Content Reviewers:Scott Caterine, BSc (Hons.), MSc, MB, BCh, BAO (Hons.), Viviana Popa, MD
The small intestine is a part of the digestive tract specialized in absorbing nutrients and minerals from the food we eat.
It’s located in the abdominopelvic cavity, and it begins at the pylorus of the stomach and it ends at the ileocecal junction, where it continues with the large intestine.
It has three major components: the duodenum, which can be divided into four parts, the jejunum and the ileum.
Now, when talking about structures of the abdomen we often encounter the terms ‘retroperitoneal’ or ‘intraperitoneal’.
Retroperitoneal is a description for abdominal structures that are only partially covered by peritoneum and lie posterior or behind the abdominal peritoneum, where intraperitoneal means that these structures have invaginated and are completely covered by the visceral peritoneum.
So, of these components, the proximal portion of the first part of the duodenum, in addition to the jejunum and ileum are intraperitoneal, where the distal portion of the first part of the duodenum, in addition to the second, third, and fourth parts of the duodenum are retroperitoneal, and are found posteriorly in the retroperitoneal cavity.
That being said, let’s have a closer look at the duodenum and its four parts.
Overall, the duodenum is shaped like the letter C, curving around the head of the pancreas, and consists of the first, or superior part; second, or descending part; third, or inferior part; and fourth, or ascending part.
The first part lies in the transverse plane and begins anterolaterally to the right of the L1 vertebral body, continuing the pylorus.
The proximal portion of the first part has a segment of the lesser omentum called the hepatoduodenal ligament attached to its superior surface, and the greater omentum attached to the inferior surface.
The proximal 2cm of the first part is also more dilated and freely mobile as it is intraperitoneal with its anterior and posterior surface covered in peritoneum, and is referred to as the ampulla or the duodenal cap.
This is in contrast to the distal 3cm which is retroperitoneal, and therefore not mobile.
The first part of the duodenum travels laterally to the right and has the liver and gallbladder overlying it, and it has the IVC, bile duct and gastroduodenal artery posterior.
The second part, or descending part of the duodenum, is completely retroperitoneal.
It curves downward around the head of the pancreas which is medial, and runs inferiorly from the L1 to the L3 vertebra, to the right of and parallel to the IVC.
Overlying the second part is the transverse colon and the convolutions of the small intestine,....where posterior to it there’s the hilum of the right kidney, its vessels and ureter.
If we open up the second part of the duodenum and look inside, we can see the major duodenal papilla on its posteromedial wall.
That’s where the main pancreatic duct combines with the common bile duct to form a hepatopancreatic ampulla, which carries the pancreatic juices and bile to the duodenum.
Of note, these can also be referred to as the papilla of vater and ampulla of vater respectively, not to be confused with the popular Darth Vader.
Sometimes, above the major duodenal papilla there is also a minor duodenal papilla where the accessory pancreatic duct opens.
The duodenum then turns to the left, and the third part starts at the level of L3.
This part is also completely retroperitoneal. The third part of the duodenum passes horizontally to the left below the head of the pancreas.
Anterior to the inferior part there are: the superior mesenteric artery, or SMA, the superior mesenteric vein, or SMV, and parts of the jejunum.
Finally, the duodenum turns upwards and becomes its fourth part, called the ascending part, which ascends to the left of the L3 vertebra and aorta, up to the L2 vertebral level and the inferior border of the pancreas.
Medial to the fourth part, there are the SMA, SMV and uncinate process of pancreas.
Then, it turns anteriorly to connect with the jejunum, forming the duodenojejunal flexure or junction at the level of L2.
This site hangs by the suspensory muscle of the duodenum, also known as the ligament of Treitz, that is made out of the skeletal muscles from the diaphragm and the smooth muscles of the duodenum.
Now, the duodenum mainly gets arterial blood from the celiac trunk and the SMA.
The celiac trunk gives off the common hepatic artery, which also gives rise to the supraduodenal artery supplying portions of the first and second duodenal parts, and the gastroduodenal artery, which has a branch called the superior pancreaticoduodenal artery, that supplies the first two parts of the duodenum up until the major duodenal papilla.
The SMA, on the other hand, gives off a branch called the inferior pancreaticoduodenal artery, which supplies the other two parts of the duodenum, distal to the major duodenal papilla.
The superior and inferior pancreaticoduodenal arteries give anterior and posterior branches that connect with each other, forming anastomoses between the celiac trunk and the SMA.
The veins of the duodenum drain alongside the arteries and venous blood is collected by the splenic and superior mesenteric vein which eventually drain into the hepatic portal vein.
The lymphatic vessels of the duodenum accompany arteries as well and drain via the pancreaticoduodenal lymph nodes located along the superior and inferior pancreaticoduodenal arteries, to the pyloric lymph nodes along the gastroduodenal artery and the superior mesenteric lymph nodes along the SMA.
All of these ultimately drain into the celiac lymph nodes.
As for the innervation of the duodenum, the sympathetic fibers derive from the greater thoracic splanchnic nerves arising from T5 to T9, the lesser thoracic splanchnic nerves from T10-T11, while the parasympathetic fibers derive from the vagus nerves.