Gastric Anatomy & Physiology

Anatomy
In adult life, stomach located T10 and L3 vertebral segment Can be divided into anatomic regions based on external landmarks
4 regions
Cardia Fundus Corpus (body) Antrum

Anatomy
Cardia- region just distal to the GE junction Fundus- portion above and to the left of the GE junction

Anatomy
Corpus- region between fundus and antrum
Margin not distinctly external, has arbitrary borders

Antrum- bounded distally by the pylorus

Which can be appreciated by palpation of a thickened ring of smooth muscle

Anatomy
Position of the stomach varies with body habitus In general- it is fixed at two points
Proximally at the GE juction Distally by the retroperitoneal duodenum

Anatomy
Anterior- in contact with Left hemi-diaphragm, left lobe and anterior segment of right lobe of the liver and the anterior parietal surface of the abdominal wall Posterior- Left diaphragm, Left kidney, Left adrenal gland, and neck, tail and body of pancreas The greater curvature is near the transverse colon and transverse colon mesentery The concavity of the spleen contacts the left lateral portion of the stomach

Vasculature

Vasculature
Well vascularized organ Arterial flow mainly derived from Celiac Artery 3 Branches Left Gastric Artery Supplies the cardia of the stomach and distal esophagus Splenic Artery Gives rise to 2 branches which help supply the greater curvature of the stomach Left Gastroepiploic Short Gastric Arteries Common Hepatic or Proper Hepatic Artery 2 major branches Right Gastric- supples a portion of the lesser curvature Gastroduodenal artery -Gives rise to Right Gastroepiploic artery -helps supply greater curvature in conjunction with Left Gastroepiploic Artery

Anatomy
Venous Drainage
Parallels arterial supply

Lymphatic drainage
Lymph from the proximal portion of the stomach drains along the lesser curvature first drains into superior gastric lymph nodes surrounding the Left Gastric Artery Distal portion of lesser curvature drains through the suprapyloric nodes Proximal portion of the greater curvature is supplied by the lymphatic vessels that traverse the pancreaticosplenic nodes Antral portion of the greater curvature drains into the subpyloric and omental nodal groups

In general- The lymphatic drainage of the human stomach, like its blood supply, exhibits extensive intramural ramifications and a number of extramural communications. Therefore spread beyond is often beyond region of origin at a distance from the primary lymphatic zone

Lymphatic drainage
The stomach is drained by four groups of lymph nodes
1. Left gastric arterial nodal group follows the left gastric artery and drain into

the celiac nodes. They drain the lesser curvature of the stomach to the left.

2. Short gastric and left gastroepiploic vessels nodal group. drain the left

side of the greater curvature of the stomach follows these vessels and drain into the pancreaticosplenic group of nodes.

3. Right gastroepiploic nodes ----drain the right half of the greater curvature of stomach as far as the pylorus 4. Pyloric nodes which drains the pyloric part of stomach to the hepatic, pyloric

and left gastric nodes.

All the vessels enter into the celiac nodes. From these nodes they pass into the intestinal lymph trunks, which then enter the cisterna chyli or the abdominal confluence of lymph trunks. The cisterna chyli drains into the thoracic duct.

Lymphatic drainage

Anatomy
Nerve Supply
Left and Right Vagus Nerves descend parallel to the esophagus within the thorax before forming a peri-esophageal plexus between the tracheal bifurcation and the diaphragm From this plexus, two vagal trunks coalesce before passing through the esophageal hiatus of the diaphragm

Anatomy
Left (anterior) Vagus Nerve
Left of the esophagus
Branches
Hepatic Branch Supplies liver and Biliary Tract Anterior gastric or Ant. Nerve of Latarget

Anatomy
Right (posterior) Vagus Nerve
Right of the esophagus
Branches
Celiac Posterior Latarget Innervates posterior gastric wall

Anatomy
Parasympathetic innervation of Stomach- Vagus Nerve
90% of fiber in vagal trunk is afferent (info transmitting from stomach to CNS)

Sympathetic innervation of StomachSplanchnic Nerve

Derived from spinal segement T5-T10

Layers of stomach
Mucosa Submucosa muscularis externa
inner oblique layer middle circular layer
Auerbach's plexus

outer longitudinal layer

Serosa

histology

Anatomy
Microscopic Anatomy
Glandular portions of stomach
Lined by simple columnar epithelium This luminal surface is interrupted at intervals by gastric pits
Opening into these gastric pits are one or more gastric glands that have functional significance Mucosa has three types of gastric glands -Cardiac -Oxyntic -Antral

Microscopic Anatomy
Cardiac Glands
Location- Cardia Contain mucous
Function- secrete mucous (provides a protective coat for lining of stomach)

Oxyntic Glands
Most distinctive feature of the stomach Location- Fundus and Corpus Contains many cell types

Microscopic Anatomy
Parietal cells
Location- neck of gastric pit Stimulated by Ach, Histamine and Gastrin Secretes HCl + Intrinsic Factor Location- base of gastric pit Stimulus- Vagal Secretes Pepsinogen (eventually leads to pepsin- digestive enzyme)

Chief Cells

Microscopic Anatomy
Antral Glands
Gastrin cells
Location- mucosa of distal stomach Stimulus- amino acids Secretion- Gastrin (stimulates HCl production by way of parietal cells)

Somatostatin
Location- mucosa of distal stomach + Duodenum Stimulus- HCl or low pH in duodenum Actions- Inhibits gastric emptying, Pancreatic secretions, and gallbladder contraction

Physiology
The stomach contains a number of biologically active peptides in nerves and endocrine cells
Ex. Gastrin, somatostatin, vasoactive intestinal peptide (VIP), substance P, and glucagon, etc The two peptides of greatest importance to human disease and clinical surgery are
Gastrin Somatostatin

