Coeliac trunk Dr. A. S.

D’ Souza 2006

It is a short wide vessel about 1.5cm in length, arises from front of the abdominal aorta [first anterior
unpaired branch] immediately below the aortic opening of the diaphragm at the level of the disc between
T12 & L1.

™ Coeliac plexus of nerves surrounds the artery

™ Anteriorly it is related to the lesser sac and lesser omentum
™ On either side related to corresponding crus of the diaphragm and coeliac ganglion
™ It passes forwards and to the right and divides into 3 branches – left gastric, hepatic and splenic.

Left gastric artery

It is the smallest of the three branches of coeliac. The left gastric artery passes upwards and to the left
towards the cardiac end of the stomach, where it arches forwards and downwards and enters the lesser
omentum. Artery then runs in the lesser omentum along the lesser curvature of the stomach, gives many
branches and anastomoses with the right gastric artery. Close to the cardiac orifice it gives a few [2 - 3]
ascending branches to the abdominal part of the oesophagus.

Hepatic artery
This is larger than the left gastric artery, passes to the right behind the lesser sac to reach the upper surface
of the first part of the duodenum. Here the artery enters the lesser omentum and gives out branches – right
gastric and gastro-duodenal. There after the artery continues within the right free margin of the lesser
omentum as hepatic artery proper. The segment of the artery till it gives gastro-duodenal branch is the
common hepatic artery.

Hepatic artery proper runs in the lesser omentum along with the bile duct [on its right side] and portal
vein [posterior]. The hepatic artery proper divides close to the porta hepatis into right and left branches,
which supply respectively the right and left physiological lobes of the liver. Right hepatic artery gives a
branch [cystic artery] to supply the gall bladder.

Right gastric artery

This is a small branch from the common hepatic artery arises close to the gastro-duodenal artery. Right
gastric artery runs to the left within the lesser omentum and gives branches to lesser curvature of the
stomach and ends by anastomosing with the left gastric artery.

Gastro-duodenal artery
It runs downwards behind the first part of duodenum. In the pancreatico-duodenal groove, gastro-
duodenal artery divides into superior pancreatico-duodenal artery and right gastro-epiploic artery.
[Sometimes gastro-duodenal artery gives out supra-duodenal artery, which is an end artery, supplies upper
margin and adjoining surface of the proximal portion of the first part of duodenum.]

Superior pancreatico-duodenal artery

It usually subdivides into anterior and posterior branches, which are lodged in the corresponding
pancreatico-duodenal grooves and anastomose respectively with the anterior and posterior branches of the
inferior pancreatico-duodenal artery [a branch of superior mesenteric artery].

Right gastro-epiploic artery

It passes to the left runs within the greater omentum and after giving series of branches to the greater
curvature and greater omentum it ends by anastomosing with the left gastro-epiploic artery.

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Cystic artery
It is usually a branch from the right branch of the hepatic artery, passes downward and to the right behind
the common hepatic duct. At the neck of the gall bladder cystic artery divides into branches to supply the
gall bladder.

Coeliac trunk & its branches

Splenic artery
It is the largest branch of the coeliac trunk and is remarkably tortuous. The artery passes to the left along
the upper border of pancreas, behind the lesser sac. It crosses the left suprarenal gland and upper part of
the kidney to enter the leino-renal [spleno-renal] ligament, through which it enters the hilum of the spleen
and divides into 5 - 7 splenic branches.

Branches of the splenic artery

1. Pancreatic branches
2. Short gastric branches
3. Left gastro- epiploic artery
4. Splenic branches

Pancreatic branches
Numerous branches arise from the splenic artery as it runs along the superior border of the pancreas to
supply most of the organ except head. One of the branches is large runs on the posterior surface of the
body of the pancreas along the major pancreatic duct and is known as the arteria pancreatica magna.
Another branch runs along the lower border towards the tail is the arteria caudae pancreatica.

Short gastric arteries

5 –7 in number arise from the terminal part of the splenic artery to supply the fundus of the stomach, after
passing between two layers of the gastro-splenic ligament.

