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  1. 1. DUODENUM Dr. Gurudasan
  2. 2. INTRODUCTION  The adult duodenum is 20– 25 cm long and is the shortest, widest and most predictably placed part of the small intestine.  The proximal 2.5 cm is intraperitoneal, and the remainder is retroperitoneal.  It is C – shaped and lies between L1 – L3 vertebra in supine position.  Head and uncinate process of pancreas lies in the concavity.  The duodenum lies entirely above the level of the umbilicus and is described as having four parts. I II III IV 15-05-2014 2
  3. 3. GROSS FEATURES  Duodenum begins at the pyloric orifice and ends at the duodeno- jejunal flexure.  It has superior & Inferior duodenal flexures which divide the duodenum into 4 parts. Length:  I part – 5 cm  II part – 8 cm  III part – 10 cm  IV Part – 2 cm Pyloric end Superior duodenal flexures Inferior duodenal flexures duodeno- jejunal flexure I II III IV L1 L3 L2 15-05-2014 3
  4. 4. 1st PART OF DUODENUM The proximal 2cm is intraperitoneal. It gives attachment to bo greater and lesser omentum. the lesser omentum is attached its upper border and the greater omentum to its lower border Hepato-duodenal Ligament (part of Lesser omentum) Greater omentum Lesser omentum Upper border of 1st part of duodenum Lower border of 1st part of duodenum I II 15-05-2014 4
  5. 5.  The fixation of duodenum is very crucial as a mobile duodenum will cause twisting and kinking of CBD and pancreatic duct which open in it.  It has a bland internal mucosal appearance and readily distend on insufflation during endoscopy. This part is frequently referred to as the duodenal ‘cap'.  Due to the absence of circular folds of mucus membrane, it has characteristic smooth appearance in contrast I II 15-05-2014 5
  6. 6. SPECIAL FEATURES OF 1ST PART  It is the most movable part being enclosed in lesser and greater omenta.  It is the only part that is related to lesser sac.  It has sparse blood supply compared to other parts, because its arteries are end arteries.  Peptic ulceration is very common as the acid contents of stomach first come in contact with 1st part of duodenum I II III IV Perforation of duodenal wall in extreme cases 15-05-2014 6
  7. 7. Relations of 1st partCommon bile duct Quadrate lobe Anterior: Quadrate lobe of liver, neck and body of gall bladder Posterior: Gastroduodenal artery, portal vein and common bile duct Superior: horizontal part of hepatic artery and epibloic foramen Neck and body of GB Epibloic foramen Gastroduodenal artery Portal vein Head and neck of pancreas (Anterior view)(Posterior view) 15-05-2014 7
  8. 8. 2nd part of duodenum  The second part of the duodenum is 8– 10 cm long.  It starts at the superior duodenal flexure to the right side of the vertebral column till L3.  It then turns sharply medially into the inferior duodenal flexure which marks its junction with the third part of the Superior duodenal flexure inferior duodenal flexure II 15-05-2014 8
  9. 9. Interior of 2nd part of duodenum Major duodenal papillae Minor duodenal papillae Circular folds Longitudinal folds superior duodenal flexure Inferior duodenal flexure Common bile duct Main Pancreatic duct Accessory pancreatic duc 15-05-2014 9
  10. 10. Mucosa of II part of duodenum The distance of major duodenal papilla from pyloric orifice is 10cm and minor duodenal papilla is 7 to 8cm.15-05-2014 10
  11. 11. Accessory pancreatic duct Common bile duct Main pancreatic duct Duodenal papillae Sphincter of CBD (choledochus) Sphincter pancreaticus Sphincter of hepato-pancreatic Ampulla (Oddi) Circular Muscle of duodenum 15-05-2014 11
  12. 12. Relations of 2nd part Gall bladder Right kidney Right colic flexure Right Psoas major IVC Head of pancreas CBD & Pancreatic duct Right Ureter 15-05-2014 12
