DEVELOPMENT OF DIGESTIVE SYSTEM

⇒ muscle, connective tissue, and peritoneal

TABLE OF CONTENTS components of the wall of the gut
A. Primitive Guy
a. Division
b. Foregut Derivatives
c. Midgut Derivatives
d. Hindgut Derivatives
B. Esophagus
a. Anomalies
C. Esophageal Atresia
D. Tracheoesophageal Fistula
a. Clinical Features of TEF
E. Stomach
a. Hypertrophic Pyloric Stenosis
F. Duodenum
G. Liver
H. Biliary Atresia
I. Pancreas
a. Annular Pancreas
J. Midgut
a. Intestinal Loop
b. Umbilical Hernia
c. Omphalocele
K. Jejunum & Ileum
a. Divisions
b. Volvulus
c. Meckel Diverticulum
L. Hindgut
M. Anal Canal
a. Imperforate Anus
b. Rectal Fistula
c. Hirschsprung’s Disease

REFERENCES: Dr. Vibar’s PPT; Langman’s Medical

Embryology by T.W. Sadler

PRIMITIVE GUT
● ENDODERM - germ layer of origin
● Formed from the incorporation of the dorsal part of
the yolk sac into the embryo
● Craniocaudal and Lateral folding of the embryo
● 4th week
⇒ Endoderm forms the epithelial lining of the digestive
tract and gives rise to the specific cells (the
parenchyma) of glands ● Three colors:
○ Blue: Ectoderm
⇒ hepatocytes
○ Red: Mesoderm
⇒ exocrine and endocrine cells of pancreas ○ Yellow: Endoderm
⇒ Visceral mesoderm
⇒ stroma (connective tissue) of glands

1
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ● The dorsal part of the yolk sac will be incorporated
into the developing part of the embryo to form the HINDGUT DERIVATIVES
primitive gut ● Left one third to one half of the transverse colon
● Primitive gut is derived from the endoderm germ
layer ○ Left side of the transverse colon is the start
of hindgut derivatives
● Descending colon and Sigmoid colon
DIVISION
● Rectum and Superior part of the Anal canal
● The Primitive gut is further divisible into 3 parts:
● Supplied by Inferior mesenteric artery
○ FOREGUT
● Transverse Colon is divisible anatomically into upper
■ supplied by Celiac trunk and its part right side and lower part left side
branches ○ Upper part right side: Midgut derivative
■ Cranial part ○ Lower part left side: Hindgut derivative
○ MIDGUT ○ Transverse colon is classified as BOTH
■ supplied by Superior Mesenteric midgut and hindgut derivative
● Anal Canal is anatomically divisible into
artery and its branches
upper/superior and lower/inferior.
■ at the middle ○ Superior/Upper: Hindgut derivative
○ HINDGUT ■ The superior part is a derivative
■ supplied by Inferior Mesenteric coming from hindgut ENDODERM
artery and its branches germ layer
■ Caudal part ○ Inferior/Lower: Ectodermal in origin
■ The inferior part comes from a
different embryonic origin,
ectoderm.

ESOPHAGUS
● Is classified as a foregut derivative.
● From the foregut we have a diverticulum form, and
that diverticulum is your Tracheoesophageal
diverticulum or laryngotracheal diverticulum
● 4th – 7th week; initially short but lengthens with
descent of heart and lungs
● Foregut is divided into the Esophagus dorsally and
Trachea ventrally – Tracheoesophageal folds – fuses
– Tracheoesophageal septum
⇒ Upper two-thirds: striated muscle coat, innervated by
FOREGUT DERIVATIVES the vagus nerve
● Esophagus and Stomach ⇒ Lower third: smooth muscle coat, innervated by the
● Duodenum ( proximal to the opening of bile duct ) splanchnic plexus
● Liver, Biliary apparatus ( Hepatic ducts, Gallbladder
and Bile duct ) and Pancreas
● Supplied by Celiac artery

MIDGUT DERIVATIVES
● Small intestine, including most of the Duodenum
● Cecum, Vermiform appendix, Ascending colon, and
the right half to two thirds of the Transverse colon
● Supplied by Superior mesenteric artery
● Duodenum is anatomically divisible into four (4)
parts/segments:
○ 1: Foregut derivative (since this is proximal
to the opening which is the part/segment 2)
○ 2: Site where the openings of the common
bile duct and the main pancreatic duct will
● Initially they have a common opening between
open
Trachea and Esophagus
○ 3: Midgut Derivative
○ 4: Midgut Derivate
2
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ● Tracheonest septum must develop, otherwise if there ○ The congenital anomaly associated with
is no development of tracheoesophageal septum Polyhydramnion is the Esophageal Atresia
there would be an abnormal communication between ● Fetus unable to swallow amniotic fluid – cannot pass
the trachea and esophagus to the intestine for absorption and transfer through the
placenta to the maternal blood for disposal
⇒ Most common form: proximal part of the esophagus
ends as a blind sac; distal part is connected to the
trachea by a narrow canal just above the bifurcation
● Newborns with esophageal atresia usually appear
healthy, and their first swallows are normal; but fluid
returns through the nose and mouth and respiratory
distress occurs

TRACHEOESOPHAGEAL FISTULA
● Fistula - means an Abnormal communication between
structures
● Abnormal communication between the trachea and
esophagus
● Associated with Esophageal atresia
● Results from improper division of the foregut by the
tracheoesophageal septum
ANOMALIES ○ The trachea and esophagus must be
● Esophagus is a continuous tube that would continue separated if there is a development of
to become stomach tracheoesophageal septum. In the event that
● Esophageal atresia there is no permission, no division of
○ Failure of recanalization (8th week) tracheoesophageal septum, there would be
Associated with TEF – 85% an abnormal communication between
○ Results to Polyhydramnios trachea and esophagus, and this results to
Tracheoesophageal Fistula
○ Failure of recanalization means that there is
an abnormal formation of the esophagus.
○ Esophagus ends as a lined pouch/ line
tube. there is no communication with
stomach
● Esophageal stenosis
○ Lumen is narrowed (8th week
○ Involves the midportion – maybe caused by
hypertrophy of the submucosal/ muscularis
externa or incomplete recanalization
○ When you say stenosis there is a narrowing
of the lumen.
○ Usually it is the part of the esophagus that is
involved
○ Failure of recanalization would result to
esophageal atresia, while incomplete NORMAL ANATOMY
recanalization recanalization would result to ● The esophagus is normal
esophageal stenosis ● It is a muscular tube that will continue to become
the stomach.
ESOPHAGEAL ATRESIA
ATRESIA WITH DISTAL FISTULA
● Polyhydramnios – accumulation of excessive
● Most Common Type of Tracheoesophageal Fistula
amount of amniotic fluid
with esophageal atresia
○ Normally newborn or fetus will swallow ● Fistula - there is communication between the
amniotic fluid, but in esophageal atresia, the esophagus and the trachea, and almost always
fetus would be unable to swallow the there is an esophageal atresia
amniotic fluid which results to ● Baby born with Tracheoesophageal Fistula, will
Polyhydramnion have an accumulation of milk, fluid in the mouth,
and a fluid, milk will return to the nose, and may go

3
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 to the respiratory system and could result in C. Esophageal atresia with a TEF at proximal end
cyanosis and to respiratory distress. D. Esophageal atresia with a TEF at distal and
proximal ends
ATRESIA WITH DOUBLE FISTULA
● there is a fistula in the proximal and distal end.
STOMACH
● Week 4 – fusiform dilatation – primitive stomach
ATRESIA WITH PROXIMAL FISTULA
● Dorsal part grows faster than ventral part – resulting
● opposite of atresia with distal fistula
to greater and lesser curvatures
FISTULA ● After rotation, the ventral part becomes lesser
● No atresia, but you only have a fistula curvature while the dorsal part becomes the greater
curvature.
CLINICAL FEATURES OF TEF ● Rotates 90 degrees clockwise
● Excessive accumulation of saliva or mucus in the ⇒ Rotates around a longitudinal and an anteroposterior
nose and mouth axis
● Episodes of gagging and cyanosis after swallowing ⇒ Left side: faces anteriorly
milk ⇒ Right side: faces posteriorly
● Abdominal distention after crying
● Reflux of gastric contents into the lungs, causing
● Pneumonitis

A. Esophageal atresia with a TEF at distal end ( most

common – 85 to 90 % of cases ) As a result of rotation, the Dorsal mesentery is carried to the
B. TEF only LEFT and eventually forms the Greater Omentum

4
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 HYPERTROPHIC PYLORIC STENOSIS
● muscularis externa in the pyloric region hypertrophies
– narrow pyloric lumen that obstructs the passage of
food
● Associated clinically with projectile vomiting after
feeding and a small palpable mass at the right costal
margin
⇒ One of the most common abnormalities of the A. Duodenal stenosis – incomplete recanalization (5th
stomach in infants – 6th weeks); involves 3rd and 4th portion
B. Duodenal atresia – 2nd and 3rd portion; “double
bubble sign”
● Stenosis means a narrow lumen, for atresia there
is no lumen.
● When there is a case of abdominal obstruction in
GIT we usually request for abdominal x-ray.