Left gastro-epiploic artery

This also arises from the terminal part of the splenic artery close to the hilus of the spleen. It passes
downwards and to the right within the greater omentum, close to the greater curvature, gives out a series
of branches to both surfaces of stomach as well as to the greater omentum. The artery ends by
anastomosing with the right gastro-epiploic artery.

Superior mesenteric artery

It arises from front of the abdominal aorta about 1cm below the coeliac trunk, opposite to the lower
border of L1. It supplies all the derivatives of the midgut, namely the lower part of the duodenum [below
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the opening of common bile duct], jejunum, ileum, caecum, appendix, ascending colon and right two
thirds of the transverse colon [in addition it also supplies lower half of the head of the pancreas].
At its origin the artery is behind the body of the pancreas, runs downwards forwards and to the right [with
a convexity to the left] in front of the uncinate process of the pancreas. The superior mesenteric artery
then crosses successively - third part of the duodenum, inferior vena cava, right psoas major and right
ureter, and passes into the mesentery to reach the right iliac fossa. In the right iliac fossa terminal part of
the artery ends by anastomosing with a branch of the ileocolic artery. The artery is surrounded by a plexus
of nerves and is accompanied by the superior mesenteric vein on its right side.

Branches of superior mesenteric artery, inferior mesenteric artery and the marginal artery

Branches
1. Inferior pancreatico duodenal artery
2. Jejunal and ileal branches
3. Ileocolic artery
4. Right colic
5. Middle colic

Inferior pancreatico duodenal artery [Usually first branch of the superior mesenteric artery]
The artery passes to the right along the upper border the third part of the duodenum and divides into
anterior and posterior branches. These branches ascend between the head of the pancreas and the
duodenum and anastomose with the corresponding branches of superior pancreatico-duodenal artery.
Branches supply the duodenum, head and uncinate process of the pancreas.

Jejunal and ileal branches

About 12 to 15 in number arise from the left side of the superior mesenteric artery and pass between the
layers of the mesentery. Within the mesentery these form arterial arches [by dividing into branches and by
anastomosing with each other].
The jejunal mesentery presents 1 - 2 arterial arcades; ileal has 3 or more arcades since ileal part of the
mesentery is longer. Straight vessels - vasa recta arise from the arterial arcades and supply the jejunum
and ileum [except terminal part of the ileum which is supplied by the ileocolic artery]. The vasa recta are
longer in the jejunum than ileum.

Middle colic artery

It arises from the superior mesenteric artery at the lower border of the pancreas and immediately enters
the root of the transverse mesocolon. Within the mesocolon artery divides into right and left branches.
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Right branch reaches the right colic flexure and anastomoses with the ascending branch of the right colic
artery and the left branch anastomoses with the left colic artery [a branch of inferior mesenteric artery].

Right colic artery

It arises near the middle of concavity of the superior mesenteric artery and passes retro-peritoneally to the
right. Close to the ascending colon it divides into ascending [anastomoses with right branch of middle
colic] and descending [anastomoses with the ascending branch of ileocolic] branches.

Ileo-colic artery
It is a branch from the right side of the superior mesenteric artery. Ileocolic artery runs downwards and to
the right [retro-peritoneally], on reaching the right iliac fossa divides into ascending and descending
branches. The ascending branch anastomoses with right colic artery and descending branch with
termination of the superior mesenteric artery. The descending branch also gives out anterior and posterior
caecal, ileal and appendicular branches.

Appendicular artery – passes behind terminal part of the ileum, enters the mesoappendix a short distance
from the appendicular base. As it passes, it gives a recurrent branch to the base of the appendix, which
anastomoses with a branch of the posterior caecal artery. The appendicular artery approaches tip of the
organ, its terminal part lies on the wall of the appendix and may be thrombosed in appendicitis resulting
in gangrene / necrosis towards its tip [Terminal part - end artery].

Jejunal & ileal arteries – arterial arcades

Inferior mesenteric artery

It arises from the front of the abdominal aorta about 4cm above the aortic bifurcation, opposite to the L3
vertebra. It supplies parts of the gut, which are derived from hindgut [left third of the transverse colon,
descending colon, sigmoid colon, rectum and upper part of the anal canal]. At its origin artery is
overlapped by the third part of the duodenum. It runs downwards and to the left behind the peritoneum,
enters lesser pelvis and continues as the superior rectal artery.

