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The stomach ("normal" empty volume 45 mL) is divided into distinct regions:
cardia: the area that receives the esophagus (gastro-esophageal junction)
fundus: formed by the upper curvature; portion of stomach above GEJ level 17
body (corpus): the main central region of the organ; central two-thirds portion from the cardia to the incisura angularis 17
pylorus (antrum): the lower section of the stomach that facilitates emptying into the small intestine, located on the right of the midline at the level of L1.
The lesser curvature forms the shorter concave border and the greater curvature forms the longer convex border of the stomach. The lesser omentum attaches the lesser curvature to the liver, while the greater omentum attaches to the greater curvature of the stomach 17.
There are two smooth muscle sphincters, esophageal and pyloric, that dictate entry into and exit from the stomach. These are under the control of several mechanisms including stimulant (parasympathetic) and inhibitory (orthosympathetic) control from the anterior gastric, posterior, superior and inferior celiac plexus and myenteric nerve plexuses.
The inner mucosal surface has many rugal folds that act to increase the surface area of the stomach lining and increase its efficiency.
incisura angularis: small anatomical notch on the stomach located on the lesser curvature of the stomach near the pyloric end, which marks the junction between the body and the antrum 17
fornix gastricus: refers to the arch-shaped superior margin of the fundus of the stomach
cardia: left gastric artery
fundus of the stomach: short gastric arteries
directly to left paracardial lymph nodes
along lymph nodes accompanying the splenic artery
along lymph nodes accompanying the celiac artery
along lymph nodes accompanying the superior mesenteric artery
It is suggested that the most likely route for para-aortic lymph node metastases is from the left gastric artery nodes accompanying the celiac artery 4.
sympathetic supply causes vasoconstriction, inhibition of gastric motility and pyloric constriction
afferents run with the sympathetic fibers (visceral pain sensation)
the anterior vagal trunk supplies the anterior surface of the upper body and fundus, antrum, parts of the lesser curvature and the pylorus
the posterior vagal trunk supplies the cardiac orifice and posterior surface of the body and antrum
parasympathetic supply is secretomotor to the gastric mucosa, promotes gastric motility and relaxes the pyloric sphincter during gastric emptying
Akin to other areas of the gastrointestinal (GI) tract, the stomach walls are composed of the following layers:
mucosa: internal layer of epithelium, the lamina propria (loose connective tissue and gastric glandular tissue) and the muscularis mucosae
submucosa: a fibrous layer of connective tissue under the mucosa
muscularis externa: this is the muscular layer of the stomach wall and is comprised of three layers (inner oblique, middle circular and outer longitudinal) unlike other GI organs which only have two layers
serosa: the outermost layer of the stomach wall consisting of connective tissue which is continuous with the peritoneum
The stomach wall contains several different types of glandular tissue. The cardia, fundus and pylorus all have different types of glands and are composed of a variety of different cells:
mucous cells: secrete a mucus gel layer and are found throughout the stomach
parietal (oxyntic) cells: secrete gastric acid and intrinsic factor throughout the stomach
chief (zymogenic) cells: secrete pepsinogen and rennin in the fundus and body 17
enteroendocrine (APUD cells): secrete a variety of products and are found throughout the stomach
Control of the stomach relates to the autonomic nervous system and various digestive system hormones:
gastrin: causes an increase in the secretion of hydrochloric acid (HCl), pepsinogen and intrinsic factor from parietal cells in the stomach; it also causes increased motility in the stomach; released by G-cells in the stomach to distension of the antrum, and digestive products; inhibited by a pH normally <4 (acidic), as well as the hormone somatostatin
cholecystokinin (CCK): greatest effect on the gallbladder, but it also decreases gastric emptying and increases release of pancreatic juice which is alkaline and neutralizes the chyme
secretin: has most effects on the pancreas, but will also diminish acid secretion in the stomach
gastric inhibitory peptide (GIP): decreases both gastric acid and motility
enteroglucagon: decreases both gastric acid and motility
glycogen: produced in the brain and stomach, affects the liver and level of glucose in the stomach
The stomach is not usually well visualized on the plain film although a gastric bubble (gas outlining the fundus of the stomach) is often visible on an erect chest or abdominal x-ray.
Gastric rugae is readily identified on supine abdominal radiograph 20,21.
Analogous to the abovementioned histological architecture, the gastric walls will consist of five concentric layers of alternating echogenicity when viewed with an appropriately high frequency transducer, characteristic of the sonographic gut signature 16.
