PRIMITIVE GUT TUBE

third and fourth weeks A. top layer (ectoderm) of the trilaminar embryonic
disc
- forms the neural plate that rolls up into a tube to
form the brain and spinal cord by the process called
neurulation

B. ventral layer (endoderm) rolls down to

-form the gut tube

embryo consists Of a tube on top of a tube:

the neural tube dorsally and the gut tube ventrally
GASTROCHISIS • occurs when body wall closure fails in the abdominal
region
• intestinal loops herniate into the amniotic cavity
through the defect, which usually lies to the right of
the umbilicus
• incidence of gastroschisis is increasing [3.5/10,000]
• common in infants from thin white women younger
than 20 years of age
• affected loops of bowel may be damaged by :
-exposure to amniotic fluid:corrosive effect
-twisting around each other [volvulus] :compromising
their blood supply
OMPAHLOCELE -Ventral body wall defect
-does not arise from a failure in body wall closure
-originates when portions of the gut tube [the midgut]
that normally herniates into the umbilical cord during
the 6th to the 10th weeks [physiological umbilical
herniation]fails to return to the abdominal cavity
Development of the primitive gut and its derivatives
PHARYNGEAL GUT OR from the oropharyngeal membrane to the respiratory
PHARYNX diverticulum
part of the foregut

REMAINDER OF FOREGUT caudal to the pharyngeal tube and extends as far

caudally as the liver outgrowth.
MIDGUT begins caudal to the liver bud and extends to the
junction of the right
two-thirds and left third of the transverse colon in the
adult.
HINDGUT extends from the left third of the transverse colon to
the cloacal membrane.
ENDODERM forms the epithelial lining of the digestive ract
gives rise to the specific cells (the parenchyma) of
glands, such as :
-hepatocytes
-exocrine and endocrine cells of the pancreas
VISCERAL MESODERM -forms the stroma (connective tissue) for the glands;
muscle; connective tissue; and peritoneal components of
the wall of the gut

Regional specification of the initiateD BY A concentration gradient of retinoic acid

gut tube into (RA) from the:
different components: A. Pharynx
-is exposed to little or no RA

B. Colon
- highest concentration of RA

-this RA gradient causes transcription factors to be

expressed in different regions of the gut tube
-SOXZ :esophagus and stomach;
-PDX1: duodenum;
-CDXC: small intestine;
-CDXA: large intestine and rectum
SONIC HEDGEHOG SHH -INITIATEepithelial—mesenchymal interaction
-expression upregulates factors in the mesoderm that
then determine the type of structure that forms from
the gut tube, such as the stomach, duodenum, small
intestine, etc.
ESOPHAGUS
4 weeks old Respi diverticulum (lung bud ) appears at the ventral
wall of the foregut
Esophagus Dorsal portion
Respi primordium Ventral
Striated , vagus Upper 2/3 esophagus
Smooth , splanchnic plexus Lower 3rd esophagus
STOMACH
4TH WEEK Start of development as fusiform dilation near the
respi diverticulum
5th week Speen priomordium appears as mesodermal prolif
Bet. 2 leaves of DORSAL mesogastrium
DIAPHRAGMATIC HERNIA Stomach remains in the thoracic cavity, compress lungs
90 deg rotation on the Left side : anterior
longitudinal axis Right side: posterior

Rotation on the Cephalic or cardiac : left

anteroposterior axis Caudal or pyloric : right

Left vagus nerve Anterior

Right vagus nerve Posterior wall
Posterior wall grows faster Greater and lesser curvature
than the anterior wall
MESSENTERIES
VENTRAL MESOGASTRIUM Part of the septum transversum
Dorsal mesogastrium Continuous
 Fr caudal end of esophagus to mesorectum
Parts of ventrak mesentery A. Lesser omentum : stomach to liver
B. Falciform ligament : liver to ventral body wall
Lesser sac ( omental bursa) Longitudinal rotation of stomach
Dorsal mesogastrium pulled to the left
Greater omentum Stomach rotation on the anteroposterior axis
Dorsal mesogastrium bulges down
Double layered sac
Like an apron
Spleen attachments Posterior abdominal wall : toldt fascia
Left kidney: ileorenal peritoneum
Stomach : gastrolineal
Liver cord thins to form A. Peritoneum liver
B. Falciform ligament
C. Lesser omentum
Umbilical vein Free margin of falciform ligament
Obliterated after birth
Becomes the ROUND LIGAMENT of LIVER
(LIGAMENTUM TERES HEPATIS)
Portal pedicis Free margin of lesser omentum
Pedicle Contains the PORTAL TRiAD and epiploic FORAMEN OF
WINSLOW
FORAMEN OF WINSLOW Opening connecting lesser sac to greater sac

MESSENTERY OF INTESTINAL LOOP

Caudal limb of the loop Dorsal mesentery twist around the origin of the SMA
moves to the right side
Free messentery Jejunum and ileum
Transverse mesocolon
Mesosigmoid
Mesoappendix
Mesorectum
DUODENUM
Duodenum Terminal part of the foregut
Cephalic part of the midgut
Rotation of the stomach + Places the Duodenum from midline to the right
the growth of pancreas
head
Duodenal cap Remains unattached to the posterior body wall
2nd month Lumen of duodenum obliterated by proliferation of cells
** recanalized shortafter
LIVER AND GALL BLADDER
Middle of 3rd week Liver primordium appears
From the endodermal outgrowth at the distal end
10 th week of development Liver is 10% of the body weight due to:
A. Sinusoids
B. Hematopoietic function
Last 2 mos of intrauterine Liver is only 5% of total body weight
life
 Hematopoietic fxn : stops
Only few hematopoietic islands remain
SEPTUM TRANSVERSUM Mesodermal plate between PERICARDIAL CAVITY and
the YOLK SAC
Hepatic diverticulum Liver bud
Penetrates the septum transversum
Bile duct Narrowed connection bet the hepatic diverticulum and
the foregut (duodenum)
Positional change of Opening of bile duct
duodenum Initial : anterior
Becomes posterior

*** biles passes behind the duodenum

Hepatic sinusoids Vitelline and umbilical vein
Liver cords Diff in the parenchyma
Form lining of the billiary ducts
Mesoderm of septum Kupffer cells
transversum Hematopoietic cells
Connective tissue cells
When the liver cells fully A. Lesser omentum : bet liver and foregut
invade the septum B. Falciform ligament : bet liver and ventral abdominal
transversum,mesoderm wall
becomes
LIVER INDUCTION
Blocks liver specific genes ectoderm
Notochord
Noncardiac Mesoderm

*** all foregut endoderm can express liver specific

genes
FIBROBLAST GROWTH By cardiac mesoderm and blood vessel forming
FACTOR 2 FGF2 endothelial cells
Inhibits the inhibiotrs in the HEPATIC REGION
Bone morphogenic proteins Enhance competence of llver endoderm to respond to
FGF 2
Secreted by septum transversum
Hepatocyte Nuclear Regulates differentiation of cells into HEPATOCYTES
Transcription Factor 3 and and billiary cell lineages
4
PANCREAS
2 BUDS (dorsal and ventral)
Fr ENDODERMAL LINING of endothelium
Dorsal pancreatic bud Dorsal mesentery
Ventral pancreatic bud Close to the bile duct
Moves together with the rotation of the entrance of
the bile duct (dorsally)
Behind and below the dorsal
Form the UNCINATE AND INFERIOR PART OF THE
HEAD OF PANCREAS
Main pancreatic duct (duct Distal part of dorsal bud plus whole ventral bud
of wirsung) Enters via the MAJOR PAPILLA
Proximal part of dorsal bud Either:
A. Obliterate
B. Form a small duct ( accessory pancreatic duct of
Santorini)
-enters the MINOR PAPILLA
10% Ducts, do not fuse
Double duct system persist
FGF 2 and ACTIVIN Produced by notocord and dorsal aorta
Repress SHH gene expression in the GUT that is
destined to be
pancreas
PAX4 and PAX6 Those that express both becomes the gamma, delta and
beta cells

PAX6 only : glucagon cells (alpha)

3rd month of fetal life Pancreatic islets develop from parenchymatous tissue
5th month Insulin secretion
Pancreatic connective tissue Visceral mesoderm surrounding pancreatic buds
MIDGUT
BEGINS: distal to the entrance of bile duct into the duodenum
ENDS : jxn of proximal 2/3 of transverse colon
5 week embryo Suspended from dorsal abdominal wall by a short
messentery
Vitelline duct Communication with the yolk sac
Development of midgut Rapid elongation of gut and mesentery
Formd PRIMARY INTESTINAL LOOP
Cephalic limb of loop Distal part of duodenum, jejunum, ileum
Caudal limb of loop Lower portion of ileum, appendix, cecum, ascending
colon, proximal 2/3 of the transverse colon
th
6 week of development Physiological herniation

Abdominal space too small for its content, intestine

descend to the extraembryonic cavity
10th week Retraction of the herniated loop due to:

1. Regression of mesopnephric kidney

2. Reduced growth of the liver
3. Expansion of the abdominal cavity
Rotation of the midgut Axis: SMA
Primary intestinal loop Counterclockwise
270 degrees when complete
Large intestine Does not participate in coiling
ROTATION during :
A. HERNIATION : 90 deg
B. Retun to abdominal cavity : 180 deg
PROXIMAL PART OF THE Firsts part to re enter
JEJUNUM Lie on the left

The rest to return : lie on the right

CECAL BUD Last to re enter
Appears at bout 6 weeks as small conical dilation of the
caudal limb of the primary intestinal loop

Distal end becaomes the appendix (narrow diverticulum)

APPENDIX
LOCATION RETROCECAL OR RETROCOLON

Develops during descent of small intestine

HINDGUT DERIVATIVES

-DISTAL 3RD OF TRANSVERSE COLON, descending, sigmoid, rectum, upper part anal
canal

Endoderm of hindgut Internal lining of urethra and bladder

PRIMITIVE ANORECTAL Posterior region of cloaca
SINUS Where terminal hindgut enters
PRIMITIVE UROGENITAL Anterior region
SINUS Allantois enters
CLOACAL MEMBRANE CLOACA
A. Endoderm lined
B. Ventral surface: ectoderm

Boundary between endo and ecto is the CM

Urorectal septum Fr. Mesoderm
Separates allantois and hindgut

End of 7th week Cloacal membrane ruptures

Anal opening for hindgut

Ventral openin for the urogenital sinus
Upper 2/3 anal canal Endoderm of hindgut
Lower 1/3 anal canal Ectoderm around proctodeum
Anal pit Formed when ectoderm in proctodeum in the surface of
cloaca proliferates and invaginates
Degeneration of cloacal Establish continuity between the upper parts of anal
membrane / anal membrane canal and lower canal
Cranial part of the anal -fr ENDODERM
canal -sup by SUPERIOR RECTAL ARTERY
-continuation of inferior mesenteric arteries
(ARTERY OF THE HINDGUT)
CAUDAL PART OF THE -FR . ECToDERM
ANAL CANAL - sup by INFERIOR RECTAL ARTERIES 9branch of
internal pudendal artery)
PECTINATE LINE -deineates between the endodermla and ectodermal
regions of anal can
-below the anal columns
-EC : fr COLUMNAR to STRATIFIED SQUAMOUS
HEPATIC PORTAL VEIN
-large but short 7-8 cm
-merger of SMV and splenic vein
-formed POSTERIOR to the NECKof PANCREAS
-conveys:
A. Nutrient rich blood : from GIT tract
B. VENOUS Blood: spleen , pancreas, gallbladder to liver

-ascend in the IVC-> part of PORTAL TRIAD in the hepatoduodenal ligament

Right and left gastric vein Drain in the HPV

BLOOD it carries 75-80%
To liver
Contains about 40 % more O2 than the blood returning
to the heart from the sytemic circuit
Sustains the LIVER PARENCHYMA (liver cells or
hepatpcytes )
Termination Porta hepatis

HPV-> R and L portal veins -> segmental patteren (in the

R and L livers)
Hepatoduodenal ligament Free edge of lesser omentum and anterior boundary of
omental foramen

Traversed by HPV as part of the extrahepatic portal

triad
PORTAL SYSTEMIC ANASTOMOSIS
LOCATIONS 1. SUBMUCOSA Systemic : azygos vein
OF INFERIOR Portal : left gastric vein
ESOPHAGUS
2. Submucosa Systemic: inferior and middle rectal
of anal canal veins draining to IVC

Portal: superior rectal vein continuing

as the IMV
3. Periumbilical Cutaneous veins (surround umbilicus)
region anastomose with para umblical veins
of hepatic portal vein
4. Posterior Systemis: retroperitoneal veins of
aspects of posterior abdominal wall or diaphragm
secondarily
 retroperitoneal
viscera / Liver Portal:
Twigs of visceral veins
Ex: colic vein, splenic vein, portal vein
HEPATIC VEINS
DRAINAGE Directly, IVC
RIGHT Intersegmental in function and distribution
LEFT
INTERMEDIATE

Bile flow
Bile canaliculi -> interlobular biliary duct -> bile duct in portal triad
SURGICAL CONSIDERATIONS
PORTAL HYPERTENSION
Scarring and fibrosis in cirrhosis may obstruct hepatic portal vein -> pressure in the vein
risen -> portal hypertension

Normal portal vein pressure 3-5 mmhg

Portal hypertension 20-30 mmhg

ESOPHAGEAL VARICES
Large amount of blood flowing from the portal to the systemic systemic at the sites of
anastomosis

Specially : LOWER ESOPHAGUS

Bleeding : severe and fatal
CAPUT MEDUSAE

-severe case of portal obstructions

-vein of anterior abdominal wall (CAVAL tributaries ) that
anastomose with peri umbilical veins may become varicose and look like small snakes
radiating under the skin

SHUNTING PROCEDURES
COMMON METHOD FOR Divert blood from portal to systemic by connecting HPV
REDUCING PORTAL and IVC
HYPERTENSION
PORTOCAVAL OR Laparatomy
PORTOSYSTEMIC SHUNT
Splenorenal anastomosis Splenic vein and left renal vein
/shunt
Transhepatic Intrahepatic Sometimes precede the liver transplant
Portosystemic Shunt Done by interventional radiologist

Catether tip with an unexpanded stent inserted to the

Right internal Jugular vein with fluoroscopic guidance
into the major hepatic veins

Via the :
-right brachiocephalic vein
-SVC
-right atrium
-IVC

Once in the hepatic vein,stent is pushed to the

parenchyma into the portal vein stend is expanded .