Vasculature - Coeliac trunk

Question 1

What is the coeliac artery?

Answer 1

It is a major artery of the abdomen. It arises from the abdominal aorta and supplies many of the GI viscera.

Question 2

Anatomical position?

Answer 2

The coeliac trunk is the second branch of the abdominal aorta ( the first branches are the paired inferior phrenic arteries). It arises from the anterior aspect of the aorta, at the aortic hiatus of the diaphragm (T12).

Question 3

What are the major branches of the coeliac trunk?

Answer 3

1) Left gastric artery
2) Splenic artery
3) Common hepatic artery

Question 4

Left gastric artery?

Answer 4

The left gastric artery is the smallest of the three branches. It ascends across the diaphragm, giving rise to oesophageal branches, before continuing along the lesser curvature of the stomach. Here, it anastomoses with the right gastric artery,

Question 5

Splenic artery?

Answer 5

The splenic artery arises from the coeliac trunk just inferior to the left gastric artery, It then travels left towards the spleen, running posterior to the stomach and along the superior margin of the pancreas. During its course, it is contained within the splenorenal ligament, It terminates into five branches which supply the segments of the spleen.

In addition to supplying the spleen, the splenic artery also gives rise to several important vessels:
1) Left gastroepiploic artery - supplies the greater curvature of the stomach. Anastomoses with the right gastroepiploic artery.

2) Short gastrics - 5-7 small branches supplying the fundus of the stomach.
3) Pancreatic branches - supply the body and tail of the pancreas.

The splenic artery has a tortuous appearance (similar to the facial branch of the ECA) and thius is easily identifiable from other nearby vessels.

Question 6

Common hepatic artery?

Answer 6

The common hepatic artery is the sole arterial supply to the liver and the only branch of the coeliac artery to pass to the right.

As it travels past the superior aspect of the duodenum, it divides into its two terminal branches - the proper hepatic and gastroduodenal arteries. Each of these arteries has multiple branches and variation in the arrangement of these branches is common.

Proper hepatic

The proper hepatic artery ascends through the lesser omentum towards the liver. It gives rise to:

1) Right gastric - supplies the pylorus and lesser curvature of the stomach.
2) Right and left hepatic - divides inferior to the porta hepatis and supply their respective lobes of the liver.
3) Cystic - branch of the right hepatic artery - supplies the gall bladder.

Gastroduodenal

The gastroduodenal artery descends posterior to the superior portion of the duodenum. Its branches are:

1) Right gastroepiploic artery - supplies the greater curvature of the stomach. Found between the layers of the greater omentum, which it also supplies.
2) Superior pancreaticoduodenal - divides into an anterior and posterior branch, which supplies the head of the pancreas.

Question 7

Anastomoses?

Answer 7

Stomach

The stomach is the only organ to receive arterial supply from all three branches of the coeliac trunk. This is achieved through a system of anastomoses along the greater (gastroepiploic arteries) and lesser (gastric arteries) curvatures,

Pancreas

The pancreaticoduodenal arcade is a network of arteries that surround and supply the head of the pancreas.

There are two main arteries - each has an anterior and a posterior branch, that anastomose (e.g. anterior to anterior) forming a ring structure.

• Superior pancreaticduodenal - a branch of the gastroduodenal artery
• Inferior pancreaticoduodenal - a branch of the superior mesenteric artery (SMA)

Question 8

Disorders of the coeliac trunk?

Answer 8

Peptic ulcer

Peptic ulcers of the stomach and duodenum have potential to cause significant GI bleeding if they erode into neighbouring arteries (usually the gastroduodenal artery).

Coeliac trunk compression syndrome

The median arcuate ligament (the fibrous anchor of the diaphragm that forms the aortic hiatus) occasionally lies anterior to the coeliac trunk, rather than its usual superior position.

This can cause compression of the coeliac trunk that may present pathologically as pain. The pain is thought to be caused by the resulting ischaemia of the abdominal organs - thorugh it also may be associated with compression of the coeliac ganglia.

The treat of coeliac compression syndrome is the surgical division of the median arcuate ligament.

Splenic artery aneurysm

These are the most common types of visceral aneurysm, comprising around 60% of the total.

The main risk factors for their development are female sex, multiple pregnancies, portal hypertension, and pancreatitis or pancreatic pseudocyst formation.

Those that are symptomatic will present with a vagus epigastric or LUQ pain. Those that rupture will present with a severe abdominal pain and haemodynamic compromise.

First line management option is endovascular repair; this is best done with embolisation or stent grafts, once the patient is haemodynamically stable (an open repair may be advised in the unstable patient),