DUODENUM
● Upper duodenum – caudal portion of the foregut
● Lower duodenum – cranial most part of the midgut
⇒ junction of the 2 parts is directly distal to the origin of
the liver bud
⇒ as the stomach rotates, the duodenum takes on the ● Double bubble sign (White Arrow) – is a radiographic
form of a C-shaped loop and rotates to the right. finding found in Duodenal Atresia.
⇒ swings the duodenum from midline position to the
right side of the abdomen LIVER
● Endodermal lining of the Foregut forms an outgrowth
– Hepatic diverticulum into the surrounding mesoderm
of the Septum transversum
⇒ appears in the middle of the 3rd week
● The hepatic diverticulum can be seen on the ventral
wall of the foregut.

● rapidly grows in 5th – 10th week

5
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ● Hepatic diverticulum
○ cranial part → Liver PANCREAS
○ caudal part → GB, cystic duct ● Develops from the dorsal and ventral pancreatic buds
that originate from the endodermal lining of the
foregut
● Dorsal pancreatic bud appears first
● 5th – 8th weeks

● Biliary system= System of ducts

● From the liver you have the right and left hepatic
ducts
● Union of Right and left hepatic ducts will form the
common hepatic duct
● From the gallbladder, there is a duct on top called the
cystic duct
● Cystic duct and common hepatic duct will unite
together to form the common bile duct.
● Main pancreatic duct and common bile duct will unite
to open to the 2nd part of the duodenum.
⇒ Hematopoietic cells, Kupffer cells, and
connective tissue cells - derived from mesoderm
of the septum transversum.
As the duodenum rotates to the right and becomes
BILIARY ATRESIA C-Shaped, the ventral pancreatic bud is carried dorsally with
● Type I: atresia of the common bile duct the bile duct – soon lies posterior to the dorsal pancreatic
● Type IIa: atresia of the common hepatic duct bud and later fuses with it
● Type IIb: atresia of common bile duct, cystic duct, and
common hepatic duct Main pancreatic duct is formed by the union of the distal part
● Type III: atresia of the common bile duct, cystic duct, of the dorsal pancreatic duct and the entire ventral
and hepatic ducts up to the porta hepatis. This is the pancreatic duct
subtype present in over 90% of patients with biliary
atresia (Majority of cases is type III) Proximal part of the dorsal pancreatic duct usually
● Causes jaundice in babies obliterates, but it may persist as an accessory pancreatic
duct

Ventral pancreatic bud rotation will fuse with dorsal causing

the formation of the pancreas

● Ventral pancreatic bud forms most of the head of the

pancreas, including the uncinate process
● Dorsal pancreatic bud forms the remainder of the
pancreas - head, body, tail and neck

6
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ANNULAR PANCREAS
● Probably results from the growth of a bifid ventral
pancreatic bud around the duodenum, parts then fuse
with the dorsal bud forming a pancreatic ring
● Anomaly produces complete obstruction / atresia or
partial obstruction / stenosis of the duodenum
⇒ Right portion of the ventral bud migrates along
its normal route, but the left migrates in the
opposite direction
⇒ Duodenum is surrounded by pancreatic tissue

● The midgut loop will protrude towards the umbilicus (

physiologic herniation) which is a cause of the sudden
growth of the liver.
● Happens during the 6th wk, and re- enters the
abdomen at the 10-12th wk.

MIDGUT UMBILICAL HERNIA

● Superior mesenteric artery
⇒ Supplies the midgut over its entire length
● Primary intestinal loops
○ cranial → distal duodenum, jejunum, upper
ileum
○ caudal → lower ileum, cecum, appendix,
asc. colon, 2/3 transverse
● 6th week – physiologic herniation
○ 90O counterclockwise rotation
○ It will protrude outside its original location
(Normal na nangyayri ‘to)
● 10th – 12th week re-enters abdomen
○ 180O rotation during reduction
● Some newborns, a mass is protruding in the
○ Dapat bumalik na siya in the abdomen
umbilicus whenever the baby cries.
INTESTINAL LOOP ● Hindi siya nag close ng maigi.

