Last revised by Jeremy Jones on 16 Apr 2023

The duodenum (plural: duodena or duodenums) is the first part of the small intestine and is the continuation of the stomach.

The duodenum is a 20-30 cm C-shaped hollow viscus predominantly on the right side of the vertebral column. It lies at the level of L1-3 and the convexity of the duodenum (called the duodenal sweep by radiologists) 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 (DJ) flexure). It is composed of four distinct parts. The first 2.5 cm of the first part of the duodenum is intraperitoneal. Meanwhile, the remaining parts of the duodenum are retroperitoneal. The anterior surface of duodenum is mostly covered by the peritoneum except for second part of the duodenum which is crossed by transverse mesocolon and the third part which is crossed by superior mesenteric vessels 5.

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 5 cm, before making a sharp curve inferiorly into the superior duodenal flexure. It is intraperitoneal for the first 2-3 cm only. Relations 3:

  • anteriorly: gallbladder, liver

  • posteriorly: common bile duct, portal vein, gastroduodenal artery

  • superiorly: epiploic foramen

  • inferiorly: pancreatic head

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.

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 

The fourth (ascending) part passes superiorly, either anterior to, or to the left 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 fibers: the ligament of Treitz. Relations 3:

  • superiorly: stomach

  • inferiorly: loops of jejunum

  • posteriorly: left psoas muscle, aorta

  • duodenal cap (first 2.5 cm): right gastric artery, right gastroepiploic artery

  • remaining D1 to mid-D2: superior pancreaticoduodenal artery (branch of gastroduodenal artery)

  • mid-D2 to ligament of Treitz: inferior pancreaticoduodenal arteries (branch of SMA) 3

  • pancreaticoduodenal nodes that drain:

    • distally to superior mesenteric nodes

    • proximally to celiac nodes 3

  • duodenal diverticulum: most commonly occurs in D2 or D3 4

  • duodenal duplication: most commonly occurs at the medial wall of D2 or D3; appears as a cystic structure that does not communicate with the lumen 4

Duodenum means "twelve" in Latin and the name derives from the belief that it measured twelve finger widths in length (duodenum digitorum) 4.

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