The stomach is the first intra-abdominal part of the gastrointestinal (GI), or digestive, tract. It is a muscular, highly vascular bag-shaped organ that is distensible and may take varying shapes, depending on the build and posture of the person and the state of fullness of the organ (see the image below). The stomach lies in the left upper quadrant of the abdomen. [1, 2]
The thoracic esophagus enters the abdomen via the esophageal hiatus of the diaphragm at the level of T10. The abdominal portion of the esophagus has a small intra-abdominal length (2-3 cm). The esophagogastric junction (cardia), therefore, lies in the abdomen below the diaphragm to the left of the midline at the T11 level.
The cardiac notch (incisura cardiaca gastri) is the acute angle between the left border of the abdominal esophagus and the fundus of the stomach, which is the part of stomach above a horizontal line drawn from the cardia. The body (corpus) of the stomach leads to the pyloric antrum (at the incisura angularis). The pyloric antrum narrows toward the right to become the pyloric canal, surrounded by the pyloric sphincter, which joins the duodenum at the L1 level (transpyloric plane) to the right of the midline (see the image below).
The anterior surface of stomach is related to the left lobe (segments II, III and IV) of the liver, the anterior abdominal wall, and the distal transverse colon. The posterior surface of the stomach is related to the left hemidiaphragm, the spleen, the left kidney (and adrenal), and the pancreas (stomach bed).
The omental bursa (lesser sac) lies behind the stomach and in front of the pancreas; it communicates with the greater sac (main peritoneal cavity) via the omental (epiploic) foramen (of Winslow) behind the hepatoduodenal ligament (HDL; the free edge of the lesser omentum).
The convex greater curvature of the stomach starts at the left of the cardia and runs from the fundus along the left border of the body of the stomach and the inferior border of the pylorus. The concave lesser curvature starts at the right of the cardia as a continuation of the right border of the abdominal esophagus and runs a short distance along the right border of the body of the stomach and the superior border of the pylorus. The junction of the vertical and horizontal parts of the lesser curvature is called incisura angularis. Lesser curvature is shorter in length than the greater curvature.
The stomach and the first part of the duodenum are attached to the liver by the hepatogastric ligament (the left portion of the lesser omentum) containing right and left gastric vessels, to the left hemidiaphragm by the gastrophrenic ligament, to the spleen by the gastrosplenic/gastrolienal ligament containing short gastric vessels, and to the transverse colon by the gastrocolic ligament (part of the greater omentum) containing epiploic (omental) vessels. Few peritoneal bands may be present between the posterior surface of the stomach and the anterior surface of the pancreas. Part of the greater omentum hangs like an apron from the transverse colon, with 4 layers of the peritoneum (often fused): 2 layers go downward from the stomach and then run upward to be attached to the transverse colon.
The celiac trunk (axis) arises from the anterior surface of the abdominal aorta at the level of L1. It has a short length (about 1 cm) and trifurcates into the common hepatic artery (CHA), the splenic artery, and the left gastric artery (LGA).
The LGA runs toward the lesser curvature of the stomach and divides into an ascending branch (supplying the abdominal esophagus) and a descending branch (supplying the stomach). The CHA runs toward the right on the superior border of the pancreas and gives off the gastroduodenal artery (GDA), which runs down behind the first part of the duodenum. After giving off the GDA, the CHA continues as the proper hepatic artery.
The right gastric artery (RGA), a branch from the proper or common hepatic artery, runs along the lesser curvature from right to left and joins the descending branch of the LGA to form an arcade along the lesser curvature between the 2 leaves of peritoneum of the lesser omentum. This arcade gives off multiple small arteries to the body of the stomach. The GDA gives off the PSPDA and then divides into the right gastro-omental (gastroepiploic) artery (RGEA) and the anterior superior pancreaticoduodenal artery (ASPDA); it also gives off the small supraduodenal artery (of Wilkie). The RGEA runs along the greater curvature from right to left.
