The most proximal portion of the small intestine is the duodenum. Its name is derived from the Latin‘duodenum digitorum’, meaning twelve fingers length. It runs from the pylorus to the duodenojejunal junction.
The duodenum can be divided into four parts;
- inferior and
Together these parts form a ‘C’ shape, which wraps around the head of the pancreas.
The first section of the duodenum (‘the cap’) is 5cm in length. It ascends upwards from the pylorus of the stomach, and is connected to the liver by the hepatoduodenal ligament. This area is most common site of duodenal ulceration.
The initial 3cm of the superior duodenum is covered anteriorly and posteriorly by visceral peritoneum, with the remainder retroperitoneal (only covered anteriorly).
The descending portion curves inferiorly around the head of the pancreas. It lies posteriorly to the transverse colon, and anterior to the right kidney.
Internally, the descending duodenum is marked by the major duodenal papilla – an opening for bile and pancreatic secretions to enter.
The duct responsible carrying these secretions is known as the ampulla of Vater (hepatopancreatic ampulla).
After the duodenum crosses the aorta, it ascends and curves anteriorly to join the jejunum at a sharp turn known as the duodenojejunal flexure.
Located at the duodenojejunal junction is a slip of muscle called the suspensory muscle of the duodenum. Contraction of this muscle widens the angle of the flexure, and aids movement of the intestinal contents into the jejunum.
Jejunum and Ileum
The jejunum and ileum are the distal two parts of the small intestine. In contrast to the duodenum, they are intraperitoneal.
They are attached to the posterior abdominal wall by mesentery (a double layer of peritoneum).
The jejunum begins at the duodenojejunal flexure. There is no clear external demarcation between the jejunum and ileum – although the two parts are macroscopically different. The ileum ends at theileocecal junction.
At this junction, the ileum invaginates into the cecum to form the ileocecal valve. Although it is not developed enough to control movement of material from the ileum to the cecum, it can prevent reflux of material back into the ileum.
Vasculature of the Small Intestine
- Proximal to the major duodenal papilla – supplied by the gastroduodenal artery (branch of the coeliac trunk).
- Distal to the major duodenal papilla – supplied by the inferior pancreaticoduodenal artery (branch of superior mesenteric artery).This transition is important – it marks the change from the embryological foregut tomidgut. The veins of the duodenum follow the major arteries and drain into the hepatic portal vein.
Jejunum and Ileum
The arterial supply to the jejunoileum is from the superior mesenteric artery.
The superior mesenteric artery arises from the aorta at the level of the L1 vertebrae, immediately inferior to the coeliac trunk.
It moves in between layers of mesentery, splitting into approximately 20 branches. These branches anastomose to form loops, called arcades.
From the arcades, long and straight arteries arise, called vasa recta. The venous drainage is via the superior mesenteric vein.
It unites with the splenic vein at the neck of the pancreas to form the hepatic portal vein.
A duodenal ulcer is the erosion of the mucosa in the duodenum. It is also known as a peptic ulcer (although this term can also be used to refer to ulcerations in the stomach). Duodenal ulcers are most likely to occur in the superior portion of the duodenum.
The most common causes of duodenal ulcers are helicobacter pylori infection and chronic NSAID therapy.
An ulcer in itself is not particularly troublesome. However, it can give rise to some serious complications if the duodenal wall is perforated: