Relations

The stomach rests on the transverse mesocolon, which covers the pancreas, solar plexus, aorta, thoracic duct, vena cava, and crura of the diaphragm posteriorly; farther to the left are the left suprarenal body, kidney, and spleen (Fig. 415).

Fig. 416.   blood supply and lymphatics of the stomach, and Hartmann Mikulicz line.

Fig. 416. - blood supply and lymphatics of the stomach, and Hartmann-Mikulicz line.

In front are the diaphragm, abdominal parietes, and liver. Above are the lesser or gastrohepatic omentum, liver, and diaphragm. Below is the gastrocolic omentum, transverse colon, and gastrosplenic omentum.

Percussion

In physical diagnosis the size of the stomach is outlined by percussion, it being filled with air or gas to distend it. In the median line its resonance above will be limited by the edge of the liver; below, while usually 5 to 7.5 cm. (2 to 3 in.) above the umbilicus, it is not considered to be dilated, especially in old people, unless it reaches below the umbilicus. It leaves the left costal margin opposite the ninth or tenth costal cartilage. In the left mammary line stomach resonance may reach up to the fifth or sixth rib, while farther to the left it reaches the spleen about in the midaxillary line.

Traube' s semilunar space is limited above by the edge of the left lung, indicated by the sixth interspace; externally by the spleen, indicated by the midaxillary line; and internally by the costal margin. Normally this area is resonant from the presence of the stomach beneath, but pleural effusion causes it to be dull on percussion.

Blood Supply

The caeliac axis gives off the gastric, hepatic, and splenic arteries, all of which give branches to the stomach. The gastric (or coronary) gives branches to the oesophagus and cardiac end and then runs along the lesser curvature to unite with the pyloric branch of the hepatic. It lies in the gastro-hepatic omentum and sends branches anteriorly and posteriorly over the surface of the stomach (Fig. 416).

The hepatic artery as it nears the pylorus gives off a pyloric branch which passes to the left along the lesser curvature, and a gastroduodenal branch, which divides into the superior pancreaticoduodenal to supply the duodenum and head of the pancreas, and the right gastro-epiploic artery which passes to the left along the greater curvature of the stomach.

The splenic artery near the spleen gives off the left gastro-epiploic artery which proceeds along the greater curvature to unite with the right gastro-epiploic, a branch of the gastroduodenal artery.

The more the stomach is distended the closer do the arteries of its greater and lesser curvatures lie to its walls. The fundus is supplied by the vasa brevia, small branches which leave the splenic artery in the gastrosplenic omentum.

The veins follow the course of the arteries. The right gastro-epiploic empties into the superior mesenteric and the left into the splenic; they then enter the portal vein. The pyloric and coronary veins empty into the portal vein direct. The latter receives branches from the oesophagus which become varicose in cirrhosis of the liver.

Lymphatics

The lymphatic nodes of the stomach are found principally around the regions of the pylorus - inferior gastric nodes, and the lesser curvature and cardiac extremity - superior gastric nodes. The inferior nodes drain the greater curvature toward the pylorus while the superior nodes drain the lesser curvature and cardiac end. The fundus is drained by radicles which empty into the nodes which accompany the splenic artery. While some nodes may be found along the greater curvature toward the pyloric end, Cuneo and Poirier state that it is rare to find nodes in the middle portion of the greater curvature and quite exceptional to meet with them in the region of the fundus.