7 The Stomach


7 The Stomach


▪ Anatomy of the Esophagus


The esophagus is located in the posterior mediastinum. It lies medial in front of the spinal column until the tracheal bifurcation (T4), after which it moves to the right side, to make room for the heart. Lastly, it crosses the diaphragm to the left of the median line. At the level of T7-T8, the aorta squeezes in between the spinal column and the esophagus. The abdominal part is only about 2 cm long.

Topographic Relationships


  • trachea

  • left main bronchus

  • mediastinal pleura

  • pericardium

  • spinal column

  • aorta

  • right lung (in the area of the esophageal hiatus)

  • vagus nerve, right and left


  • peritoneum in the front

  • liver

  • crus to the left of the diaphragm

  • left side: left triangular ligament

  • right side: lesser omentum

  • T10 and T11


  • organ pressure

  • turgor

  • mediastinal connective tissue

  • phrenoesophageal ligament (ring-shaped disk in the hiatus).

The esophagus remains mobile in the lengthwise direction.



  • inferior thyroid artery

  • small branches from the subclavian/communal carotid/vertebral arteries, etc.

  • inferior thyroid vein (from the superior vena cava)


  • bronchial arteries

  • aorta

  • azygos/hemiazygos/accessory hemiazygos vein (from the superior vena cava)


  • left gastric artery

  • inferior phrenic artery

  • celiac trunk

  • left gastric vein (main drainage) to the portal vein

Lymph Drainage

  • deep cervical cord (internal jugular vein-parotid gland-clavicle)

  • intercostal, thoracic nodes near the spinal column

  • paratracheal nodes along the recurrent laryngeal nerve

  • tracheobronchial nodes

These nodes all drain into the right/thoracic lymphatic duct.

  • nodes around the celiac trunk (cisterna chili—thoracic duct)


  • sympathetic nervous system from T4 to T6

  • further path of sympathetic innervation: pharyngeal plexus-superior cervical/stellate ganglion-greater splanchnic nerve-celiac plexus

  • vagus nerves accompany the esophagus into the abdomen

▪ Anatomy of the Stomach


Division into:

  • cardia (stomach entrance)

  • fundus (cranial region, filled with air)

  • body

  • antrum

  • pylorus

  • greater curvature

  • lesser curvature

Table 7.1 Projection onto the wall of the torso.


Projects to

Greater tuberosity

Fifth ICS on the left

Front of cardia

Left seventh costochondral joint

Back of cardia

T11 on the left costovertebral joint

Lesser curvature

Below the cardia at the level of the seventh costochondral joint on the left parallel to the spinal column up to L1 (T10–L1)


When standing about L3, when lying down L1-L2

ICS, intercostal space.

Cardia and pylorus are relatively fixed points; in between, great variability is possible depending on the state of fullness.

Topographic Relationships

  • diaphragm

  • indirect: pleura and left lung, pericardium and heart

  • ribs 5–8 and costal cartilage 9 on the left

  • liver

  • celiac trunk and plexus

  • omental bursa

  • left crus of the diaphragm

  • left adrenal gland

  • left kidney

  • pancreas

  • transverse colon

  • transverse mesocolon

  • left colic flexure

  • duodenum (horizontal and ascending part)

  • duodenojejunal flexure and start of the jejunum

  • spleen


  • organ pressure

  • turgor

  • gastrophrenic ligament

  • lesser omentum

  • greater omentum

  • gastrocolic ligament

  • gastrolienal ligament

  • left phrenicocolic ligament

Fig. 7.1 Upper abdominal organs, transverse section.
Fig. 7.2 Topographic relationships of the stomach.
Fig. 7.3 Attachments of the stomach.
Fig. 7.4 Attachments of the stomach, schematic.



  • right gastric artery (from proper hepatic artery)

  • left gastric artery (from celiac trunk, anastomosed with the right gastric artery)

  • right gastro-omental artery (gastroduodenal artery)

  • left gastro-omental artery (splenic artery—celiac trunk)

  • gastroduodenal artery (common hepatic artery—celiac trunk)


Portal vein.