Branches 1. Left colic artery

2. Sigmoid arteries
3. Superior rectal artery

Left colic artery

It passes upwards and to the left behind the peritoneum and divides into ascending and descending
branches. The ascending branch enters the transverse mesocolon and anastomoses with middle colic
artery. The descending branch runs along the descending colon to end by anastmosing with the highest
sigmoid artery.

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Sigmoid arteries
These are 2 - 5 in number, pass downward and to the left and anastomose with each other. Upper most
anastomoses with the descending branch of the left colic artery and the lowest sigmoid artery sends a
branch to anastomose with the superior rectal artery.

Superior rectal artery

It is the continuation of inferior mesenteric artery; on reaching the rectosigmoid junction [S3] artery
divides into right and left branches that descend on each side of the rectum. Branches pierce the rectal
wall and break up into submucous plexus. Straight vessels arising from the plexus reach the anal columns.
Plexus and branches communicate with middle and inferior rectal arteries in the submucosa of the anal
canal.

Marginal artery [of Sudeck or Drummond]

It is an arterial arcade formed by anastomoses of branches of superior and inferior mesenteric arteries,
which is within the concavity of the large intestine [Described by Sudeck 1907 and Drummond in 1914].

¾ The artery is formed by continuous chain of anastomosis between the branches of ileocolic, right
colic, middle colic, left colic and sigmoid arteries.
¾ It lies at a distance of 1 –1.5 inches from the colon. Vasa recta [long and short] arise from the
marginal artery and supply the gut.
¾ This is an important vessel because in the event of occlusion of superior mesenteric artery, it
represents the only surviving route of supply to the gut; flow proceeding retrograde from the inferior
to the superior mesenteric artery.
¾ The anastomosis between the branches of superior and inferior mesenteric arteries may be poor
close to the splenic flexure of colon.

Pancreas
The pancreas is a soft lobulated gland that has both endocrine and exocrine parts.
It is an elongated structure [length 12 –15 cm] lies across the posterior abdominal wall [level of L1 and
L2], extending slightly upwards and to the left from the concavity of duodenum.
It weighs around 80 – 90 gm and resembles a retort shaped flask. It occupies posterior part of the
epigastrium and left hypochondrium and is situated posterior to the stomach.

Parts - From right to left pancreas presents head, neck, body and tail.

Head
It is the expanded right extremity of the pancreas, which is contained within the ‘C’ shaped concavity of
the duodenum. The head is flattened from before backwards and lies at a lower level than the body. It has
3 borders [Superior, inferior and right lateral], 2 surfaces [anterior and posterior] and uncinate process.

Uncinate process – is a triangular projection towards left from the lower part of the head. It passes
upwards and medially posterior to the superior mesenteric vessels and lies on a more posterior plane than
rest of the gland. Tumors of the uncinate process may compress the III part of the duodenum.

Superior border – overlapped by the first part of the duodenum

Inferior border - related to the third part of the duodenum
Right lateral border is related to the second part of the duodenum, terminal part of the bile duct and
the anastomosis between the superior and inferior pancreatico- duodenal arteries.

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 Anterior surface – separated from the neck by the gastro-duodenal artery and is related to the
transverse colon. The superior mesenteric vessels pass anterior to the uncinate process
Posterior surface is related to the IVC, right crus of the diaphragm and bile duct.

Fig. Parts of the pancreas

Neck of the pancreas

This is the slightly constricted part connects head with the body and measures 2cm in length. It is directed
upwards, forwards and to the left and is the most anterior part of the gland. The neck has anterior and
posterior surfaces and superior and inferior borders.

™ Anterior surface is covered by the peritoneum of the lesser sac and is related to the pyloric part of the
stomach
™ Posterior surface presents a shallow groove, which lodges the superior mesenteric vein in the lower
part and portal vein in the upper part.

