Duodenum
Duodenum.

Duodenum.

The video clip displays second and third portion.

The duodenum, into which the stomach opens, is about 25 cmlong, C-shaped and begins at the pyloric sphincter. It is almostentirely retroperitoneal and is the most fixed part of the smallintestine.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.



 

 

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Duodenum intestinal villis

Video Endoscopy with Magnifying.

Duodenum the intestinal villis are observed.

The gastrointestinal tract is considered one of thelargest immune organs of the body. Disruption of bowelmucosa not only compromises digestive and absorptivefunctions, but also vital immune functions.

Gut-associated lymphatic tissue (GALT) confers specificimmunity in the form of secretory immunoglobulin-A (sIgA) while specialized cells in the mucosa, such asmacrophages, natural killer cells, mast cells andintraepithelial lymphocytes, protect against absorptionof intestinal toxins and pathogens. Non-specificimmunity is conferred by gastric acidity, mucus, motility,digestive enzymes and normal bacterial flora. Chronicpermeability defects and associated mucosal damagemay therefore lead to considerable compromise ofimmune function.

 

 

Magnifying Duodenoscopy

Magnifying Endoscopy.

Magnifying Duodenoscopy of the duodenal bulb, theintestinal villis are observed.

To know the more detailed findings of the small intestinalmucosa with the use of a magnifying endoscope.

Most cells formed from the undifferentiated columnar cell atthe base of the crypt, migrate along the sides of the villi up tothe tip of the villi where they are sloughed off. As theymigrate they differentiate into the absorptive columnar cellor the goblet cell. This is a continuous process whereby thecells of the epithelium are replaced every 3 days. The rapidlyreplicating undifferentiated columnar cells are almostcontinually undergoing mitosis which makes them especiallysensitive to the effects of radiation therapy, cancer chemotherapy and various toxins and enzymes of microbialcells. When their reproduction is interrupted, the other cellsof the epithelium continue to migrate and slough off. Thisdisrupts the epithelium which causes 3 major effects:compromization of the first line of microbial defense,malabsorption and diarrhea.

The intestine absorbs both exogenous fluids and its ownsecretions. The secretions of the intestine and digestiveglands are so great that, were they not resorbed, death fromdehydration would result in 24 hours.

Magnifying Duodenoscopy

Magnifying Duodenoscopy.

Magnifying Duodenoscopy of the duodenal bulb.
The intestinal villis are observed.

 

Papilla of Vater.

Papilla of Vater.

In the video clip the continuous flow of bile emerging from the papilla is observed

The ampulla of Vater, also known as the hepatopancreatic ampulla,or as hepatopancreatic duct, is formed by the union of the pancreatic duct and the common bile duct. The ampulla is specifically located at the major duodenal papilla.

The ampulla of Vater is an important landmark, halfway along the second part of the duodenum that marks the anatomical transition from foregut to midgut, and hence the point where the celiac trunk stops supplying the gut and the superior mesenteric artery takes over.

 

Papilla of Vater

Papilla of Vater.

A normal papilla Vater, this picture was taken
through a forward-viewing gastroscope.

Vater, Abraham (1684-1751), German anatomist. Vater was aprofessor of anatomy and botany and later of pathology andtherapeutics at Wittenberg. In 1710 he first noted the ampullathat has been named after him, but he did not publish adescription of it until 1720. In 1717 he described the terminalcapsules of certain sensory nerve fibers. They were laterdescribed by the Italian anatomist Filippo Pacini in 1840. Nowthese corpuscles are more commonly identified with Pacini thanwith Vater.

 

 

 

 

Vater´s papilla major and minor

Video Endoscopic Sequence 1 of 2.

Vater´s papilla major and minor.

The main papilla of Vater is a small nipple-like structure on thewall of the duodenum, in its "second part." The papilla forms themain exit hole for the bile and pancreatic juices which flow downthe bile duct and pancreatic duct. Rarely there are two separateholes close together within the same papillary nipple. The papillaremains closed at rest, because of the activity of a muscular valve(sphincter). The sphincter (of Oddi, another Italian) surrounds theexit of the bile duct and pancreatic duct. It opens by reflex actionwhen foods enter the stomach, so that juices can be released tohelp in their digestion.