Lymph Drainage

  • paracardial lymph nodes

  • pancreatic lymph nodes

  • splenic nodes

  • celiac nodes—thoracic duct (main drainage)


  • sympathetic nervous system from T6 to T9 via the greater and lesser splanchnic nerves

  • further path of sympathetic innervation runs to the celiac and superior mesenteric ganglion

  • vagus nerve

Organ Clock

Maximal time: 7-9a.m.

Minimal time: 7-9p.m.

Organ-Tooth Interrelationship

For basic information, see page 34.

  • Second premolar in the lower jaw on both sides

  • Second molar in the upper jaw on both sides

Movement Physiology according to Barral


The esophagus has lengthwise mobility. During movements of the head and neck, it must be able to adjust its length.

To transport food, peristaltic waves run through the esophagus during the act of swallowing.

The stomach shows mobility in three planes: frontal, sagittal, and transverse.

Frontal Plane

During inhalation, the diaphragm guides the lateral parts of the fundus of the stomach inferomedially. The distance between the lesser and greater curvature decreases, as does the distance between the fundus and antrum. Looked at from the front, the stomach rotates in a clockwise direction.

The axis of movement is a sagittotransverse axis through the angular incisure of the lesser curvature.

Sagittal Plane

In this plane, the stomach performs a tilt with the cranial parts of the fundus in an anterior direction, accompanied by a simultaneous shift posteriorly in the antral area. The frontotransverse axis of movement runs roughly through the center of the stomach.

Transverse Plane

The stomach performs a rightward rotation along a frontosagittal axis through the inferior part of the esophagus.


The motions of motility correspond in direction and axis to those of mobility.


Proximal and Distal Stomach

The relief structure of the stomach wall serves as a “slide” for the chyme in the direction of the pylorus. The proximal stomach acts as food storage and is marked by continuous tension in the walls.

The distal stomach has the task of mixing, homogenizing, and emulsifying the food. For this purpose, peristaltic waves run from a central pacemaker through the distal stomach. A distension in the stomach stimulates these waves; a distension in the small intestine inhibits the activity of the distal stomach (enterogastric reflex).

The pylorus does not close so tightly that fluids are unable to pass. It relaxes synchronously with each contractile wave of the distal stomach, but only far enough that small food particles can still pass while the large parts are thrown back.

Main Functions of the Stomach

  • grinding up solid food, emulsification of fats, predigestion of proteins

  • secretion of gastric juice

Gastric Juice


Mucus is secreted by the epithelial cells on the surface of the stomach, the side cells of the fundic glands, and the cardiac and pyloric glands.


Bicarbonate is secreted by the epithelial cells in the stomach mucosa.

Both components of gastric juice serve to protect the stomach walls from hydrochloric acid (HCl). An H+ gradient exists across the mucosa, from strongly acid on the lumen side to slightly alkaline on the epithelium side (effect of bicarbonate).


Pepsinogen is secreted by the chief cells of the fundic and body glands. At a pH < 3, it is activated into pepsin and cleaves proteins.

Hydrochloric Acid

Hydrochloric acid is secreted by the parietal cells in the fundic glands.

Intrinsic Factor

The intrinsic factor is necessary for the absorption of vitamin B12 in the small intestine.

Regulating the Secretion of Gastric Juice

The secretion of gastric juice has several trigger mechanisms.

Cephalic Phase

The secretion of gastric juice is stimulated via the vagus nerve by smell, taste, and glucose deficiency in the brain.

Gastric Phase

Distension of the stomach, amino acids (especially tryptophan and phenylalanine), and Ca2+ ions increase the secretion of gastric juice.

Intestinal Phase

This is stimulation by the voiding of chyme into the duodenum. The secretion of gastric juice is inhibited by a strongly acid pH balance in the stomach which inhibits the release of gastrin; this, in turn, inhibits the secretion of HCl in the parietal cells.



Gastrin is secreted by the antral glands (two-thirds) and the duodenal mucosa (one-third).

Release Stimulation

  • presence of peptides or certain amino acids

  • vagal efferents

  • high catecholamine concentration in the plasma

Release Inhibition

The pH of gastric juice is < 3.


  • stimulates HCl secretion in the parietal cells

  • increases strength and frequency of antral peristalsis

  • promotes epithelial growth in the stomach and duodenum

  • stimulates the pancreatic acini, bile secretion, and gallbladder contraction


Cholecystokinin (CCK) is secreted in the duodenal and jejunal epithelia.

