Small intestine

Dr Yasrul Izad Abu Bakar

Faculty of Medicine
UniSZA
 Learning outcome
• Describe the morphology of small intestine

• Explain the gross anatomy and relations of duodenum

• Explain all the differences between duodenum, jejunum and ileum

• Describe the formation, attachment and contents of mesentery

• Describe the microscopic structure of duodenum, jejunum and

ileum

• Discuss the applied anatomy related to small intestine

 Introduction: intestine
The intestine can be divided
into:
• Small intestine (duodenum,
jejunum & ileum) – long,
less distensible (more surface area
for absorption of digested materials)

• Large intestine – shorter,

more distensible (adapted for
absorption of water & formation of fecal
mass)
 Thyphoid fever
• Caused by Salmonellae typhi bacteria.

• Is contracted by ingestion of contaminated food

or water.

• Symptoms including fever with diffuse

abdominal pain & other gastrointestinal
manifestations.

• Diagnosis is made when the Salmonella bacteria

are detected in a stool culture.

• Which organ is mostly affected by the bacteria?

• Is it a life threatening illness?
 General gross features
of small intestine
Internal surface:

1. Circular folds of mucous membrane (plicae

circulares)

2. Lymphatic follicles
 Circular folds of mucous membrane
• A.k.a valves of Kerkring, plicae circulares Duodenum

• Folds are permanent (not obliterated by

distension)

• Begin – 2nd part of duodenum

• Progressively diminish in distal ½ of

jejunum & proximal ½ of ileum (absent in
½ of ileum)
Plicae
• Function: increase surface area & slowing circulares
down passage of contents for absorption
 Lymphatic follicles
• The mucous membrane of small intestine
contains 2 type of lymphatic follicles:

1. Solitary lymphatic follicles

2. Aggregated lymphatic follicles

• Both are most numerous at puberty (diminish in size

& number at old age)
 Lymphatic follicles
Aggregated lymphatic follicles:
• A.k.a Peyer’s patches
• Form circular patches (2-10cm)
• Containing 10-200 follicles
• Largest & most numerous in ileum
• Located at the antimesenteric
border of intestine

Solitary lymphatic follicles:

• 1-2mm diameter
Solitary
• Distributed throughout small & lymphatic Peyer’s
large intestine follicles patches
 Small intestine
• Consists of duodenum, jejunum &
ileum

• Extends from pylorus (of stomach) to stomach

ileocecal junction

• Divided into:
1. Upper fixed part -
• Duodenum

2. Lower mobile part - Ileocecal

junction
• Jejunum
• Ileum
 Pylorus
Duodenum
• The shortest, widest & most
fixed part of small intestine

• It extends from pylorus of

stomach to duodenojejunal Duodenojejunal flexure
flexure

• It curves around the head of

pancreas (C-shaped) Duodenum

• It lies above the level of

umbilicus opposite the L1, L2 &
L3
Jejunum (cut)
 Duodenum: peritoneal relations
Ampulla
• Mostly retroperitoneum
– fixed

• Excepts at the ampulla

(1st part of duodenum) &
the end of duodenum
(suspended by folds of peritoneum)

– mobile

*Ampulla = the initial 2cm

End of duodenum
of duodenum
 Duodenum
- Mostly
retroperitoneum
 Duodenum: parts
• Duodenum is about 25cm

Divided into 4 parts:

• 1st (superior) part – 5cm
1st

• 2nd (descending) part – 7.5cm

2nd

• 3rd (inferior) part – 10cm

4th 3rd

• 4th (ascending) part – 2.5cm

 Duodenum: 1 part st

Hepatoduodenal ligament
Ascends from the pylorus

• Lies anterolateral to L1
vertebra

The proximal part is attached:

1st
1. Superiorly- hepatoduodenal
ligament (part of lesser omentum)
2. Inferiorly- greater omentum
Greater omentum

• Continues as 2nd part at

superior duodenal flexure
 Quadrate lobe

Duodenum: 1st part

Epiploic
Visceral relations: foramen
• Anterior – quadrate lobe of
liver, gall bladder

Portal
• Posterior – bile duct, portal vein
vein & gastroduodenal artery Bile duct

