL WALL

- divided into 9 regions by two horizontal and vertical lines

*horizontal line drawn at the level of 9th costal cartilage
and superior border of iliac crest
*vertical line drawn from middle of subcostal margin
(midclavicular) and middle of inguinal ligament

- can also be divided into four quadrants by 2 perpendicular

imaginary lines that will pass through the umbilicus
DIVISIONS OF THE ABDOMEN

RIGHT EPIGASTRIC LEFT

HYPOCHONDRIAC HYPOCHONDRIAC
Liver Liver, Stomach, Fundus of Stomach,
Pancreas Spleen

RIGHT LUMBAR UMBILICAL LEFT LUMBAR

Ascending Colon Small intestines, Descending Colon
Transverse Colon,
Greater Omentum

RIGHT INGUINAL HYPOGASTRIC LEFT INGUINAL

Ileocecal Junction, Small Intestines Sigmoid Colon
Appendix Pregnant Uterus
Full Urinary Bladder
ANTERIOR ABDOMINALWALL
Skin
Cutaneous Nerve Supply:
anterior rami of lower six thoracic and first lumbar nerves
*thoracic (lower five intercostals and subcostal nerves)
*lumbar (iliohypogastric and ilioinguinal nerves)
Dermatome: T7 – epigastrium over xiphoid process
T10 – umbilicus
L1 just above inguinal ligament and xiphoid process
Blood Supply: superior and inferior epigastric arteries
branches from intercostal, lumbar and deep
circumflex iliac arteries
Venous Drainage: axillary vein via lateral thoracic vein
femoral vein via superior epigastric vein and
great saphenous veins
Lymphatics: above umbilicus – anterior axillary nodes
below umbilicus – superficial inguinal nodes
BLOOD SUPPLY OF THE ANTERIOR ABDOMINAL WALL

1. Superior Epigastric Artery

- arises from the internal thoracic artery an enters the rectus
sheath
- descends behind the rectus muscle and supplies upper central
part of anterior abdominal wall
- anastomoses with inferior epigastric artery

2. Inferior Epigastric Artery

- arises from external iliac artery above the inguinal ligament
- runs medial to deep inguinal ring and enters rectus sheath
- ascends behind the rectus muscle and supplies lower central
part of anterior abdominal wall
- anastomoses with superior epigastric artery
BLOOD SUPPLY OF THE ANTERIOR ABDOMINAL WALL

3. Deep Circumflex Iliac Artery

- branch of external iliac artery; runs upward and laterally
toward the ASIS
- supplies the lower lateral part of abdominal wall

4. Lower two posterior intercostal arteries (from descending

thoracic aorta) and four lumbar arteries (from abdominal
aorta)
- supplies lateral part of anterior abdominal wall
- superficial epigastric artery, superficial circumflex iliac
artery and superficial external pudendal artery branch
of femoral artery also supply the lower anterior abdominal
wall
VENOUS DRAINAGE
1. Superior and Inferior Epigastric Veins and Deep Circumflex
Iliac Veins
- follow the arteries and drain into internal thoracic and
external iliac veins
2. Posterior intercostal veins – drain into azygos veins
3. Lumbar Veins – drain into IVC
4. Superficial epigastric, superficial circumflex iliac, and
superficial external pudendal veins
- drain into the great saphenous vein then to femoral vein
5. Thoracoepigastric vein
- anastomoses between the lateral thoracic vein and
superficial epigastric vein, a tributary of the great
saphenous vein
- alternative path for venous blood in case of obstruction
in the SVC or IVC
NERVE SUPPLY OF THE ANTERIOR ABDOMINAL WALL

Anterior Rami of Lower Six Thoracic and First Lumbar Nerves

- run downward and forward between the internal oblique
and transversus abdominis muscles.
- supply the skin, muscles, and parietal peritoneum of anterior
abdominal wall
- lower six thoracic nerves pierce the posterior wall of the
rectus sheath
- first lumbar is represented by the iliohypogastric and
ilioinguinal nerves, which do not enter the rectus sheath
- iliohypogastric nerve pierces the external oblique aponuerosis
above the superficial inguinal ring
- ilioinguinal nerve passes through the inguinal canal to emerge
through the ring
 LAYERS OF THE COVERINGS OF
ABDOMINAL WALL SPERMATIC CORD/
TESTES

1. Skin 1. Skin
2. Superficial (Camper’s) Fascia 2. Colles’ Fascia and
Dartos Muscle
3. External Oblique Muscle 3. External Spermatic
Fascia
4. Internal Oblique Muscle 4. Cremasteric
Fascia
and Muscle
5. Transversus Abdominis Muscle 5. Absent
6. Transversalis Fascia 6. Internal Spermatic
Fascia
7. Extraperitoneal Fat 7. Extraperitoneal Fat
8. Parietal Peritoneum 8. Tunica Vaginalis
SUPERFICIAL FASCIA
1. Camper’s Fascia (Superficial Fatty Layer)
- continuous with the superficial fascia over rest of the
body and extremely thick in obese individuals
- represented as a thin layer of smooth muscle in the
scrotum (Dartos muscle)

2. Scarpa’s Fascia (Deep Membranous Layer)

- fades out laterally and above; passes over inguinal
inguinal ligament to fuse with deep fascia of the thigh
(fascia lata)
- not attached to pubis in the midline but forms a tubular
sheath for the penis (clitoris)
- attached to one side to margins of pubic arch (Colles’ Fascia)
- fuses posteriorly with perineal body and posterior margin
of perineal membrane
DEEP FASCIA
- thin layer of areolar tissue covering the muscle

Muscles of Anterior Abdominal Wall

- three broad thin sheets that are aponeurotic in front
External Oblique, Internal Oblique, Transversus Abdominis
- Rectus Abdominis: found on either side of midline
*aponeurosis of three sheets pass forward and enclose
Rectus Abdominis to form the Rectus Sheath
- Pyramidalis Muscle: may be present in the lower part of
the Rectus Sheath
Rectus Sheath
- long fibrous sheath that encloses rectus abdominis and
pyramidalis (if present)
- contains anterior rami of lower six thoracic nerves and
superior and inferior epigastric vessels and lymph vessels
- internal oblique aponeurosis splits to form an anterior and
posterior laminae
- external oblique aponeurosis fuses with anterior lamina
- transversus abdominis aponeurosis fuses with posterior lamina
- at level of ASIS, all 3 aponeurosis past anteriorly to the
rectus muscle (sheath becomes deficient posteriorly)
Rectus Sheath
- arcuate line: lower crescent-shaped edge of posterior wall
of rectus sheath
- all aponeurosis fuse with each other and with the other side
to form the linea alba
- anterior wall of rectus sheath attached to tendinous
intersections of rectus abdominis
*xiphoid, umbilicus and in between

Linea Semilunaris: lateral edge of rectus muscle

Conjoint Tendon: union of internal oblique and transversus

abdominis muscle
strenghtens medial half of floor of
inguinal canal
 Muscles of the Abdominal Wall
• The abdominal wall is composed of four paired
muscles (internal and external obliques, transversus
abdominis, and rectus abdominis), their fasciae, and
their aponeuroses
• Fascicles of these muscles run at right and oblique
angles to one another, giving the abdominal wall
added strength
 Muscles of the Abdominal Wall

• In addition to forming the abdominal wall,

these muscles:
– Are involved with lateral flexion and rotation of the
trunk
– Help promote urination, defecation, childbirth,
vomiting, coughing, and screaming
Muscles of the Abdominal Wall