Release Stimulation

Presence of free fatty acids, peptides, aromatic amino acids, or glucose in the duodenal lumen.

Release Inhibition

Trypsin in the intestinal lumen (protein-cleaving enzyme from the pancreas).


  • stimulates the acinar cells of the pancreas (neutral chloride-rich juice with proenzymes)

  • stimulates the secretion of alkaline pancreatic juice rich in bicarbonate

  • releases all pancreatic hormones

  • promotes pancreatic growth

  • stimulates the chief cells of the stomach (⇒ pepsinogen ↑)

  • inhibits HCl secretion

  • strong stimulator of gallbladder contraction, opens the sphincter of Oddi

  • satiety hormone

Fig. 7.5 Voiding times from ingestion.


Secretin is secreted in the duodenal and jejunal epithelium.

Release Stimulation

Acid chyme.


  • stimulates the secretion of alkaline pancreatic juice rich in bicarbonate

  • alkalizes the bile in the bile duct system

  • inhibits the resorption of water and salt in the gallbladder

  • slows down the emptying of the stomach by inhibiting the stomach muscles

  • antitrophic effect on the gastric mucosa


▪ Symptoms that Require Medical Clarification

  • Tarry stools

  • Signs of peritonitis

  • Upper abdominal pain that worsens or improves on food intake

  • Palpable lymph node at the medial end of the left clavicle (Virchow node)

Hiatus Hernia


Prolapse of parts of the stomach or of the entire stomach (possibly even of other organs) through the esophageal hiatus into the thorax.


Sliding Hernia

Movement of the cardia and fundus into the rear mediastinum, with the pointed angle of His being lifted.

Frequently asymptomatic. About 25% of patients develop reflux symptoms; reflux esophagitis is possible (5% of cases).

Paraesophageal Hernia or Rolling Hernia

Protrusion of parts of the fundus into the thorax (past the esophagus and the cardia, which is fixed in its normal location), with a pointed angle of His.

The sphincter continues functioning and reflux is unlikely to occur. Cardinal symptoms are pain in the epigastrium and iron deficiency anemia.

Hybrid forms between the two are possible.

Functional Hernia according to Barral

In cases with similar symptoms, the radiological signs of a hiatus hernia are absent. Such conditions can be caused by a spasm in the gastroesophageal transition or nonphysiologic tissue pulls in the peritoneum, ligaments, or fascia.

Prerequisites for a Healthy Sphincter Function according to Barral

  • physiologic pressure conditions in the abdomen and thorax

  • causes for pathologic changes: pregnancy, cough, obstipation with impaired defecation

  • soft anatomic surroundings that are free from nonphysiologic tissue pulls

  • causes for pathologic changes: surgery or effects of inflammation

  • physiologic lengthwise tension in the esophagus

  • causes for pathologic changes: kyphotic posture or inflammation

  • functional diaphragm tension and position

  • for healthy sphincter function, the angle of His must be pointed

  • normotonic muscle tension at the gastroesophageal transition

Clinical. Roughly 95% of all reflux patients have a hiatus hernia; by contrast, only about 5% of patients with hiatus hernia have reflux disease.


Cardinal symptoms of reflux disease include:

  • pain in the epigastrium

  • heartburn

Additional symptoms:

  • regurgitation

  • retrosternal burning

  • pain in the middle to lower thoracic spinal column (TSC)

The symptoms are aggravated by:

  • lying down

  • lifting heavy loads

  • bending down

  • food intake

  • stress

  • alcohol

  • nicotine

Acute Gastritis

Definition. Acute inflammation of the gastric mucosa with loss of the protective mucus barrier and damage to the mucosa from gastric acid.


Exogenous factors:

  • Bacteria (Helicobacter pylori) or toxins (staphylococci)

  • alcohol

  • medications (acetylsalicylic acid, nonsteroidal antirheumatics or NSARs, cytostatics)

Endogenous factors:

  • uremia

  • portal hypertension

  • stress-related ischemia (trauma, burns, shock, competitive sports)

  • food allergies


  • epigastric pain

  • nausea

  • vomiting

  • lack of appetite

  • diarrhea

  • bad breath

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Jul 12, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on 7 The Stomach

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