Development of stomach

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Development of stomach, Rotations, Abnormal rotations leading to volvulus

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  • It is reported that most cases of chronic gastric volvulus are related to mesenteroaxial rotation. Additionally is described in the literature that a normal stomach cannot rotate more than 180° unless the gastrosplenic or gastrocolic ligaments are divided. The aetiology of gastric volvulus is thought to be secondary to laxity or lack of the gastric (gastrohepatic, gastrosplenic, gastroduodenal, and gastrophrenic) ligaments, allowing approximation of cardiac and pyloric ends when the stomach is full, leading to volvulus,The mortality rate of gastric volvulus is reported to be up to 42–56%, secondary to gastric ischaemia, perforation, and necrosisRef: http://dx.doi.org/10.1155/2013/561752Gastric Volvulus and Wandering Spleen: A Rare Surgical Emergency
  • Development of stomach

    1. 1. EMBRYOLOGY, BLOOD SUPPLY AND RELATED SURGICAL ANATOMY OF STOMACH
    2. 2. The stomach is a muscular, hollow, dilated part of the digestion system, which functions as an important organ of the digestive tract. It is involved in the second phase of digestion, following mastication (chewing). The stomach is located between the esophagus and the small intestine.
    3. 3. The trilaminar embryonic plate undergoes four foldings to produce the ultimate three dimensional embryo.
    4. 4. During the cephalocaudal and lateral folding of embryo, a portion of the endoderm lined yolk sac is incorporated into the embryo to form the primitive gut. Foregut Midgut Hindgut Subdivisions of primitive gut Foregut Midgut Hindgut
    5. 5. 2 – 3 weeks (IUL) The gastrointestinal tract (GIT) extending from the Buccopharyngeal membrane to the Cloacal membrane arises initially from the endoderm of the trilaminar embryo. It later has contributions from all the germ cell layers. Stomodeum Cloacal membrane Septum transversum Foregut Midgut Hindgut
    6. 6. Larygo-tracheal groove Pre laryngeal (Cephalic part) Post laryngeal (Caudal part) Foregut Oesophagus Stomach Duodenal segment Off shoots – liver (biliary apparatus) & Pancreas
    7. 7. The stomach appears as a dilation of the foregut caudal to the esophagus during the fourth week of development. Stomach Oesophagus Intestines Buccopharyeal membrane Cloacal membrane Ventral (Anterior) Dorsal (Posterior) RL
    8. 8. Descent-Due to rapid elongation of the esophagus, the cardiac end of the stomach descends from C2 at 4 weeks to T11 at 12 weeks As stomach enlarges, it slowly rotates through 90 degrees,
    9. 9. The stomach evolves by two rotations along a 1. Longitudinal and 02. Anteroposterior axis. Longitudinal axis Anteroposterior axis
    10. 10. The longitudinal rotation of the stomach involves a 90° clockwise rotation resulting in the right side of the stomach becoming posteriorly oriented and the left side of the stomach facing anteriorly.
    11. 11. This explains why the left vagus nerve innervates the anterior wall of the stomach and the right vagus nerve innervates the posterior wall of the stomach in the adult.
    12. 12. The stomach subsequently rocks on its longitudinal axis, causing the pylorus to shift to right and the cardiac orifice to shift to the left.
    13. 13. • Initially the two ends of the stomach lie in the midline. • During rotation: – the cranial end moves to the left and slightly downward. – the caudal end moves to the right and upward. • After rotation, stomach assumes its final position with its long axis running from above left to below right.
    14. 14. During this rotation one side of the stomach grows faster than the other forming the greater and lesser curvatures of the stomach Oesophagus Intestines Stomach Lessercurvature Greatercurvature
    15. 15. Development of omentum • Ventral border of stomach – connected with anterior body wall by ventral mesogastrium • Dorsal border of stomach - connected with posterior abdominal wall by dorsal mesogastrium. Dorsal mesogastrium Ventral mesogastrium
    16. 16. Hepatic bud divides ventral mesogastrium into 1) Lesser omentum 2) Falciform & coronary ligament. Developing spleen divides the dorsal mesogastrium into 1) Gastro-splenic ligament 2) Lieno-renal ligament . Lienorenal Ligament Gastrosplenic Ligament Lesser omentum Falciform Ligament
    17. 17. Begins as small isolated clefts in the dorsal mesogastrium, that soon join to form a single cavity Rotation of stomach pulls the dorsal mesogastrium to the left thus enlarging the cavity The bursa expands transversely and cranially and lies between the stomach and the posterior abdominal wall
    18. 18. The superior part of the bursa is cut off as the diaphragm develops. Inferiorly it persists as the superior recess of the omental bursa The inferior part grows Within the 4-layered greater omentum forming the inferior recess of the omental bursa. The inferior recess later on closes down because of fusion of the layers of the greater omentum.
    19. 19. Factors demanding rich vascularity: 1. Highly distensible & mobile area in GI Tract (Frequent changes in volume) 2. Five types of cells – High metabolic activity 3. 2nd phase of digestion – Brisk peristalsis 4. Three layers of sheets of muscles. 5. Propulsive pressures against pyloric sphincter and physiological oesophageal sphincter. Coeliac trunk : Direct anterior branch from aorta is main source of arterial supply.
    20. 20. Arterial arcade Subserosal plexus Intramuscular plexus Sub mucosal plexus Mucosal plexus Mucosal capillaries Along the lesser and the greater curvature of stomach Patch of mucosa is prone to vascular obstruction They do not anastomose with each other
    21. 21. 1.Oesophagus 2.Duodenum 3.Lesser omentum 4.Phrenico colic lig. 5.Gastro splenic lig. 6.Blood vessels – Coeliac trunk 7.Veins, Lymphatics & Nerves 8.Structures forming stomach bed 9.Liver, spleen and diaphragm 10.anterior and lateral abd. Wall 11.Intra abdominal pressure.
    22. 22. 01. Malrotation of stomach 02. Changes in shapes of stomach 03. Variation of origin of blood vessels 04. Congenital hypertrophic pyloric stenosis
    23. 23. Gastric volvulus or volvulus of stomach a twisting of all or part of the stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death. The twisting can occur around the long axis of the stomach - organoaxial or around the axis perpendicular to this - mesentericoaxial. About one third of volvulus cases are associated with hiatus hernia.
    24. 24. Gastric volvulus is a rare but potentially life-threatening clinical entity due to possible gastric necrosis. A wandering spleen may also be associated with gastric volvulus.
    25. 25. Borchardts triad: 1. Severe epigastric pain 02. Vomiting followed by violent retching with inability to vomit 03. Inability to pass NGT
    26. 26. The stomach rotates around an axis that connects the Gastro-esophageal junction and the pylorus. Antrum rotates in opposite direction to the fundus of stomach Comprises 59% of cases of gastric volvulus. Obstruction is common in organoaxial volvulus Short axis Antrum
    27. 27. The axis bisects the lesser and greater curvatures. The antrum rotates anteriorly and superiorly so that the posterior surface of the stomach lies anteriorly Comprises 29% of cases of gastric volvulus. Ischaemia is common in mesentericoaxial volvulus. Greater curvature Long axis Lesser curvature
    28. 28. A A A B B B

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