Physiology
Gastrin
Most important stimulus is a meal
amino acids that results from proteolysis Fat and carbohydrates are not stimuli for gastrin secretion Gastric distention that occurs from a meal will stimulate cholinergic neurons thereby releasing gastrin Gastrin will then prompt Parietal cell to secrete HCl

Once Gastric distention diminishes, VIP-containing neurons are activated causing stimulation of somatostatin, thus attenuating Gastrin secretion Overall, a lumen pH >3.0 will potentiate gastrin release, whereas a pH <3.0 will inhibit its release

Physiology
Somatostain
Like Gastrin, plays an integral role in gastric physiology Also, used for important therapeutic applications in treatment of digestive diseases
Main stimulus is a low or acidic (<3.0)luminal pH
Many peptides have shown to release somatostatin Ex. Secretin, Cholecystokinin and gastrin

Overall, the most important gastric function of somatostatin is to regulate acid secretion and gastrin release

In contrast, stimulation of Vagal nerves along with cholinergic neurons inhibit somatostatin

Gastric Acid Secretion

Gastric Acid Secretion

Basolateral membrane of the parietal cell contains specific receptors for the three major stimulants of acid production
Histamine Gastrin Acetylcholine

Each stimulant has its own 2nd messenger system which allows for stimulation of the parietal cell

Gastric Acid Secretion

Humans normally secrete 2 to 5 mEq/h of HCl in the fasting state, constituting basal acid secretion
Both Vagal tone and ambient Histamine secretion are presumed to regulate basal acid secretion Gastrin is not thought to play a role in basal acid secretion Therefore, a Vagotomy or use of H2 blockers (ex. Cimetidine) will decrease basal acid production

Gastric Acid Secretion

Stimulated acid secretion begins with
Cephalic phase
Thought, sight or smell of food stimulates acid secretion Mediated by Vagal stimulation

Vagal discharge
Directs the cholinergic mechanism for stimulation Can be inhibited by Atropine (anticholinergic) Inhibits release of somatostatin Vagal effects inhibit tonic inhibition that is provided by somatostatin

Gastric Acid Secretion

Gastric Phase
Begins when food enters the stomach
The following are responsible for stimulation of acid secretion Presence of partially hydrolyzed food constituents Gastric distention Gastrin is the most important mediator of this phase

Ends when Antral muscosa is exposed to acid

When luminal pH is <2.0 in the antrum, gastrin release stops Somatostatin release is increased

Entry of digestive products into the intestine begins the intestinal-phase inhibition of gastric acid secretion

Gastric Acid Secretion

Intestinal Phase Also, releases HCl by way of Gastrin Releases secretin to inhibit Gastrin which ultimately decreases Acid production

Other Factors
Pepsin
Secreted from gastric chief cells Contributes to the overall coordination of the digestive process Main function is to initiate protein digestion, usually is incomplete
Partially hydrolyzed protein by pepsin are important signals for release of
Gastrin Cholecystokinin

Other Factors
Intrinsic Factor (IF)
Located in the parietal cells (oxyntic gland) Main function is to absorb cobalamin (Vitamin B12) form ileal mucosa and then transported to the liver Secretion of IF is similar to acid secretion
stimulated
Ach Histamine Gastrin

Other Factors
Bicarbonate
Secreted from the gastric mucosa Theory is that bicarbonate is secreted to maintain a neutral pH at the mucosal surface, even if acidic in lumen Cholinergic agonist, vagal nerve stimulation have been shown to increase gastric bicarbonate production

Gastric Motility
To understand gastric motility the stomach is divided into two functional terms as two different regions which have distinctive smooth muscle Proximal 1/3
3 layers of smooth muscle
Outer longitudinal Middle Circular Inner Oblique

Distal 2/3

Gastric smooth muscle ends at the pylorus, a septum of connective tissue marks the change from pylorus to the duodenum

Only a distinctive outer longitudinal layer

Gastric Motility
Proximal 1/3
Have prolonged and tonic gastric contractions No action potentials or pacesetter
Thus no peristalsis

Distal 2/3
In general, gastric smooth muscle exhibit myoelectric activity based on a highly regular pattern, called slow waves
Slow waves set a maximum rate at which contrations can occur (3 contractions/min); they do not cause contractions

Gastric Motility
Contraction occur when action potential are phase locked with a crest of a slow wave pattern When an action potential is combined with a pacesetter potential (partially depolarized smooth muscle cells) a ring of smooth muscle cell contraction moves with peristalsis

Coordination of Contraction
Receptive Relaxation
Vagally mediated relaxation of fundus (proximal stomach) when degluttination occurs Allows the proximal stomach to act as a storage site for ingested food in the immediate postprandial period
Meal is accepted without a significant increase in intragastric pressure

Soon proximal contractile activity increases eventually leading to compressive movement of gastric content form fundus to antrum

Coordination of Contraction
Food enters antrum
Food peristaltically propelled toward the pylorus Pylorus closes before the antral contraction
This coordinated closing allows for small bolus of liquid and food particles to pass, while the main bulk of the gastric content undergoes retropulsion back into the antrum

Next, there is a churning action in the antrum that mixes the ingested food particle, gastric acid and pepsin
Solid food particles >1mm will not pass through the pylorus

Coordination of Contraction
Overall, Liquids are empty more quickly than solid
Liquids empty exponentially Solids endure this lag period or antral contraction (empties linearly)

In general
Proximal stomach is the dominant force in determining liquid emptying based on the gastroduodenal pressure gradient generated by proximal gastric contractions Distal stomach is postulated as controlling emptying of solids through its grinding and peristaltic actions