Review
Gastrointestinal Imaging
February 10, 2021

Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation

Abstract

OBJECTIVE. The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions.
CONCLUSION. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.
The ligament of Treitz is one of the frequently forgotten structures within the abdomen. It was named after the Austrian physician and anatomist Wenzel Treitz, who in 1853 first described the ligament as a thin, triangular, fibromuscular band extending from the upper surface of the duodenojejunal junction [1]. It is also known as the suspensory ligament of the duodenum because it suspends the duodenojejunal flexure from the retroperitoneum. In the medical literature, the term “ligament of Treitz” is often used interchangeably with the term “duodenojejunal flexure” [2]. This fibromuscular structure plays an important role in the embryonic development of the alimentary tract by holding the intestine during rotation of the gut around the superior mesenteric artery; therefore, the ligament of Treitz contributes to the development of superior mesenteric artery syndrome (SMAS) [3]. In addition, it is an important anatomic landmark for distinguishing between the fore-gut and the midgut, and its presence can therefore differentiate between sources of upper and lower gastrointestinal bleeding [4].

Anatomy

Understanding the exact anatomy, location, and clinical significance of the ligament of Treitz remains a challenge among medical professionals, including clinicians, surgeons, and radiologists. The ligament of Treitz is a thin, triangular, double fold of the peritoneum that lies posterior to the pancreas and anterior to the left renal vein. The inferior mesenteric artery lies adjacent to the ligament of Treitz, creating an identifiable anatomic demarcation where the duodenum becomes the jejunum as the duodenum emerges from the retroperitoneum into the peritoneum. The ligament of Treitz consists of two parts that are joined at the connective tissue surrounding the celiac artery, giving the ligament its elon-gated triangular shape. The superior part, called the Hilfsmuskel, is a skeletal muscle that arises from the right crus of the diaphragm at the esophageal hiatus and is gradually replaced by fibrous tissue while inserting into the connective tissues surrounding the celiac artery. The inferior part, known as the suspensory muscle of the duodenum, is a smooth muscle that arises from the duodenum and duodenojejunal flexure and is then gradually replaced by fibrous tissue where it inserts into the connective tissues surrounding the celiac artery, passing between the pancreas anteriorly and the left renal vein posteriorly. This is the part that actually suspends the duodenojejunal flexure [5] (Fig. 1).
Fig. 1 —Illustration of coronal section of lower chest and upper abdomen shows anatomy and structural attachments of ligament of Treitz as it arises from right crus of diaphragm at esophageal hiatus and extends inferiorly to duodenum and duodenojejunal junction.
(© 2021 The University of Texas MD Anderson Cancer Center, used with permission)
Normal anatomic variations exist for the distal attachments of the ligament of Treitz (Fig. 2). The ligament most commonly (in 40–60% of cases) attaches to the third and fourth parts of the duodenum and the duodenojejunal flexure at the level of the inferior border of the first lumber vertebra (Fig. 2A). In 31–53% of cases, the ligament attaches to the third and fourth parts of the duodenum only (Fig. 2B). Attachment to the duodenojejunal flexure occurs in only 0–8% of cases (Fig. 2C). Attachment to the duodenum in multiple separate divisions is not unusual [6, 7] (Fig. 2D). Attachment of the ligament to the third and fourth portions of the duodenum allows opening of the angle at the duodenojejunal junction, thereby facilitating normal emptying of the bowel [3]. The ligament is innervated by nonmyelinated nerve fibers originating from the celiac and mesenteric plexuses [7]. Because it is not outlined by retroperitoneal fatty tissue, the ligament of Treitz is not easily recognized by cross-sectional imaging modalities such as CT and MRI [2].
Fig. 2A —Illustrations of coronal section show anatomic attachments of suspensory ligament of Treitz.
A, Illustration shows attachment to third and fourth parts of duodenum and duodenojejunal flexure. This is most common type of attachment, occurring in 40–60% of cases.
(© 2021 The University of Texas MD Anderson Cancer Center, used with permission)
Fig. 2B —Illustrations of coronal section show anatomic attachments of suspensory ligament of Treitz.
B, Illustration shows attachment to third and fourth parts of duodenum only. This is second most common type of attachment, occurring in 31–53% of cases.
(© 2021 The University of Texas MD Anderson Cancer Center, used with permission)
Fig. 2C —Illustrations of coronal section show anatomic attachments of suspensory ligament of Treitz.
C, Illustration shows attachment to duodenojejunal flexure, which occurs in only 0–8% of cases.
(© 2021 The University of Texas MD Anderson Cancer Center, used with permission)
Fig. 2D —Illustrations of coronal section show anatomic attachments of suspensory ligament of Treitz.
D, Illustration shows multiple separate attachments.
(© 2021 The University of Texas MD Anderson Cancer Center, used with permission)

