Anatomically the small intestine extends from the pylorus to the ileocaecal junction. It’s about 6 m long and split into 3 parts: duodenum, jejunum, and ileum. The proximal fixed part that is about 10 inches (25 cm) long is referred to as duodenum. The staying long part that’s freely mobile is split into 2 parts- jejunum and ileum.
The duodenum is mostly retroperitoneal and fixed. It gets chyme from the stomach, bile from the gallbladder, and pancreatic juice from the pancreas. The fixation of duodenum is important because mobile duodenum will cause twisting and kinking of common bile duct (CBD) and pancreatic ducts which open into it. It’s closely connected with pancreas and extra hepatic biliary apparatus. Thus, medically it’s regarded as another thing.
The jejunum and ileum are largely concerned with the digestion and absorption of digested food; for this reason these 2 parts together create the small intestine appropriate. This description of the small intestine is confined only to the jejunum and ileum.
The frst part of the small intestine is the duodenum. This C-shaped structure, adjacent to the head of the pancreas, is 20 to 2 5 em long and is above the level of the umbilicus; its lumen is the widest of the small intestine. It is retroperitoneal except for its beginning, which is connected to the liver by the hepatoduodenal ligament, a partn of the lesser omentum.
See Duedenum for more.
Jejunum and Ileum
The small intestine suitable stretches from the duodenojejunal flexureto the ileocaecal junction. Its upper two fifth creates the jejunumand its lower 3-fifth creates the ileum. Nevertheless, there’s no clear line of demarcation. The jejunum and ileum are suspended from the posterior abdominal wall by a large fold of peritoneum known as the mesentery of small intestine; thus, the small intestine appreciates a substantial freedom. The structure of the small intestine corresponds to its functional demands.
The wall of the small intestine contains 4 layers. From inside outward, these are: (a) mucosa, (b) submucosa, (c) muscle layer, and (d) serosa.
The mucosa presents the subsequent 3 important features. Larger Surface Area.
For digestion and absorption of nutriments, the surface area of mucus membrane is extremely improved by plicae circulares, villi, and microvilli.
- Plicae circulares (or valves of Kerckring): All these are circular folds, that are long-lasting and aren’t obliterated by distension.
- Villi: The surface of circular folds is thrown into small (0.5 mm or less in length) finger like projections named villi.
- Microvilli: The surface epithelium covering the villi presents microvilli (or striated border).
Points to be noticed
- The overall surface area of mucosa of the small intestine is all about 200 m2.
- The whole epithelial lining of the small intestine is replaced in every 2 to 4 days.
Intestinal Glands (Crypts of Lieberkuhn).
Between the bases of villi, the epithelium is invaginated in the lamina propria to create intestinal glands. They secrete digestive enzymes and mucous.
The lamina propria of the mucous membrane includes 2 types of lymphatic follicles.
- Solitary lymph follicles: These are 1-2 millimeters in diameter and are spread through the length of the small intestine.
- Aggregated lymph follicles: They create circular or oval Positions named Peyer’s patches. Every Peyer’s patch is composed of about 260 solitary lymph follicles and its length varies from 2 to 10 cm. They’re present lengthwise along the antimesenteric border. Peyer’s patches are small, circular, and fewer in the distal part of the jejunum, and large, oval, and numerous in the ileum especially in its distal part. In the distal part of the ileum where Peyer’s patches are a lot bigger and most numerous may go in the submucosa after breaking the muscularis mucosa.
It’s created from loose areolar tissue and includes blood vessels, lymph vessels, and nerve plexus (Meissner’s plexus).
It’s created from outer longitudinal and inner circular layers of smooth muscle. Auerbach’s plexus of nerves is present between these 2 layers.
It’s created by the visceral peritoneum and is lined by the simple squamous epithelium.
Typhoid And Tubercular Ulcers
Peyer’s patches may be felt via the antimesenteric border of the ileum. They may ulcerate in typhoid fever creating feature vertically oriented, oval ulcers which might occasionally perforate. Because of this, patients afflicted by typhoid fever are given hot soft diets.
N.B. After mending, the typhoid, ulcers don’t cause intestinal obstruction like tubercular ulcers. Notice, the tubercular ulcers are circularly put; therefore, after recovering they frequently cause constriction of the lumen of small intestine by fibrous tissue, resulting in Intestinal Obstruction
The jejunum and ileum are provided by the jejunal and ileal branches (12-15 in number) of the superior mesenteric artery they originate from the left side of the superior mesenteric artery and goes into the mesentery to reach the intestine the terminal part of the ileum is provided by the ileal branches of the ileocolic branch of the superior mesenteric artery as soon as these goes into the mesentery they break up into smaller branches which anastomose with every other to create a series of arterial arcades that are more complex in the ileum than in the jejunum.
From the convexities of the endmost arcades, small parallel straight vessels named “vasa recta” originate and pass to the mesenteric border of the gut to be spread instead to the opposite surfaces of the small intestine. The anastomosis between the vasa recta is lousy.
