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Duodenum

Dr Henry Knipe and Dr Jeremy Jones et al.

The duodenum is the first part of the small intestine and is the continuation of the stomach.

Gross morphology

The duodenum is a 20-30cm C-shaped hollow viscus predominantly on the right hand side of the vertebral column. It lies at the level of L1-3 and the convexity of the duodenum usually encompasses the head of the pancreas.

The duodenum begins at the duodenal bulb and ends at the ligament of Treitz, where it continues as the jejunum (this is often called the duodenojejunal or D-J flexure). It is composed of four distinct parts and is neither wholy peritoneal or retroperitoneal.

Segments

First part (D1)

The first (superior) part of the duodenum begins as a continuation of the duodenal end of the pylorus. It passes laterally to the right, superiorly and posteriorly, for approximately 5cm, before making a sharp curve inferiorly into the superior duodenal flexure. It is intraperitoneal for the first 2-3cm only. Relations ³:

anteriorly - gallbladder, liver
posteriorly - common bile duct, portal vein, gastroduodneal artery
superiorly - epiploic foramen
inferiorly - pancreatic head

Second part (D2)

The second (descending) part of the duodenum begins at the superior duodenal flexure. It passes inferiorly to the lower border of vertebral body L3, before making a sharp turn medially into the inferior duodenal flexure - the end of the descending part. Relations ³:

anteriorly - transverse mesocolon
posteriorly - right kidney, right ureter, right adrenal gland
superiorly - liver, gallbladder (variable)
inferiorly - loops of jejunum
laterally - ascending colon, hepatic flexure, right kidney
medially - pancreatic head

The pancreatic duct and common bile duct enter the descending duodenum through the major duodenal papilla (ampulla of Vater). This part of the duodenum also contains the minor duodenal papilla, the entrance for the accessory pancreatic duct. The junction between the embryological foregut and midgut lies just below the major duodenal papilla.

Third part (D3)

The third (inferior/horizontal) part of the duodenum begins at the inferior duodenal flexure and passes transversely to the left, crossing the vertebral column. Relations ³:

anteriorly - small bowel mesentery root
posteriorly - right psoas muscle, right ureter, gonadal vessels, aorta and IVC
superiorly - pancreatic head
inferiorly - loops of jejunum

Fourth part (D4)

The fourth (ascending) part passes superiorly, either anterior to, or to the right of, the aorta, until it reaches the inferior border of the body of the pancreas. Then, it curves anteriorly and terminates at the duodenojejunal flexure where it joins the jejunum. The duodenojejunal flexure is surrounded by a peritoneal fold containing muscle fibres: the ligament of Treitz. Relations ³:

superiorly - stomach
inferiorly - loops of jejunum
posteriorly - left psoas muscle, aorta

Blood supply

arterial supply ³:
- duodenal cap (first 2.5cm) - right gastric artery, right gastroepiploic artery
- remaining D1 to mid-D2 - superior pancreaticodudenal artery (branch of gastroduodenal artery)
- mid-D2 to ligament of Trietz - inferior pancreaticoduodenal arteries (branch of SMA)
venous drainage ³:
- duodenal cap (first 2.5cm) - prepyloric vein (drains to portal vein)
- remaining duodenum - superior pancreaticoduodenal vein (drains to portal vein) and inferior pancreaticoduodenal vein (drains to inferior mesenteric vein)

Lymphatic supply

pancreaticoduodenal nodes that drain:
- distally to superior mesenteric nodes
- proximally to coeliac nodes ³

Nerve supply

content pending

Normal variants

duodenal diverticulum - most commonly at D2 or D3 ⁴
duodenal duplication - most commonly at the medial wall of D2 or D3; appear as a cystic structure that does not communicated with the lumen ⁴