• Superior – epiploic foramen (of

Winslow) Gastroduodenal
artery

• Inferior – pancreas (head &

neck)
 Duodenum: 2nd part
Begins at superior duodenal
flexure

• Lies along the right side L1-L3

vertebrae

2nd
• Parallel to right side of IVC

• Passes inferiorly curving around

head of pancreas towards the
inferior duodenal flexure
Duodenum: 2nd part
Liver
Visceral relations:

Anterior: Transverse
• Right lobe of liver colon
• Transverse colon

Medial:
• Head of pancreas
• Bile duct Kidney

Posterior:
• Right kidney
• Right renal vessels
• Right psoas major
 Duodenum: 2nd part
Internally, it have papilla (elevation) at
the inferior area of 2nd part:

Minor
1. Major duodenal papilla: duodenal
• Located posteromedially papilla
• Opening of Hepatopancreatic
ampulla (bile + main pancreatic ducts)
• 8-10cm from pylorus
Major
2. Minor duodenal papilla: duodenal
papilla
• Opening of accessory pancreatic
duct
• 6-8cm from pylorus
 Duodenum: 3rd part
Begins at inferior duodenal
flexure (at the right side of L3)

• Passes horizontally to the

left in front of IVC & aorta
3rd

• Joint the 4th part in front of

aorta
 Duodenum: 3rd part
Visceral relations:
Anterior:
• Superior mesenteric vessels (SMVs)
Superior
mesenteric artery
Posterior:
• Right gonadal vessels
• IVC
• Aorta
Head of pancreas
Superior:
• Head of pancreas & uncinate
process
 Duodenum: 4th part
Runs superiorly in front of aorta

• Begins at left side of L3 vertebra

• Ends at inferior border of body

of pancreas (L2 level) as
duodenojejunal flexure 4th

• Continues anteriorly as jejunum

Jejunum
 Duodenum: 4th part
Visceral relations:

Superior:
• Body of pancreas

Posterior:
• Left gonadal vessels
 Duodenal ulcer

• Commonly occurs in which part of duodenum?

 Clinical importance
• Most duodenal ulcers occur in the
ampulla (duodenal cap) - because
of possible direct exposure to the Ampulla
acidic contents from stomach Pylorus

Duodenal ulcer:
• Are inflammatory erosions of
duodenal mucosa
• Ulcer pain felt at the right side of
epigastrium
• Anterior ulcer may involve liver,
gallbladder
• Posterior ulcer may erode & lead to
gastroduodenal artery hemorrhage
 Ligament of Treitz
(suspensary muscle of duodenum)
• Is a fibromuscular band which
suspends & supports the
duodenojejunal flexure

• It arises from right crus of diaphragm

• Passes behind pancreas & splenic vein

• Attached to posterior part of:

1. Duodenojejunal flexure
2. 3rd & 4th parts of duodenum Ligament of
Treitz
 Ligament of Treitz
(suspensary muscle of duodenum)
Is made up of:
1. Striped of skeletal muscle fibres
from the diaphragm (upper part)

2. Fibromuscular band of smooth

muscle from 3rd & 4th part of
duodenum (lower part)

• Normally, its contraction may

widen the angle of
duodenojejunal flexure (facilitating Ligament of
movement of intestinal contents) Treitz
 Right iliac fossa pain

• Differential Diagnosis?
 Jejunum & ileum
Jejunum:
• Begins at the duodenojejunul flexure
• Located in upper 2/5 (of mobile small intestine)
• Most lies in left upper quadrant

Ileum:
• Ends at ileocecal junction
• Located in lower 3/5
• Most lies in right lower quadrant

Both:
• Suspended by the mesentery (intraperitoneum)
• Mobile part of small intestine

*no clear demarcation between jejunum & ileum but they have
distinctive characteristics that are surgically important
 Jejunum & ileum: gross differences
Jejunum Ileum
1. Locations Upper & left part of intestine Lower & right part of intestine
2. Colour Red Pink (pale)
3. Vascularity More Less
4. Walls Thicker Thinner
5. Lumen Wider (often empty) Narrower (often loaded)
6. Plicae circulares Larger & closely set Smaller & sparse
(absent in distal part)
 The Mesentery
Mesentery
• A.k.a mesentery of
small intestine