Sonographic localization of the stomach is typically performed with epigastric transducer placement with the patient in a supine or right lateral decubitus position. The gastric antrum is commonly visualized just to the right of anatomic midline using the following sonographic landmarks; 11
lies cephalad and anterior to the gastric antrum 16
inferior to the gastric antrum
Visualization of the gastric body is often possible by sweeping leftward of the gastric antrum. Visualization of the gastric fundus may require using the spleen as a sonographic window, using a left intercostal probe position. The sonographic appearance of the stomach, most notably the gastric antrum, may differ based on the patient's prandial status as follows;
gastric antrum may appear as a flattened ovoid with absent to minimally appreciable luminal contents 11
targetoid or "bulls eye" appearance 12
may also appear round, with homogenous anechoic fluid filling the lumen
When well distended, the normal gastric wall will have a thickness of 5-7 mm in the antrum and 2-3 mm in the body 17.
congenital gastric condition
- 1. Gray's Anatomy 39th Edition, Elsevier
- 2. Schumacher U. Thieme Atlas of Anatomy. Thieme Georg Verlag. (2006) ISBN:3131421118. Read it at Google Books - Find it at Amazon
- 3. Butler P, Mitchell A, Healy JC. Applied Radiological Anatomy. Cambridge University Press. (2012) ISBN:0521766664. Read it at Google Books - Find it at Amazon
- 4. Nomura E, Sasako M, Yamamoto S et al. Risk Factors for Para-Aortic Lymph Node Metastasis of Gastric Cancer from a Randomized Controlled Trial of JCOG9501. Jpn J Clin Oncol. 2007;37(6):429-33. doi:10.1093/jjco/hym067 - Pubmed
- 5. Yamada S, Okajima K. Study of lymph node metastasis around the left renal vein in gastric cancer, (1991) Surgical Gastroenterology.14:177-82/ (in Japanese).
- 6. Nishi M, Ohta K, Ishihara S, Nakajima T, Katoh H. Clinopathological study about the paraortic lymphnode metastases of gastric cancer, (1991) Surgical Gastroenterology, 14:165-76. (in Japanese).
- 7. Last, R. J., McMinn, R. M. H.. Last's Anatomy, Regional and Applied. (1994) ISBN: 044304662X - Google Books
- 8. Kruisselbrink R, Arzola C, Jackson T, Okrainec A, Chan V, Perlas A. Ultrasound assessment of gastric volume in severely obese individuals: a validation study. (2017) British journal of anaesthesia. 118 (1): 77-82. doi:10.1093/bja/aew400 - Pubmed
- 9. Van de Putte P, Vernieuwe L, Jerjir A et-al. When fasted is not empty: a retrospective cohort study of gastric content in fasted surgical patients†. (2017) British journal of anaesthesia. 118 (3): 363-371. doi:10.1093/bja/aew435 - Pubmed
- 10. Alakkad H, Kruisselbrink R, Chin KJ et-al. Point-of-care ultrasound defines gastric content and changes the anesthetic management of elective surgical patients who have not followed fasting instructions: a prospective case series. (2015) Canadian journal of anaesthesia = Journal canadien d'anesthesie. 62 (11): 1188-95. doi:10.1007/s12630-015-0449-1 - Pubmed
- 11. Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. (2014) British journal of anaesthesia. 113 (1): 12-22. doi:10.1093/bja/aeu151 - Pubmed
- 12. Perlas A, Van de Putte P, Van Houwe P et-al. I-AIM framework for point-of-care gastric ultrasound. (2016) British journal of anaesthesia. 116 (1): 7-11. doi:10.1093/bja/aev113 - Pubmed
- 14. Sijbrandij LS, Op den Orth JO. Transabdominal ultrasound of the stomach: a pictorial essay. (1991) European journal of radiology. 13 (2): 81-7. Pubmed
- 15. Jacoby J, Smith G, Eberhardt M, Heller M. Bedside ultrasound to determine prandial status. (2003) The American journal of emergency medicine. 21 (3): 216-9. Pubmed
- 16. Carol M. Rumack. Diagnostic Ultrasound. (2019) ISBN: 9780323053976
- 17. Jeffrey Klein, Emily N. Vinson, Clyde A. Helms, William E. Brant. Brant and Helms' Fundamentals of Diagnostic Radiology. (2018) ISBN: 9781496367396
- 18. Susan Standring. Gray's Anatomy. ISBN: 9780702052309
- 19. Clinical Anatomy: Applied Anatomy for Students and Junior Doctors 14th Edition ISBN 9781119325536 p79 by Harold Ellis (Author), Vishy Mahadevan
- 20. Lee H. Plain Abdominal Radiography in Infants and Children. Korean J Pediatr Gastroenterol Nutr. 2011;14(2):130. doi:10.5223/kjpgn.2011.14.2.130
- 21. Field S. Plain Films: The Acute Abdomen. Clin Gastroenterol. 1984;13(1):3-40. doi:10.1016/s0300-5089(21)00773-2