Ducts of the Pancreas

Body
It is triangular in cross section and has 3 borders [anterior, superior and inferior] and 3 surfaces [anterior,
posterior and inferior].
Anterior surface – related to lesser sac and the stomach
Posterior surface - related to the aorta [with origin of the superior mesenteric artery], left crus of the
diaphragm, left suprarenal gland, left kidney, left renal vessels and splenic vein.
Inferior surface is related to the duodeno-jejunal flexure and left colic flexure

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 Superior border – close to the right end presents a conical projection - tuber omentale [close to the
lesser curvature, behind the lesser omentum]. To the left of the tuber omentale superior border is
related to the splenic artery.
Anterior border – gives attachment to the root of the transverse mesocolon.

Tail [length ranges between 1.5 - 3.5cm]

It is the narrow left end of the gland, passes between the layers of the leino-renal ligament along with
splenic vessels towards the spleen. Tail is the mobile part of the gland and is at a higher level. The tip of
the tail may be in contact with the splenic hilum and is prone for injury during splenectomy.

Ducts of the pancreas

Two ducts – main and accessory pancreatic ducts, drain the exocrine part of the pancreas.

Main pancreatic duct [duct of Wirsung]

It begins in the tail by the union of a number of smaller ducts, passes from left to right through the body
midway between the superior and inferior margins close to the posterior surface. The duct receives a
number of smaller ducts, which open at almost right angles resembling ‘herring bone pattern’.
At the neck the duct bends sharply passing downward, backwards and to the right and reaches the postero-
medial wall of the second part of the duodenum, where it is closely related to the bile duct. Both the ducts
pierce the wall of the duodenum and then unite to form the hepatopancreatic ampulla [of Vater], which
opens on the summit of the major duodenal papilla about 8 - 10cm from the pylorus.

Accessory pancreatic duct [duct of Santorini]

It begins in the lower part of the head and uncinate process of the pancreas, passes upwards and to the
right anterior to the main pancreatic duct [with which it communicates]. It opens into the second part of
the duodenum on the summit of the minor duodenal papilla situated 2 cm above and slightly ventral to the
major duodenal papilla.

Fig. Arterial supply of the pancreas

Arterial supply
1. Superior pancreatico-duodenal artery [branch of gastro-duodenal artery]
2. Inferior pancreatico-duodenal artery [branch of superior mesenteric artery]
3. Pancreatic branches from the splenic artery – major source of supply, supplies the body and tail
(Arteries derived from both coeliac trunk and superior mesenteric artery supply the pancreas, since it
develops at the junction of foregut and midgut)

Venous drainage - corresponds to the arteries and drain into superior mesenteric [inferior pancreatico-
duodenal], splenic and portal [superior pancreatico-duodenal] veins.

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Nerve supply - Sympathetic nerves are derived from the coeliac and superior mesenteric plexuses and
parasympathetic are from both the vagus nerves.

Lymphatic drainage
The head and neck of the pancreas drain into pancreatico-duodenal lymph nodes, body and tail drain into
pancreatico-splenic nodes. Lymph from these nodes flows into coeliac and or superior mesenteric nodes.

Endocrine part of the pancreas

This part is made up of microscopic elements - pancreatic islets of Langerhans. These are ovoid masses of
cells distributed throughout the pancreas [they are most numerous in the tail]. About one to two million
islets are found in the human pancreas.

Applied Anatomy
Head of the pancreas is an occasional site of carcinoma. The malignant growth may obstruct the bile duct
[producing jaundice] and / or compress the portal vein [producing portal hypertension / ascites].

Duodenum
The duodenum is the shortest, widest and most fixed part of the small intestine. It extends from the
pylorus to the duodeno-jejunal flexure with a ‘C’ shaped curve, which encloses the head of the pancreas.
The duodenum lies above the level of the umbilicus, opposite to L1, L2 and L3. The duodenum is mostly
retro-peritoneal, except the first 2cm which is peritoneal [enclosed by the hepato-duodenal part of the
lesser omentum]. It measures 25cm in length and is subdivided into four parts.

First part – [Length: 5cm] begins at the pylorus, passes upwards, backwards and to the right to the
superior duodenal flexure [till the neck of the gall bladder].