In most people there is a second smaller (minor, or accessory)papilla, situated about 2 cm (3/4 inch) above the main papilla,slightly to its right. This is the exit hole for Santorini's duct.The minor papilla acts as a useful safety valve when the mainpapilla is not able to function correctly, but becomes the main siteof drainage for pancreatic juices in the rare congential disease ofpancreas divisum.

 

Vater´s papilla major and minor

Video Endoscopic Sequence 2 of 2.

In the video clip you can see the papilla major being
retracting and become hidden in a duodenal diverticula. 

The papilla of Vater is involved in the regulation of bile flow (inhibition and facilitation) into the duodenum and the prevention of reflux into the bile and pancreatic duct system. These functions are achieved by a special muscular, neural and mucosal structure of the papilla of Vater. The mucosa of the papilla of Vater consists of a complicated system of mucosal folds which can function as an anti-reflux valve or might even participate in the regulation of bile outflow. The smooth muscle of the sphincter of Oddi differs anatomically and embryologically from the surrounding duodenal muscle. It shows spontaneous electrical and mechanical activity acting independently from the duodenum but integrated into the overall function of the gastrointestinal tract by myogenic mechanisms, extrinsic and intrinsic nerves and circulating hormones. A spontaneous myogenic electrical activity propagates distally and leads to distally propagating phasic contractions. With endoscopic manometry in humans these phasic contractions as well as basal tone, bile duct pressure and pancreatic duct pressure can be measured. Changes of the basal tone and the phasic activity will alter the flow resistance thus regulating bile flow and inducing gallbladder filling. The most characteristic feature of the sphincter of Oddi is the inhibitory effect of cholecystokinin, which is a powerful contractor of the gallbladder, on the sphincter of Oddi motor activity. Cholecystokinin released in response to intra-duodenal fat and other nutrients might be the physiological stimulus of the increased bile flow post-prandially. The function of other hormones is still rather speculative and their physiological significance awaits further confirmation.

 

Emerging Bilis from the papilla.

Video Endoscopic Sequence 1 of 3.

Emerging Bilis from the papilla.

In this endoscopic sequence of video clips you can
appeciate the bilis that emerged from the papilla.

 

Video Endoscopic Sequence 2 of 3.

Emeging Bilis from the papilla.

 

Video Endoscopic Sequence 3 of 3.

Emerging bilis from the papilla.

 

A normal appearing papilla.

A normal papilla Vater seen to the left in these pictures
and video clips are taken through a forward-viewing
endoscope.

 

Ampulla of Vater.

The main papilla of Vater (named after an Italian) is a smallnipple-like structure on the wall of the duodenum, in its "secondpart." The duodenum is the upper part of the small intestine, intowhich food flows from the stomach. The papilla forms the mainexit hole for the bile and pancreaticjuices which flow down the bile duct and pancreatic duct. Rarelythere are two separate holes close together within the samepapillary nipple. The papilla remains closed at rest, because of theactivity of a muscular valve (sphincter). The sphincter (of Oddi,another Italian) surrounds the exit of the bile duct and pancreaticduct. It opens by reflex action when foods enter the stomach, sothat juices can be released to help in their digestion. In mostpeople there is a second smaller (minor, or accessory)papilla, situated about 2 cm (3/4 inch) above the main papilla, andslightly to its right. This is the exit hole for Santorini's duct. Theminor papilla acts as a useful safety valve when the main papilla isnot able to function correctly, but becomes the main site ofdrainage for pancreatic juices in the rare congential disease ofpancreas divisum.

 

Duodenal bulb seen in retroflexed maneuver.

The pylorus is seen. Adult endoscope was used. The video
clip shows the endoscope pass from the bulb to the antrum.

 

Duodenum in retroflexed maneuver.

Papilla of Vater.

With frenulum and prominent plica longitudinalis.

 

Papilla of Vater.

The papilla of Vatter is found at the medial aspect at the
midpoint of the c loop. The papilla is bordered by the
plica longitudinalis from the above and by another
longitudinal fold, the frenulum, from below.
The plica longitudinalis corresponds to the intraduodenal
portion of the common bile duct, it windens as it
approaches the papilla and ends in a bulging transverse
fold.
The preputium, which occasionally covers the papilla
itself.
The shape of the papilla may be hemispheric, papillary, or
flat. It not only varies from patient to patient but its
appearance may change somewhat during the examination. 

 

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