Figure 10.11a
Muscles of the Abdominal Wall

Figure 10.11b
Muscles of the Abdominal Wall

Figure 10.11c
Inguinal (Poupart’s) Ligament
- connects ASIS to pubic tubercle
- formed by lower border of external oblique aponeurosis
Lacunar (Gimbernat’s) Ligament
- extends from medial end; goes backward and upward to
the Pectineal Line on superior ramus of pubis;
where it becomes continuous with pectineal ligament
(periosteal thickening)
- lower border attached to the fascia lata
Cooper’s Ligament
- lateral continuation of lacunar ligament
- extends from base of lacunar ligament laterally along the
pectineal line to which it is attached
Fascia Transversalis
- thin layer that lines trasnversus abdominis
- continuous with a similar layer lining the diaphragm and
iliacus muscle
- forms femoral sheath together with fascia iliaca
SPERMATIC CORD
- collection of the following structures that pass through
the inguinal canal to and from the testis
1. Vas Deferens
2. Testicular Artery
3. Testicular Vein (pampiniform plexus)
4. Testicular Lymph nodes
5. Autonomic Nerves
6. Remains of the Processus vaginalis
7. Cresmeasteric Artery
8. Artery of the Vas Deferens
9. Gential branch of genitofemoral nerve,
which supplies cremasteric muscle
Coverings:
1. External Spermatic Fascia – external oblique muscle
2. Cremasteric Fascia – internal oblique muscle
3. Internal Spermatic Fascia - fascia trasnversalis
PROCESSUS VAGINALIS
- peritoneal diverticulum formed in the fetus that passes
throught the layers of lower abdominal wall to form
the inguinal canal
normally, cavity of tunica vaginalis is shut off from the
upper part of processus and periotneal cavity just
before birth; becomes a closed sac invaginated from
behind by the testis

GUBERNACULUM TESTES
- muscular ligamentous cord that connects the fetal testis to
the floor of developing scrotum
- plays an important role in the descent of the testis
- homologous to female round ligament of the ovary and
round ligament of the uterus
SCROTUM
- outpouching of the lower part of the anterior abdominal
wall and contains the testis, epididymis, and lower ends
of the spermatic cord
- layers
1. Skin
2. Superficial Fascia: Dartos muscle (smooth muscle)
replaces fatty layer
3. External Spermatic Fascia from external oblique
4. Cremasteric Fascia from internal oblique
*cremasteric muscle supplied by genital branch of
genitofemoral nerve
5. Internal Spermatic Fascia – from fascia transversalis
6. Tunica Vaginalis: closed sac that covers the
anterior, medial and lateral
surface of each testis
TESTIS – paired ovoid organ responsible for the
production of spermatozoa and testosterone.
*descent to abdominal cavity allows normal
spermatogenesis to take place
- outer fibrous capsule is called tunica albuginea
EPIDIDYMIS - lies on each side, posterior to the testis
- has head, body and tail
- coiled tube about 20 feet (6 m) long
- vas deferens emerges from the tail
BLOOD SUPPLY/DRAINAGE/LYMPHATICS
- supplied by testicular artery which is a branch of the
abdominal aorta
- testicular veins emerges from testis and epididymis as a
venous network called pampiniform plexus
-right testicular vein drains to IVC and left joins left renal vein
- lymphatics: para-aortic nodes at L1 level
INGUINAL CANAL
- oblique passage through the lower part of anterior abdominal
wall present in both sexes
- about 4 cm long in adults; extends from deep inguinal ring,
(hole in the fascia transversalis) downward and medially to
superficial inguinal ring (hole in external oblique aponeurosis)
- deep inguinal ring: oval opening in the fascia transversalis,
about 1.3 cm above the inguinal ligament; margins of the ring
give attachment to internal spermatic fascia
- superficial inguinal ring: triangular-shaped defect in the
external oblique aponeurosis; lies immediately above and
medial to the pubic tubercle; margins give attachment to
external spermatic fascia
WALLS OF THE INGUINAL CANAL
Anterior: external oblique aponeurosis, reinforced laterally by
origin of internal oblique from inguinal ligament
Posterior: conjoint tendon medially, fascia transversalis laterally
Roof or Superior: arching fibers of internal oblique and
transversus abdominis
Floor or Inferior: inguinal ligament and lacunar ligament

FUNCTIONS OF INGUINAL CANAL

- allows passage of structures to and from the testis to the
abdomen in males or round ligament of uterus from uterus
to labium major in females
-transmits ilioinguinal nerve in both sexes
MECHANICS OF INGUINAL CANAL
- site of potential weakness in both sexes
- arching lowest fibers of internal oblique and transversus
abdominis muscles contract during coughing and straining,
which flattens out the arch so that the roof of the canal is
lowered toward the floor and the canal is virtually closed
HERNIA
- protrusion of a viscus through an opening in the wall of the
cavity in which it is contained
- important features: hernial orifice and sac
- hernial orifice: defect in the innermost aponeurotic layer of the
abdomen
- hernial sac: outpouch of the peritoneum
- can be internal or external

INGUINAL HERNIA
- occurs above the inguinal ligament
- two types: direct and indirect
Indirect Inguinal Hernia
- hernial sac is the remains of processus vaginalis
- most common form of hernia; more common in males
- more common on the right side
- usually seen in children and young adults
- hernial sac enters the inguinal canal through deep inguinal ring
and lateral to inferior epigastric vessels; neck is narrow
- hernial sac may extend through the superficial inguinal ring
above and medial to pubic tubercle
- hernial sac may extend down to scrotum or labia majora

Direct Inguinal Hernia

- common in elderly men with weak abdominal muscles
- sac bulges forward through the posterior wall of the inguinal
canal medial to the inferior epigastric vessels
- neck is wide
PERITONEUM
- serous membrane lining the abdominal and pelvic cavities
and clothing the viscera
- may be regarded as a balloon into which organs are pressed
into from the outside
- parietal layer lines the walls of the abdominal and pelvic cavities
- visceral layer covers the organs
- potential space between the parietal and visceral layer is called
peritoneal cavity
*closed cavity in males
*communicates in the open in females through the fallopian
tubes, uterus and vagina
Peritoneal Cavity
- divided into two parts: greater and lesser sac
- greater sac: main component of the peritoneal cavity and
extends from the diaphragm down into the pelvis
- lesser sac: smaller and lies behind the stomach
- greater and lesser sac communicates through the epiploic
foramen or foramen of Winslow
- peritoneum secretes a small amount of serous fluid, which
lubricates the surfaces of the peritoneum and facilitates
free movement between the viscera
- boundaries of epiploic foramen
anteriorly: free border of lesser omentum, bile duct,
hepatic artery and portal vein
posteriorly: inferior vena cava
superiorly: caudate process of the caudate lobe of the liver
inferiorly: first part of the duodenum
PERITONEAL LIGAMENTS, OMENTA AND MESENTERIES
- permits blood, lymphatic vessels and nerves to reach the viscus
Peritoneal Ligaments
- two-layered folds of peritoneum that connect solid viscera to
the abdominal walls eg. Liver is connected to diaphragm
by the falciform ligament, coronary ligament, and right and
left triangular ligaments
Omenta
- two-layered folds of the peritoneum that connect the stomach
to another viscus
- greater omentum connects the greater curvature of the stomach
to the transverse colon; hangs down like an apron in front of
the cells of the small intestines and is folded back in itself
- lesser omentum suspends the lesser curvature of the stomach
to the fissure of the ligamentum venosum and porta hepatis
of the liver
- gastrosplenic omentum (ligament) connects the stomach to the
hilus of the spleen
Mesenteries
- two-layered folds of peritoneum connect parts of the intestines
to the posterior abdominal wall
eg. Mesentery of the small intestines, transverse mesocolon,
sigmoid mesocolon

Lesser Sac
- lies behind the stomach and lesser omentum
- extends upward as far as the diaphragm and downward
between the layers of the greater omentum
- left margin is formed by the spleen, the gastrosplenic omentum,
lienorenal ligament
- right margin of the sac opens into the greater sac through
the epiploic foramen
PERITONEAL FOSSAE, SPACES AND GUTTERS

Duodenal Fossae – close to the duodenojejunal junction, there

may be four small pouches of peritoneum called superior
duodenal fossa, inferior duodenal fossa, paraduodenal fossa
and retroduodenal fossa
Cecal Fossae - folds of peritoneum close to the cecum produce
three peritoneal fossa called the superior ileocecal, inferior
ileocecal and retrocecal fossae
Subphrenic Space - lies between the diaphragm and the liver
and are called the right and left anterior and posterior
subphrenic spaces are important since they may provide
sites for the accumulation of pus
Paracolic Gutter - lies on the lateral and medial sides of the
ascending and descending colons respectively; provides
channels for the movement of infected fluid in the peritoneal
cavity
NERVE SUPPLY OF THE PERITONEUM

Parietal Peritoneum (for pain, temperature, touch and pressure)

- supplied by the lower six thoracic and first lumbar nerves
- parietal peritoneum in the pelvis is mainly supplied by the
obturator nerve

Visceral Peritoneum (for stretch only)

- supplied by autonomic nerves that supply the viscera or are
traveling in the mesenteries
 THANK YOU

AND

GOOD AFTERNOON