Relations
Anterior: Quadrate lobe of the liver and gall bladder
Posterior: Gastro-duodenal artery, bile duct and portal vein
Superior: Epiploic foramen
Inferior: Head and neck of the pancreas

Second part – [Length: 7.5cm] begins at the superior duodenal flexure, passes downwards along the right
side of the vertebral column to the level of third lumbar vertebra. Here it curves to the left [inferior
duodenal flexure] and is continuous with the third part.

Relations
Anterior: Duodenal impression on the right lobe of the liver, transverse colon and coils of the small
intestine [jejunum].
Posterior: Anterior surface of the right kidney close to the hilus, right renal vessels, right psoas major and
right edge of IVC.
Lateral: Right colic flexure
Medial: Head of the pancreas and bile duct

Interior of the second part

1. Circular mucous folds – permanent mucosal folds as seen in other parts of the small intestine.

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2. Major duodenal papilla – conical projection arising from the postero-medial wall. Its summit presents
a single orifice through which the bile duct and pancreatic duct open after forming the heapato-
pancreatic ampulla [sometimes they may have separate openings].
3. Minor duodenal papilla – smaller conical projection situated 2cm above and slightly ventral to the
above. Accessory pancreatic duct when present opens on its summit.

Third Part – [Length: 10cm] begins at the inferior duodenal flexure, passes almost horizontally till the
abdominal aorta and then continues as the fourth part.

Relations
Anterior – superior mesenteric vessels and root of the mesentery
Posterior – right psoas major, right ureter, IVC, and abdominal aorta

Fourth part [Length: 2.5cm]

This part extends from front of the aorta to the duodeno-jeunal flexure situated at the level of L2 about
1.25 cm below the transpyloric plane and 2.5cm to the left of the median plane. The flexure is maintained
in position by suspensory ligament of the duodenum.

Relations
Anterior: Transverse colon and postero-inferior surface of the stomach
Posterior: Left crus of the diaphragm, left psoas major, left renal vessels

Suspensory ligament of the duodenum [Ligament of Trietz]

It is a fibro-muscular band that arises from the right crus of the diaphragm close to the oesophageal
opening. It passes downwards and forwards by the side of the coeliac artery, behind the pancreas and is
attached to the postero-superior surface of the duodenojejunal flexure. The upper third of the band
consists of striated muscle, middle third of elastic tissue and lower third of smooth muscle fibres.

Fig. Arterial supply of the duodenum

Arterial supply
The duodenum develops from both foregut and midgut [opening of the bile duct into the second part of
the duodenum represents the junction between the two]. Above the level of the opening of the bile duct,
the duodenum is supplied by the superior pancreatico-duodenal artery and below it by the inferior
pancreatico-duodenal artery. [Branches from right gastric artery, supra-duodenal artery, retroduodenal
branches of gastro-duodenal artery and some branches from the right gastro-epiploic artery in addition
supply the first part].

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Venous drainage -veins correspond to the arteries and drain into splenic / superior mesenteric / portal vein

Nerve supply - sympathetic nerves are derived from T6 –T10 segments of the spinal cord and pass through
the coeliac and superior mesenteric plexus. The parasympathetics are derived from both vagus nerves.

Lymphatic drainage - lymph vessels drain into the pancreatico-duodenal lymph nodes

Applied Anatomy
™ The first part of duodenum is one of the sites for peptic ulcer. Sometimes the gastro-duodenal artery
passing behind the first part is eroded by the peptic ulcer, producing severe haemorrahge
™ Annular type of pancreas encircles the duodenum; a growth in this type of pancreas may produce
duodenal obstruction.
™ In X-rays taken after a barium meal, first part of the duodenum is seen as a triangular shadow -
duodenal cap

PORTAL VEIN
The [hepatic] portal system includes all the veins draining abdominal part of the digestive tube [except for
the lower part of the anal canal], spleen, pancreas and gall bladder. The portal vein conveys blood from
these viscera to the liver, where it ramifies like an artery ending in the sinusoids, from which vessels
[venules] converge to reach the IVC via the hepatic veins.