• Is a broad fan-shaped
fold of peritoneum
that suspends
jejunum & ileum from
the posterior
abdominal wall Superior mesenteric
artery in the mesentery
 The Mesentery
Attachment (Root) of Root of
mesentery
mesentery:

• The attached border of

mesentery at posterior wall

• Directed oblique, inferiorly

& to the right

• 15cm long
• 20cm breadth (from root to intestinal
border)
 The Mesentery
Root of mesentery crosses: Root of
mesentery
1. 3rd & 4th part of duodenum (where the
SMVs enters into the mesentery)

2. Abdominal aorta

3. IVC

4. Right ureter

5. Right testicular/ovarian vessels

6. Right psoas major

 The Mesentery
• Contents of the mesentery are:
SMA
1. Superior mesenteric artery with
its jejunal & ileal branches

2. Accompanying veins

3. Nerve plexuses

4. Lympatics & mesenteric lymph

nodes

5. CT with fat
 Mesentery
Distribution of fat:

• Fat tends to accumulate

near the root
Window

• Near the intestinal border,

it leaves circular fat-free,
translucent areas known as
windows
 Jejunum & ileum: the mesentery
Jejunum Ileum
Mesentery Windows Present Absent
Fat Less More
Arterial arcades Few & large loops Many & small loops
(anastomotic loops)
Vasa recta Longer & fewer Shorter & numerous
(straight arteries)

Window

Arcades
(horizontal)

Vasa recta
(Vertical)
Blood supply, innervation &
lymphatic drainage
Duodenum, jejunum & ileum
 Duodenum: arterial supply
Arises from: Coeliac
trunk
1.Coeliac trunk
Gastroduo
2.Superior mesenteric artery denal a
(SMA)

Above opening of bile duct: SPDa

• supplied by superior pancreaticoduodenal
artery (SPDa) – from coeliac trunk
SMA
Below opening of bile duct:
• supplied by inferior pancreaticoduodenal
artery (IPDa) – from SMA

Both arteries anastomose approximately at IPDa

the level of opening of bile duct
 Duodenum: arterial supply
Important transition of blood
supply of digestive tract occurs in
the 2nd part of duodenum:

1. Coeliac trunk supplies structures

from the abdominal part of
oesophagus until the opening of
bile duct
2. SMA supplies structures from
opening of bile duct distally to
the left colic flexure
Embryology:
- Duodenum developed from
both foregut & midgut
- Opening of bile duct is the
junction between foregut &
midgut
 Jejunum & ileum: arterial supply
Jejunal
Arterial supply: arteries
SMVs
Superior mesenteric
vessels through

1. Jejunal arteries

2. Ileal arteries

Ileal
arteries
 Jejunum & ileum
Jejunal
arteries
Superior mesenteric artery – SMA
• Arises from abdominal aorta (1cm Vasa
below coeliac trunk) recta
• Gives rise to 15-18 branches of
jejunum & ileal arteries
Arterial
Jejunum & ileal arteries – arcades
• Unite to form loops called
arterial arcades
• Arterial arcades give rise to
straight arteries called vasa recta
Ileal
arteries
Venous & lymphatic drainage
Hepatic LN

Coeliac LN
Duodenum:
Venous drainage:
1. Splenic vein Portal
2. Superior mesenteric vein vein
• Portal vein

Lymphatic drainage:
• Pancreaticoduodenal LN Pancreatico
• Hepatic LN duodenal LN

• Coeliac LN Splenic
SMv
• Superior mesenteric LN vein
Jejunum & ileum: venous drainage
Superior mesenteric vein
SMV

• It end by unites with

splenic vein to form
portal vein

Jejunal &
ileal veins
 Jejunum & ileum: lymphatic drainage

Lymphatic drainage:
• Lacteals drain into lymphatic vessels
between layers of mesentery
Superior
• Within the mesentery, the lymph central LN
passes into groups of superior
mesenteric LN
1. Juxta-intestinal LN (close to intestinal wall)
2. Mesenteric LN (scattered among arterial
arcades)
3. Superior central LN (near the root of SMA)