Pathologic Conditions Involving the Ligament of Treitz

Abnormalities of the ligament of Treitz can result in pathologic processes that involve the surrounding structures. The ligament of Treitz plays a fundamental role during embryonic development of the gut by holding the duodenum during rotation of the gut around the superior mesenteric artery [8]. An abnormal increase in the length of the ligament can cause intestinal malrotation. Abnormal thickening, hypertrophy, or shortening of the ligament can lead to SMAS [9, 10]. In addition, the ligament of Treitz is an anatomic landmark between the foregut and the midgut that helps gastroenterologists to distinguish between upper and lower gastrointestinal bleeding [11]. Some primary and metastatic tumors can involve the ligament of Treitz [12].

Intestinal Malrotation

Intestinal malrotation is a congenital anomaly resulting from abnormal rotation or peritoneal fixation of the gut or a combination of such rotation and fixation occurring during embryonic development, resulting in abnormal positioning of the duodenojejunal junction and the small and large bowel loops within the peritoneal cavity [8, 10]. The alimentary tract develops from the yolk sac and is divided depending on the blood supply: the celiac artery supplies the foregut, the superior mesenteric artery supplies the midgut, and the inferior mesenteric artery supplies the hindgut. Intestinal rotation primarily involves the midgut and occurs around the axis of superior mesenteric artery. Intestinal mal-rotation involves a spectrum of anomalies that range from complete nonrotation of the gut to incomplete rotation of the gut around the superior mesenteric artery. Complete nonrotation is the classic and most common form and results from failure of rotation of either the duodenojejunal or cecocolic loops around the axis of superior mesenteric artery, leading to abnormal positioning of the small and large bowel loops within the peritoneal cavity. The small bowel occupies the right peritoneal cavity, and the colon is displaced to the left [8, 10, 13]. Malrotation usually presents within the first few months of life as acute abdominal symptoms, typically bilious vomiting with or without abdominal distention. However, intestinal malrotation may remain asymptomatic, or it may present with intermittent, vague abdominal symptoms and be discovered incidentally later in life during radiologic work-up performed to assess for unrelated conditions [10, 14]. Fernandez-Moure et al. [15] reported a case of congenital intestinal mal-rotation that was initially diagnosed in a 92-year-old patient.
Intestinal malrotation is associated with numerous anomalies and syndromes, including duodenal stenosis or atresia, biliary atresia, Marfan syndrome, annular pancreas, Hirschsprung disease, imperforate anus, and intussusception [8]. Intestinal malrotation is also associated with an increased risk of midgut volvulus, which is a life-threatening surgical emergency that results from abnormally short mesenteric attachments of the midgut—especially the portion from the duodenojejunal junction to the cecum. Intestinal malrotation can lead to acute intestinal obstruction, bowel ischemia, necrosis, potential loss of the involved bowel, and development of short gut syndrome [8, 16]. Patients with complete nonrotation have the lowest risk of midgut volvulus [8].