Fig. Showing the formation of the portal vein

Special features of the portal vein

1. The portal system of veins begins like veins from the capillary plexus, but ends like arteries by
dividing into branches.
2. In addition to the venous blood it carries absorbed products of digestion.
3. Portal vein and its tributaries are devoid of valves.
4. Two streams of blood pass through the portal vein; right branch of the portal vein conveys most of the
blood from the superior mesenteric vein and the left branch carries that from the splenic vein. [When
the blood passes through the trunk of the portal vein the two streams pass on the respective sides and
there is minimal mixing of blood from superior mesenteric and splenic veins]
5. Out of 1500 ml of blood circulating through the liver per minute about 1200 ml [80%] comes from the
portal vein and 300 ml [20%] from the hepatic artery.
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Formation of the portal vein
It is formed by the union of superior mesenteric and splenic veins behind the neck of the pancreas,
anterior to the IVC and at the level of the 2nd lumbar vertebra.

Course

The portal vein measures about 8cm in length. From its formation it passes upwards and slightly to the
right posterior to the first part of the duodenum. It then enters the right free margin of the lesser
omentum to reach the porta hepatis where it divides into right and left branches.
The right branch is shorter, wider and more vertical; it receives the cystic vein before it enters the
right lobe of the liver.
The left branch is longer, more oblique and smaller in caliber. It traverses the porta hepatis from right
to left, gives branches to caudate and quadrate lobes and just before entering the left lobe it receives
the para-umbilical veins. The left branch is connected to ligamentum teres and ligamentum venosum.
Corresponding branches of the hepatic artery accompany the right and left branches. Hepatic plexus of
nerves and lymph nodes / lymph vessels surround the portal vein in its course.

Fig. Structures entering and leaving porta hepatis

Relations of the portal vein

For descriptive purposes the course can be divided into three parts – Infraduodenal, retro-duodenal and
supra-duodenal

Infra-duodenal part
Anterior – neck of the pancreas
Posterior – IVC
Right – Bile duct

Retro-duodenal part
Anterior – First part of the duodenum, bile duct and gastro-duodenal artery
Posterior – IVC

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Supra-duodenal part
Anterior – hepatic artery and bile duct
Posterior - IVC and epiploic foramen

Intra-hepatic part
The right and the left branches of the portal vein supply the physiological lobes of the liver; branches of
the hepatic artery and bile duct accompany branches of the portal vein.

Tributaries
1. Formative tributaries – superior mesenteric and splenic veins
2. Right and left gastric veins join the trunk of the portal vein
3. Cystic [to the right branch] and para-umbilical veins [to the left branch] join the branches

Porto-systemic communications [Porto-caval anastomosis]

These communications form routes of collateral circulation in portal hypertension / obstruction
Portal obstruction [intra-hepatic or extra-hepatic] may cause ascites.
In cirrhosis of the liver, portal radicles are compressed by contraction of the fibrous tissue.
The portal vein may be compressed by hepatic tumors, enlarged lymph nodes in the lesser omentum
or carcinoma of the head of the pancreas.

Site Portal system Caval system Importance

Lower end of the Oesophageal tributaries of Oesophageal tributaries of Oesophageal varices,

oesophagus the left gastric vein azygos and hemiazygos Haemetemesis
veins
Umbilicus Veins along the Tributaries of the superior Caput medussae –
[Anterior ligamentum teres – para- and inferior epigastric veins dilated tortuous veins
abdominal wall] umbilical veins radiating from
umbilicus
Lower end of the Superior rectal vein [drains Inferior & middle rectal Varicosity leads to
anal canal into the inferior mesenteric veins – drain into internal hemorrhoids [piles]
vein] iliac vein
Retro-peritoneal Veins of colon, duodenum, Renal, lumbar, azygos and Dilated veins around the
organs [parts of pancreas, spleen etc phrenic veins posterior abdominal
colon, duodenum wall
etc]
Bare area of the Venous sinusoids of the Diaphragmatic veins [inter- ----------
Liver liver costal and phrenic]
Patent ductus Left branch of the portal IVC Mixture of portal
venosus vein [products of digestion]
and IVC blood

Development

1. Infra-duodenal part – from a part of the left vitelline vein

2. Retro-duodenal part – from the dorsal anastomosis between the left and right vitelline veins
3. Supra-duodenal part – from the cranial part of the right vitelline vein

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