The veins correspond to the branches of superior mesenteric artery and drain into the portal vein, which takes the products of protein and carbs to the liver.
The lymph vessels from the small intestine go through a large number of mesenteric nodes (lymph nodes within the mesentery) and ultimately drain into superior mesenteric nodes present around the origin of superior mesenteric artery. The lymphatics of the small intestine have a circular course in its wall. The circular tubercular ulcers and following strictures in the small intestine are because of participation of these lymphatics in tuberculosis.
The small intestine is provided by both sympathetic and parasympathetic nerve fibres. The sympathetic provide is originated from T10 T11 spinal sections via splanchnic nerves and superior mesenteric plexus. Because of this, pain from the jejunum and ileum is referred to the umbilical region. The parasympathetic provide is originated from the vagus nerves via the coeliac and superior mesenteric plexuses.
The sympathetic fibres are motor to the gut-sphincters on the other hand the parasympathetic fibresstimulate the peristalsis and are inhibitory to the sphincters.
Mesentery of The Small Intestine
It’s a broad fan-shaped fold of the peritoneum, which suspends the small intestine (jejunum and ileum) from the posterior abdominal wall. It’s the root (connected margin) and free margin (intestinal margin). The root is connected to an oblique line across the posterior abdominal wall going from the duodenojejunal flexureto the ileocaecal junction.
The duodenojejunal flexure is located to the left side of 2nd lumbar vertebra, on the other hand ileocaecal junction is located at the right sacroiliac joint.
The root of mesentery is around 6 inches (15 cm) long while its free margin (periphery of the mesentery) is about 6 m long. This accounts for the creation of folds/ pleats in it (a frill-like arrangement resembling a full skirt).
Surface Marking of The Root of Mesentery
The point representing the duodenojejunal flexure is located 1 cm below the transpyloric plane and 2.5 cm to the left of midline. The point representing the ileocaecal junction corresponds to the point of intersection between right lateral and transtubercular planes.
A. The great length of the mesentery enables the descent of the loop of small intestine into the sac of inguinal or femoral herniae.
B. A group of lymph nodes when contaminated may become adherent to an adjoining loop of small intestine and can lead to the mechanical obstruction. An acute terminal mesenteric lymphadenitis is usually indistinguishable from an acute appendicitis.
C. Mesenteric cyst: The mesentery is the site of cystic swellings which largely originate from the mesenteric lymph nodes. Medically, the mesenteric cyst shows as a painless, cystic fluctuant swelling in the umbilical region. On evaluation, the characteristic attribute of the swelling is that it’s more mobile in the way at right angles to the line of the connection of the mesentery and less mobile along the line of connection of the mesentery.
D. The failure of root of mesentery to fuse over its whole length together with the posterior abdominal wall enables a pocket of the peritoneum to be created which may create a sac of an intraparietal hernia referred to as mesenteric parietal hernia of Waldeyer.
The differences between the duodenum and small intestine suitable (jejunum and ileum) are provided in the following box:
Differences between the Jejunum and Ileum
Both jejunum and ileum have characteristic features which make them identifiable during procedure by the surgeons.
The jejunum is more vascular than the ileum and is somewhat wider in diameter compared to the ileum. It feels thicker between the finger and thumb in relation to the ileum, because its mucous membrane is thrown into more and closely place circular folds (plicae circulares). The ileum, on the flip side, possesses many more aggregated lymph follicles (Peyer’s patches) in its wall than jejunum.
Differences Between The Jejunum And Ileum
The jejunum and ileum grow from the U shaped midgut loop having cephalic and caudal limbs. The cephalic limb provides rise to the jejunum and upper part of the ileum, and the caudal limb provides rise to the lower part of the ileum. In the embryonic life, the apex of the midgut loop interacts with the yolk sac via the vitello-intestinal duct. The vitelline duct is usually obliterated by the sixth week of intrauterine life.
Meckel’s Diverticulum (or Ileal Diverticulum)
Itis the continual proximal part of the embryonic vitello-intestinal duct. It presents the following characteristic features:
- It takes place in 2 percent of the themes.
- It’s generally 2 inches (5 cm) long.
- It’s situated about 2 feet (60 cm) proximal to the ileocaecal junction.
- It’s much more common in men.
- The calibre and structure of its wall are quite similar to that of the ileum.
- Its apex could be free or connected to the umbilicus by a fibrous band.
- It’s connected to the antimesenteric border of the ileum.
- It may include ectopic gastric mucosa and pancreatic tissue.
Normally, it’s symptomless but might cause the following clinical problems:
- It can cause intestinal obstruction.
- When it includes ectopic gastric mucosa or pancreatic tissue, its thin wall may ulcerate, perforate, and bleed to mimic the acute abdomen.
- When inflamed, its symptoms are like that of “acute appendicitis”.
Dictum: In a medically diagnosed case of acute appendicitis, if a healthy appendix is seen during procedure the surgeon should look for Meckel’s diverticulum.