Lacteals = specialized lymphatic vessels Mesenteric LN

in intestinal villi
 Innervation of small intestine
• Blue = parasympathetic
(vagus) Right
greater
splanchnic
• Red = sympathetic nerve

(T8 & T10)

Coeliac
ganglia &
• Both pass through the plexus

coeliac ganglia &

plexus
 Small intestine: Greater
splanchnic
innervation nerves

Sympathetic – Coeliac
ganglia
• Originates from T8-T10 > sympathetic Posterior
& plexus
trunks & splanchnic nerves > coeliac & vagal trunk
superior mesenteric ganglia (synapse with
postsynaptic neurons) > intestine
SM ganglia
• Reduces intestinal motility & secretion & plexus
(reducing digestive activity)
• Vasoconstriction

Parasympathetic –
• Derived from posterior vagal trunks >
coeliac & superior mesenteric ganglia >
myenteric & submucosal plexuses in
intestinal wall (synapse with postsynaptic
neurons)
• Increases intestinal motility & secretion
(restore digestive activity)
 Clinical importance
Meckel’s diverticulum (Ileal diverticulum)

• Is a congenital anomaly (1-2% in population)

• Is the persistent proximal part of vitellointestinal duct (normally

dissapears during 6th week intrauterine life)

• Usually appear as a finger-like pouch

• Always at the site of yolk stalk attachment that is
antimesenteric border of ileum

• Its calibre & mucosa equal to ileum

• Its apex may be free (74%) or attached to umbilicus (26%)

• It may become inflamed (produce pain resemble appendicitis)

Histology of small intestine

The duodenum, jejunum & ileum

exhibit similar histological features
with minor differences
Layers of GIT (general)

Muscularis
externa
layer
 Layers of GIT: Mucosa
• The innermost layer

• Also known as mucous Epithelium

membrane
Lamina Mucosa
propia
• Subdivided into 3 layers:
Muscularis
1) Epithelium mucosae
2) Lamina propia
3) Muscularis mucosae
 Epithelium

• Simple columnar
epithelium with
microvilli (striated
border)

• Function: Absorption
Epithelial surface modifications: Microvili

 Cytoplasmic extension
of epithelial cells

 Regular (striated
border)

 Increase intestinal
surface area 20x
 Surface modifications: Villi
Villi are mucosal
(epithelium & lamina
propia) outgrowths that
projects into lumen

• Give intestinal surface a

velvety appearance

• Increase intestinal
surface area 10x
 Surface modifications: Plicae circulares

• Permanent longitudinal folds of

mucosa & submucosa layer

• Well developed in jejunum

• Increase intestinal surface 3x

Plicae circulares:
Folds consist of mucosa & submucosa

Vili
Folds consist of mucosa only
(epithelium & lamina propia)

Microvilli Microvilli + villi + plicae circulares =

Protrusion of epithelial cytoplasma increase 600x of intestinal surface area
 Intestinal gland: Crypts of Liberkuhn
• Located between the villi

• Small tubular invagination

of epithelium into the
lamina propria

• Simple tubular gland

• Lined by absorptive, goblet,

stem, enteroendocrine and
Paneth cells Intestinal gland
CRYPTS OF LIBERKUHN
 Cells of the mucosa
• There are 6 types of cells in the
epithelium/gland (mucosa) of small intestine:
1. Enterocytes
2. Goblet cells
3. Paneth cells
4. Enteroendocrine cells
5. Stem cells (undifferentiated cells)
6. M cells
 Enterocytes
• Also known as intestinal
absorptive cells

• Tall columnar epithelial cells with

microvilli (striated border)

• Site:
• Chiefly on villi
• Less in intestinal gland

• Function: absorption of nutrients

produced by digestion
 Goblet cells
Goblet cell
• Interspersed between the absorptive cells

Site:
• Less abundant in duodenum
• More numerous in ileum

• Produce mucins at apical portion H+E staining

• Appears empty in H+E staining
(mucinogen granules are washed off during preparation)
 Paneth cells
 Exocrine cells
 Site: basal portion of intestinal gland
 Under light microscope:
 Pyramidal-shaped
 Eosinophilic apical cytoplasm
(abundant zymogens granule)
 Basophilic basal cytoplasm

