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SECTION E: STOMACH AND DUODENUM

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Chapter 44

Gastric Anatomy and Physiology

Michael W. Mulholland

Key Points

1 The stomach is an extremely well-vascularized organ, supplied by a number of major arteries and

protected by a large number of extramural and intramural collaterals.

2 Oxyntic glands occupy the fundus and body of the stomach and contain the oxyntic or parietal cells,

which are the sites of acid production. Oxyntic glands also contain chief cells, the site of gastric

pepsinogen synthesis.

3 The most important stimulant of gastrin release is a meal. Postprandial luminal pH also strongly

affects gastrin secretion.

4 The basolateral membrane of the parietal cell contains specific receptors for histamine, gastrin, and

acetylcholine, the three major stimulants of acid production.

5 Pepsins are a heterogeneous group of proteolytic enzymes that are secreted by the gastric chief cells.

6 The gastric mucosa is the site of production of intrinsic factor, which is necessary for the absorption

of cobalamin from the ileal mucosa. Total gastrectomy is regularly followed by cobalamin

malabsorption, as is resection of the proximal stomach or atrophic gastritis that involves the oxyntic

mucosa.

GROSS ANATOMY

The stomach and duodenum, along with the esophagus, liver, bile ducts, and pancreas, are derived from

the embryonic foregut. During the fifth week of gestation, the future stomach is marked as a dilation in

the caudal portion of the foregut. Cranial to this dilation, the trachea forms as a bud from the future

esophagus. At this time, the primitive stomach is invested with both ventral and dorsal mesenteries. The

embryonic ventral mesentery is represented in postnatal life by the falciform ligament and by the

gastrohepatic and hepatoduodenal mesenteries that form the lesser omentum. The celiac artery, the

major blood supply to the foregut, passes within the dorsal mesentery. The primitive dorsal mesentery

ultimately forms three structures: the gastrocolic ligament, the gastrosplenic ligament, and the

gastrophrenic ligament.

During the sixth and seventh weeks of gestation, the typical morphology of the stomach is

established. Accelerated growth of the left gastric wall, relative to the right, establishes the greater and

lesser curvatures. This unequal growth also rotates the stomach and causes the left vagal nerve trunk to

assume its anterior position, whereas the right vagal trunk is located posteriorly. The growth of

structures cephalad to the stomach causes the organ to descend. During the sixth week, the primitive

stomach lies between the T10 and T12 vertebral segments. By the eighth week, the stomach is located

between the T11 and the L4 segments. In adult life, the stomach is most commonly located between the

T10 and the L3 vertebral segments.

The stomach can be divided into anatomic regions based on external landmarks (Fig. 44-1). Although

this division is commonly referred to in surgical texts and is useful in discussing gastric resective

procedures, it does not necessarily reflect the secretory or motor functions of the mucosal and muscular

layers of the stomach. The gastric cardia is the region of the stomach just distal to the gastroesophageal

junction. The fundus is the portion of the stomach above and to the left of the gastroesophageal

junction. The corpus constitutes the region between the fundus and the antrum. The margin between the

corpus and antrum is not distinct externally but can be defined arbitrarily by a line from the incisura

angularis on the lesser curvature to a point one-fourth the distance from the pylorus to the esophagus

along the greater curvature. The gastric antrum is bounded distally by the pylorus, which can be

appreciated by palpation as a thickened ring of smooth muscle.

The stomach is mobile in most people and is fixed at only two points, proximally by the

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gastroesophageal junction and distally by the retroperitoneal duodenum. Therefore, the position of the

stomach varies and depends on the habitus of the person, the degree of gastric distention, and the

position of the other abdominal organs. Anteriorly, the stomach is in contact with the left

hemidiaphragm, the left lobe and the anterior segment of the right lobe of the liver, and the anterior

parietal surface of the abdominal wall. The posterior surface of the stomach is related to the left

diaphragm; the left kidney and left adrenal gland; the neck, tail, and body of the pancreas; the aorta and

celiac trunk; and the periaortic nerve plexuses. The greater curvature of the stomach is near the

transverse colon and the transverse colonic mesentery. The concavity of the spleen contacts the left

lateral portion of the stomach.

1 The stomach is an extremely well-vascularized organ, supplied by a number of major arteries and

protected by a large number of extramural and intramural collaterals. Gastric viability can be preserved

after ligation of all but one primary artery, an advantage that can be exploited during gastric

reconstructive procedures. Also, the rich network of anastomosing vessels means that gastric

hemorrhage cannot be controlled by the extramural ligation of gastric arteries. Most gastric blood flow

is ordinarily derived from the celiac trunk (Fig. 44-2). The lesser curvature is supplied by the left gastric

artery, which is the first major branch of the celiac trunk, and by the right gastric artery, which is

derived from the hepatic artery. Branches of the left gastric artery also supply the lowermost portion of

the esophagus. The greater curvature is supplied by the short gastric and left gastroepiploic arteries,

which are branches of the splenic artery, and by the right gastroepiploic artery, a branch of the

gastroduodenal artery. In instances of celiac trunk occlusion, gastric blood flow is usually maintained

from the superior mesenteric artery collaterally by way of the pancreaticoduodenal arcade. In general,

venous effluent from the stomach parallels the arterial supply. The venous equivalent of the left gastric

artery is the coronary vein.

Figure 44-1. Topographic relations of the stomach.

As a first approximation, the lymphatic drainage of the stomach parallels gastric venous return (Fig.

44-3). Lymph from the proximal portion of the stomach along the lesser curvature first drains into

superior gastric lymph nodes surrounding the left gastric artery. The distal portion of the lesser

curvature drains through suprapyloric nodes. The proximal portion of the greater curvature is supplied

by lymphatic vessels that traverse pancreaticosplenic nodes, whereas the antral portion of the greater

curvature drains into the subpyloric and omental nodal groups. Secondary drainage from each of these

systems eventually traverses nodes at the base of the celiac axis. These discrete anatomic groupings are

misleading. The lymphatic drainage of the human stomach, like its blood supply, exhibits extensive

intramural ramifications and a number of extramural communications. As a consequence, disease

processes that involve the gastric lymphatics often spread intramurally beyond the region of origin and

to nodal groups at a distance from the primary lymphatic zone.

The left and right vagal nerves descend parallel to the esophagus within the thorax before forming a

periesophageal plexus between the tracheal bifurcation and the diaphragm. From this plexus, two vagal

trunks coalesce before passing through the esophageal hiatus of the diaphragm (Fig. 44-4). The left

vagal trunk is usually closely applied to the anterior surface of the esophagus, whereas the posterior

vagal trunk is often midway between the esophagus and the aorta. The anterior vagus supplies a hepatic

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