  13. 13. 3rd part of duodenum  The third part of the duodenum starts at the inferior duodenal flexure and is approximately 10 cm long.  It runs from the right side of the lower border of the third lumbar vertebra, angled slightly superiorly, across to the left, anterior to the inferior vena cava, becoming continuous with the fourth part in front of the abdominal Inferior duodenal flexure Transverse colon Abdominal Aorta III IV I II 15-05-2014 13
  14. 14. Relations of 3rd part of duodenum Uncinate process of head of pancreas Superior mesenteric vessels Inferior mesenteric artery Abdominal AortaIVC Right ureter 15-05-2014 14
  15. 15. 4th part of duodenum It starts just to the left of the aorta, runs superiorly and laterally to the level of the upper border of the L2, then turns sharply anteroinferiorly at the duodenojejunal flexure to become continuous with the jejunum. Abdominal aorta Duodeno-jejunal flexure Superior mesenteric vessels 15-05-2014 15
  16. 16. Relations of 4th part of duodenum Transverse colon Body of pancreas Left psoas major Left gonadal vein Superior mesenteric vessels Left kidney and ureter 15-05-2014 16
  17. 17. STRUCTURE OF DUODENUM 15-05-2014 17
  18. 18. Peritoneal recesses When the retroperitoneal duodenum becomes intraperitoneal jejunum at the duodeno-jejunal flexure, small pockets of pouches (recesses) develop. These are sometimes responsible for the strangulation of hernia and15-05-2014 18
  19. 19. Suspensory ligament of duodenum It is a fibromuscular band which suspends the duodeno-jejunal flexure from Right crus of diaphragm. It consists of I) Striated muscle fibre in the upper part II) Elastic fibres in middle part III) Non – striated muscle fibres in the lower part15-05-2014 19
  20. 20. BLOOD SUPPLY  The main vessels supplying the duodenum are the superior and inferior pancreaticoduodenal arteries.  The first and second parts also receive contributions from several sources including the right gastric, supraduodenal, right gastroepiploic, hepatic and gastroduodenal Common hepatic artery 15-05-2014 20
  21. 21. BLOOD SUPPLY Superior Pancreatico-duodenal Artery (Anterior branch) Inferior Pancreatico-duodenal Artery (Anterior branch) Superior Pancreatico-duodenal Artery (posterior branch) Inferior Pancreatico-duodenal Artery (posterior branch) Gastro-duodenal artery Gastro-duodenal artery Common hepatic artery 15-05-2014 21
  22. 22. VENOUS DRAINAGE Veins correspond to the arteries and drain into superior mesenteric and into the trunk of portal vein. Portal vein Splenic vein Superior mesenteric vein Anterior Superior pancreatico- duodenal vein Anterior Inferior pancreatico- duodenal vein 15-05-2014 22
  23. 23. LYMPHATIC DRAINAGE Coeliac nodes Superior mesenteric nodesPancreatico-duodenal nodes 15-05-2014 23
  24. 24. NERVE SUPPLY: Sympathetic nerves : Coeliac and superior mesenteric ganglia and plexus (T6-T9). Parasympathetic nerve: Vagus Coeliac ganglia and plexus Superior mesenteric ganglia and plexus Posterior vagal trunk Anterior vagal trunk 15-05-2014 24
  25. 25. CLINICAL ANATOMY  Peptic ulcer: It is very common in 1st part of duodenum because the contents of stomach first comes in contact with 1st part. Pain > after food. When food is ingested into the stomach Pylorus closes and no seepage of gastric acid into duodenum No irritation to duodenal mucosa so pain is relieved.15-05-2014 25
  26. 26. Artery of duodenal haemorrhage  Gastroduodenal artery is related to the 1st part of duodenum.  Ulcer on the posterior wall may erode gastroduodenal artery and leads to severe internal bleeding.  Therefore gastroduodenal artery is called 15-05-2014 26
  27. 27. Endoscopic retrograde cholangiopancreatography(ERCP) 15-05-2014 27
  28. 28.  Endoscopic retrograde cholangiopancreatograph y (ERCP) is a technique that combines the use of endoscopy and fluroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenu m and inject radiographic contrast into the ducts in the biliary tree 15-05-2014 28
  29. 29. THANK YOU 15-05-2014 29