 Antibacterial function:
 Lysozyme enzyme in the granule will
breakdown the wall of certain bacteria
 Phagocytose certain bacteria
 Enteroendocrine cells
• Scattered individually in varying numbers among the enterocytes
• Contains fine granules at basal cytoplasm close to lamina propia & blood vessels
• Produces hormones e.g Gastric inhibitory peptide, Secretin & Cholecystokinin

• Functions of these hormones:

 Regulation of secretions (gastric, pancreas) necessary for digestion
 Control of peristalsis of intestine & contraction of gall bladder

Enteroendocrine
cells
The hormones secreted by this cells
will be directly released into the blood
vessel.
 Stem cells
 Give rise to all types of cell in
mucosa

 Actively divides to replace the

enterocytes & goblet cells once
every 2-4 days

 Lack of distinguish characteristic Stem

cells

 Activities can be detected by

intensely basophilic masses of
condensed chromatin (indicating
active mitosis)
 M cells

 Specialized epithelial cells

overlying the Peyer’s patches
(in ileum)

 Function:
 Endocytose luminal
antigen
 Transport the antigen to
the underlying lymphocyte
& macrophage (MALT) in
lamina propia
 Layers of GIT: Mucosa

• Subdivided into 3 layers:

1) Epithelium Epithelium

Mucosa
2) Lamina propria Lamina
propria
Muscularis
mucosae
3) Muscularis mucosae
 Lamina propria
• Composed of loose connective tissue Lamina propria
• Penetrates the core of each villus

Lymphoid
• Consist of: tissue
1) Lacteal (lymphatic capillaries)
2) Lymphatic nodules:
a. Found throughout small intestine
b. Peyer’s patches:
- Dense collection of lymphoid tissue in
the lamina propria that may extend
into submucosa
3) Mucosa Associated Lymphoid Tissue (MALT)
4) Neurovascular bundles & smooth muscle
 LACTEAL

LACTEAL PEYER’S PATCHES

 Thyphoid fever
Thyphoid fever is a life threatening illness if not
treated early.

• After the ingestion of contaminated food or water,

the Salmonella bacteria invade the small intestine
and enter the bloodstream temporarily.

• Monocytic infiltrates the Peyer patches and

narrows the bowel lumen.

• Peyer patches may be ulcerated in Thyphoid fever

• Necrotic Peyer patches may cause bowel

perforation and peritonitis.
 Layers of GIT: Mucosa

• Subdivided into 3 layers:

1) Epithelium Epithelium

Mucosa
2) Lamina propia Lamina
propia
Muscularis
mucosae
3) Muscularis mucosae
 Muscularis mucosae
Muscularis
mucosa

• Thin layer of smooth

muscles
Layers of GIT (general)

Muscularis
externa
layer
 Small intestine: Submucosa
• Composed of areolar connective
tissue
Submucosa of duodenum with
• Contains: Brunner’s gland
1. Blood vessels
2. Lymphatic vessels
3. Submucosal plexus (Meissner’s
plexus):
• Composed of ganglion cells, nerve
fibers & glial cells
4. Brunner’s gland (in duodenum
only):
• Branched tubular gland
• Produces alkaline to optimize pH of
intestinal contents from the pylorus
(for protection & enzyme action)
Cross section of plicae circularis showing submucosa in the
centre. Presence of ganglion cells of Meissner’s plexus
Layers of GIT (general)

Muscularis
externa
layer
 Small intestine: Muscularis Externa

• Composed of Inner circular &

outer longitudinal smooth
muscles

• Contains Myenteric
(Auerbach’s) plexus between
the 2 muscular layers

• Covered by thin serosa with

mesothelium
 Histological differences between
duodenum, jejunum & ileum
Duodenum Jejunum Ileum
Villi Broad Narrower than Narrowest
(leaf-shaped) duodenum (finger-like)

Number of Few More goblet cells Abundant

Goblet cells than duodenum

Lymphatic Present Present Large & numerous

nodules (Peyer’s patches)

Submucosal Present (Brunner’s Absent Absent

gland gland)
 Duodenum

Jejunum

Ileum

Number of goblet cells are in increasing pattern

From duodenum to illeum
Duodenum Jejunum

Ileum
Thank you…