The splenic artery runs toward the left on the superior border of the distal body and tail of pancreas and gives off the left gastro-epiploic (gastro-omental) artery (LGEA), which runs from left to right along the greater curvature and joins the RGEA to form an arcade along the greater curvature between the two leaves of peritoneum of the greater omentum. This arcade gives off multiple small arteries to the body of the stomach.
The greater curvature arcade formed by the RGEA and the LGEA provides several omental (epiploic) branches to supply the highly vascular greater omentum. The splenic artery also gives off 3-5 short gastric arteries that run in the gastro-splenic (gastro-lienal) ligament and supply the upper part of the greater curvature and the gastric fundus. Few small posterior gastric arteries may arise from the splenic artery. The stomach has a rich network of vessels in its submucosa.
The left gastric (coronary) vein drains into the portal vein at its formation (by the union of the splenic and superior mesenteric veins). The right gastric and right gastro-omental veins drain into the portal vein. The left gastro-omental vein drains into the splenic vein, as do the short gastric veins.
The pylorus is marked by a prepyloric vein (of Mayo), which lies on its anterior surface. The gastrocolic trunk (GCT) of Henle is present in a large number of cases and lies at the junction of the small bowel mesentery and the transverse mesocolon. It may drain branches from the middle colic, and ASPDV and right gastro-omental veins.
The short gastric arteries and veins are sometimes collectively referred to as the vasa brevia.
Lymph nodes draining the stomach are numbered and divided into 4 levels, as follows:
Level I (perigastric lymph nodes) - Right paracardiac (1), left paracardiac (2), along lesser curvature (3) along greater curvature (4), suprapyloric (5), infrapyloric (6)
Level 2 - Along LGA (7), along CHA (8), along celiac axis (9), at splenic hilum (10), along splenic artery (11)
Level 3 - In hepato-duodenal ligament (12), behind duodenum and pancreas head (13), at the root of small bowel mesentery (14)
Level 4 - Mesocolic (15), paraaortic (16)
The esophageal plexus of vagus (para-sympathetic) nerves lies in the posterior mediastinum below the hila of the lungs. It divides into 2 vagal trunks that enter the abdomen along with the esophagus through the esophageal hiatus in the left dome of diaphragm. The right (posterior) vagus is behind and to the right of the intra-abdominal esophagus, whereas the left vagus is in front of the intra-abdominal esophagus.
The right vagus gives off a posterior gastric branch called the criminal nerve of Grassi, which traverses to the left and supplies the cardia and fundus of the stomach; the nerve is so called because it is often missed during vagotomy and is then responsible for recurrence of peptic ulcer. The right vagus gives off a celiac branch (which supplies the pancreas and the small and large bowel), and the left vagus gives off a hepatic branch (which supplies the liver and the gallbladder).
After giving off the celiac and hepatic branches, respectively, the right and left vagal trunks continue along the lesser curvature of the stomach (in close company with the vascular arcade formed by the left and right gastric vessels) as the posterior and anterior gastric nerves of Latarjet, which supply the corpus (body) of the stomach, the antrum, and the pylorus.
Sympathetic nerve supply to the stomach comes from celiac ganglia (T5-T9).
Anatomy on diagnostic imaging
The stomach and duodenum are evaluated radiologically with barium studies using fluoroscopy. It should be noted that on computed tomography (CT), the cardia is on a lower horizontal plane than the dome of the fundus is.
Cardia (esophagogastric junction), incisura angularis, and pylorus are very well seen on upper GI endoscopy (UGIE).
Stomach is a reservoir; its size and shape changes from time to time depending on the volume of its contents (food/fluid). The shape and position of the stomach also changes with the position of the patient, whether erect or supine. A large J-shaped stomach can descend as low down as into the pelvis.
Severe pain in any part of the body (eg, headache, ureteric colic due to stone) may give rise to pylorospasm and reflex vomiting.
The esophagus is lined with nonkeratinized stratified squamous epithelium, which changes into columnar epithelium in the stomach. The columnar cells in all of the stomach secrete mucin; the chief (zymogenic) cells in the fundus secrete protein digesting pre-enzyme pepsinogen; the parietal (oxyntic) cells in the body (corpus) of the stomach secrete acid (H+ ions) and intrinsic factor; and the G cells in the antrum secrete gastrin (which in turn acts on parietal cells).