OMPHALOCELE

7
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ⇒ Omphalocele - herniation of abdominal viscera
through an enlarged umbilical ring
⇒ The viscera, which may include liver, small and large
intestines, stomach, spleen, or gallbladder, are
covered by amnion.
⇒ The origin of the defect is a failure of the bowel to
return to the body cavity from its physiological
herniation during the 6th to 10th weeks.

JEJUNUM & ILEUM

● Jejunum - (proximal 2/5), begins at the
duodenojejunal flexure and the Ileum (distal 3/5),
ends at the ileocecal junction
● 6 to 7 meters long
● Jejunum lies in the LUQ; ileum lies in the RLQ

● Gastroschisis – occurs when there is a defect in the

ventral abdominal wall – there is massive evisceration
of the intestines; incomplete closure of the lateral
folds; NO protective sac; common in males
⇒ Protrusion of abdominal contents through the
body wall directly into the amniotic cavity
⇒ Defect is most likely due to the abnormal
closure of the body wall around the connecting
stalk
● Seen on the lateral
⇒ Occurs lateral to the umbilicus usually on the
right DIVISIONS
● no protective covering ● Cecum
⇒ Viscera are not covered by peritoneum or ● Appendix
amnion, and the bowel may be damaged by ● Colon – ascending, transverse, descending, sigmoid
exposure to amniotic fluid ● Rectum
● Surgically repaired ● Anal canal
⇒ More prevalent in babies born to younger women
⇒ Volvulus (rotation of the bowel) resulting in a
compromised blood supply may kill large regions of
the intestine and lead to fetal death

8
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 CASE 1
A 2 y/o boy is brought to the emergency room with fever,
vomiting and abdominal pain. The mother told the attending
physician that these symptoms began 12 hours ago and
have progressively worsened. She also noticed that his stool
and diaper were colored with bright red blood. Laboratory
results showed that hematocrit and hemoglobin were on the
low end of normal. Abdominal radiology showed a bowel
obstruction that appears related to an abnormal intestinal
outpocketing connected to the anterior abdominal wall.

MECKEL DIVERTICULUM
● Ileal diverticulum
● Persistence of remnant of vitelline duct forming an
outpouching located on the ileocecal valve on the
antimesenteric border of ileum
● Yolk sac/ vitelline duct
● Occurs at ileum
⇒ If it contains heterotopic pancreatic tissue or gastric
mucosa, it may cause ulceration, bleeding, or even
perforation

VOLVULUS

● True diverticulum that is located approximately 2 ft

from the ileocecal junction, occurs in about 2% of the
population, about 2 inches long and may contain
ectopic gastric or pancreatic cells
● occurs at <2 y/o
● Bleeding associated with ulceration of the ectopic
● Duodenum, jejunum and ileum is on the right side cells, obstruction and pain that is referred over the
Cecum, appendix and ascending colon is on the area of umbilicus or may mimic referred pain of
center inflamed appendix
● Impaired rotation ● differentiate w/ appendicitis: blood in stool
● Volvulus- twisting of the intestine
○ Usually small intestine because it is not fixed
● Complication: obstruction and should be corrected

9
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ● Cloaca – terminal end of the hindgut which is
partitioned by the urorectal septum into rectum and
upper anal canal
● Cloacal membrane is partitioned by the urorectal
septum into the anal membrane and urogenital
membrane

HINDGUT
● Inferior mesenteric artery
⇒ Gives rise to:
○ Left lower 1/3 transverse colon, desc. colon,
sigmoid colon, rectum, and superior part of
anal canal
⇒ Endoderm of the hindgut also forms the internal lining
of the bladder and urethra
⇒ Terminal portion enters into the posterior region of the
cloaca - primitive anorectal canal
⇒ Allantois enters into the anterior portion - primitive
urogenital sinus

ANAL CANAL
● Upper – from Hindgut; endoderm
○ simple columnar epithelium
● Lower – from Proctodeum; ectoderm
○ stratified squamous nonkeratinized
epithelium
● Junction – Pectinate line
○ divide the anal canal into superior (hindgut
derivative) and inferior (proctodeum
derivative)

10
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 IMPERFORATE ANUS
● 8th week – anal membrane ruptures
● No anal opening
● 1/5000
● more common in males
● secondary to abnormal development of the urorectal
septum
⇒ The anorectal canal forms normally, but the
anal membrane separating the ectodermal
and endodermal portions of the anus is
abnormally thick. This thickened anal
membrane may fail to rupture or may rupture
incompletely, resulting in imperforate anus or
anal stenosis.

CASE 2
After his birth, a newborn was placed in the hospital’s
nursery room. Within 24 hours, the newborn developed
RECTAL FISTULA
abdominal distention and his vomitus contained bile. It was
● Improper development of urorectal septum
also noted that he had failed to pass meconium during this
● Usually there is also no anal opening
time. Physical examination of the newborn at birth revealed
● There is a meconium passage. (Vagina in female,
normal findings.
Urethra in male)

HIRSCHSPRUNG’S DISEASE
● Congenital Megacolon
○ absence of autonomic ganglion cells in
Myenteric and Meissner’s plexus

11
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ○ Failure of neural crest cell migration during ANAL OPENING MECONIUM
5th – 7th week PASSAGE
○ Rectum and sigmoid colon IMPERFORATE None None
○ 33% of neonatal obstructions ANUS
○ 4 males:1 female RECTAL None Yes
FISTULA
CONGENITAL Yes None
MEGACOLON

● Failure of migration of neural crest cells (Myenteric /

auerbach’s andMeissner’s plexus) leading to
abnormal innervations of the bowel
● Most common cause of lower intestinal obstruction in
neonates

12
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 CONGENITAL ANOMALIES STRUCTURAL DEFECTS PRESENTATIONS
MECKEL’S DIVERTICULUM Persistence of remnant of vitelline duct Bleeding associated with ulceration of the
forming an outpouching located on the ectopic cells, obstruction and pain that is
antimesenteric border of ileum referred over the area of umbilicus or may
mimic referred pain of inflamed appendix
HIRSCHSPRUNG'S DISEASE “Congenital Megacolon” ● Most common cause of lower
● Absence of autonomic ganglion intestinal obstruction in neonates
cells in Myenteric ad Meisnner’s ● Absence of meconium passage
plexus
RECTAL FISTULA ● Improper development of ● Absence of anal opening
urorectal septum
IMPERFORATE ANUS ● Secondary to abnormal ● Absence of anal opening and
development of the urorectal meconium passage
septum
OMPHALOCELE Failure of the bowel to return to the body Herniation of abdominal viscera through
cavity from its physiological herniation an enlarged umbilical ring
during the 6th to 10th weeks
VOLVULUS Impaired rotation or twisting of the Compromised blood supply that may kill
intestine (usually small intestine) large regions of the intestine and lead to
fetal death
ANNULAR PANCREAS Growth of bifid ventral pancreatic bud Complete obstruction / atresia or partial
around the duodenum, parts then fuse obstruction / stenosis of the duodenum
with the dorsal bud forming a pancreatic
ring
BILIARY ATRESIA ● Type I: atresia of the common Causes jaundice in babies
bile duct
● Type IIa: atresia of the common
hepatic duct
● Type IIb: atresia of common bile
duct, cystic duct, and common
hepatic duct
● Type III: atresia of the common
bile duct, cystic duct, and hepatic
ducts up to the porta hepatis.
This is the subtype present in
over 90% of patients with biliary
atresia (Majority of cases is type
III)
DUODENAL ATRESIA / STENOSIS ● Duodenal atresia - “double ● Duodenal atresia - with narrow
bubble sign” lumen
● Duodenal stenosis - incomplete ● DUodenal stenosis - no lumen
recanalization during 5th to 6th
week
HYPERTROPHIC PYLORIC STENOSIS Muscularis externa in the pyloric region Projectile vomiting after feeding and a
hypertrophies = narrow pyloric lumen that small palpable mass at the right costal
obstructs the passage of food margin
ESOPHAGEAL ATRESIA / STENOSIS ● Esophageal atresia - failure of ● Esophageal atresia - associated
recanalization during the 8th with TEF and results to
week Polyhydramnios (accumulation of
excessive amount of amniotic

13
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 ● Esophageal stenosis - fluid); esophagus has no
hypertrophy of the submucosal / connection with the stomach
muscularis externa or incomplete ● Esophageal stenosis - narrowed
recanalization lumen during the 8th week
TRACHEO-ESOPHAGEAL FISTULA Improper division of the foregut by the ● Abnormal communication
tracheoesophageal septum between the trachea and
esophagus
● Associated with esophageal
atresia

14
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA
 15
ALABAN • BAUTISTA • BULANHAGUI • FERNANDEZ • FORMENTO • LEONCIO • NENENG • PEREZ • RAYMUNDO • SOMERA