The innermost lining of the stomach wall is mucosa, which consists of columnar epithelium, lamina propria, and muscularis mucosa. Submucosa contains a rich network of blood vessels and Meissner’s nerve plexus. The smooth muscles of the stomach are arranged in 3 layers: inner oblique (unique to stomach), middle circular (forms the pylorus), and outer longitudinal. These muscles are supplied by the Auerbach’s nerve plexus. Serosa is the visceral peritoneum that covers most of the stomach. Mucosa and submucosa are thrown into several longitudinal folds called rugae.
The lower esophageal sphincter (LES), or gastroesophageal sphincter, is not a true (anatomic) sphincter; however, the pylorus is a true sphincter composed of circular muscles.
Wall layers on ultrasonography
Endoscopic ultrasonography (EUS) is a newer technical tool for evaluating stomach. An ultrasound probe is mounted at the tip of an upper gastrointestinal (GI) endoscope, which is passed into the stomach. The wall of the stomach is seen as 5 alternating layers, as follows:
Lamina propria (hypoechoic)
Muscularis propria (hypoechoic)
EUS is very helpful in the diagnosis and staging of early gastric cancer.
Congenital hypertrophic pyloric stenosis seen in infants presents as pyloric obstruction at 2-4 weeks of life.
Types of vagotomy include truncal, selective, and highly selective.
In truncal vagotomy (TV), both anterior and posterior vagal trunks are divided as they enter the abdomen. In selective vagotomy (SV), the anterior and posterior vagi are divided below their hepatic and celiac branches, respectively. The nerve supply to the viscera (eg, liver, gallbladder, common bile duct [CBD], pancreas, and small and large bowel) is preserved. In highly selective vagotomy (HSV; also referred to as proximal gastric vagotomy [PGV] or parietal cell vagotomy [PCV]), the anterior and posterior nerves of Latarjet are preserved, which maintains the nerve supply to the antrum and pylorus. TV and SV denervate the antrum and pylorus and necessitate a drainage procedure (gastrojejunostomy or pyloroplasty); HSV does not require drainage.
Parietal cell mass is increased in Zollinger-Ellison syndrome, resulting in hypersecretion of acid. Antrectomy removes the G cells and results in reduction of acid production by taking away stimulation of parietal cells by gastrin.
The artery involved in a bleeding duodenal ulcer is gastroduodenal artery, which runs vertically down behind (posterior to) the first part of the duodenum.
Pseudocyst of the pancreas is a collection of fluid that develops in a lesser sac behind the stomach; it can be drained into the stomach (cystogastrostomy) either surgically or endoscopically.
The stomach can be mobilized after division of the left gastric artery (proximal to its bifurcation) and left gastroepiploic artery and can survive on the right gastric artery and right gastroepiploic artery, to be taken through the mediastinum into the neck (even as high as the pharynx) after total esophagectomy. The vascular arcades on the lesser and greater curvatures have to be preserved.
Esophagogastric anastomosis is done to the fundus—the highest point of the mobilized stomach.
When making a gastrotomy (incision) in the wall of the stomach, vessels are encountered in the submucosal plane—these must be controlled with suture, diathermy, or any other energy device.
The lesser sac is opened by dividing the gastrocolic omentum between the greater curvature of the stomach and transverse colon—this exposes the body and tail of the pancreas, with splenic artery running on its upper (cranial) border. The gastrocolic omentum is opened towards its left, away from the middle colic vessels, where it is thinner and broader.
The spleen is at risk for injury when short gastric vessels are divided during mobilization of the fundus and the upper part of the greater curvature of the stomach. Similarly, fundus of the stomach can be injured when short gastric vessels are divided during splenectomy.
The transverse mesocolon, containing middle colic vessels, or the transverse colon itself may be involved in stomach cancer. Posterior infiltration of stomach cancer occurs into the pancreas.
A vascular flap of greater omentum based on an epiploic artery can be used to provide cover to an anastomosis in the abdomen (eg, esophagogastric, biliary enteric, pancreaticoenteric).