Diagnosis of intestinal malrotation, especially in older patients, remains clinically and radiologically challenging and requires a high index of suspicion. The reference standard for confirming a diagnosis of intestinal malrotation is an upper gastrointestinal series with small bowel follow-through. The small bowel will be seen within the right side of the abdominal cavity with a lack of cecal air in the right lower quadrant, whereas the right colon and cecum are misplaced into the midepigastrium with inferior displacement of the ligament of Treitz and duodenojejunal junction [17, 18]. However, inferior displacement of the duodenojejunal junction caused by malrotation should be differentiated from the normal anatomic variant that can be seen in premature infants or the inferior displacement of the ligament of Treitz by the adjacent distended stomach or bowel. The duodenojejunal junction normally presents at the level of the duodenal bulb to the left of the left-sided pedicles of the vertebral bodies on frontal views and retroperitoneal on lateral views [18, 19]. In addition, images from an upper gastrointestinal series can show the classic corkscrew sign in cases of midgut volvulus (Fig. 3). CT, particularly when performed with oral contrast medium, can help to confirm the diagnosis of malrotation by showing the abnormal positioning of the bowel loops and ligament of Treitz and the abnormal relationship of the superior mesenteric vessels, and CT can help in the early detection of complications such as intestinal obstruction [20, 21] (Fig. 4). The role of conventional radiography is confined to detecting complications such as pneumoperitoneum in the case of intestinal perfo-ration and identifying possible differential diagnoses, such as the double bubble sign in the case of duodenal atresia.
Fig. 3A —2-day-old boy who presented with bilious vomiting.
A, Unenhanced radiograph of abdomen (A) and images from upper gastrointestinal series (B–F) show abnormal positioning of small and large bowel loops, with small bowel loops seen within right side of abdominal cavity. Classic corkscrew sign (arrow, D) is suggestive of midgut volvulus. Abnormal displacement of duodenojejunal junction (arrow, F) is seen to right of left-sided pedicle of vertebral body.
Fig. 3B —2-day-old boy who presented with bilious vomiting.
B, Unenhanced radiograph of abdomen (A) and images from upper gastrointestinal series (B–F) show abnormal positioning of small and large bowel loops, with small bowel loops seen within right side of abdominal cavity. Classic corkscrew sign (arrow, D) is suggestive of midgut volvulus. Abnormal displacement of duodenojejunal junction (arrow, F) is seen to right of left-sided pedicle of vertebral body.
Fig. 3C —2-day-old boy who presented with bilious vomiting.
C, Unenhanced radiograph of abdomen (A) and images from upper gastrointestinal series (B–F) show abnormal positioning of small and large bowel loops, with small bowel loops seen within right side of abdominal cavity. Classic corkscrew sign (arrow, D) is suggestive of midgut volvulus. Abnormal displacement of duodenojejunal junction (arrow, F) is seen to right of left-sided pedicle of vertebral body.
Fig. 3D —2-day-old boy who presented with bilious vomiting.
D, Unenhanced radiograph of abdomen (A) and images from upper gastrointestinal series (B–F) show abnormal positioning of small and large bowel loops, with small bowel loops seen within right side of abdominal cavity. Classic corkscrew sign (arrow, D) is suggestive of midgut volvulus. Abnormal displacement of duodenojejunal junction (arrow, F) is seen to right of left-sided pedicle of vertebral body.
Fig. 3E —2-day-old boy who presented with bilious vomiting.
E, Unenhanced radiograph of abdomen (A) and images from upper gastrointestinal series (B–F) show abnormal positioning of small and large bowel loops, with small bowel loops seen within right side of abdominal cavity. Classic corkscrew sign (arrow, D) is suggestive of midgut volvulus. Abnormal displacement of duodenojejunal junction (arrow, F) is seen to right of left-sided pedicle of vertebral body.
Fig. 3F —2-day-old boy who presented with bilious vomiting.
F, Unenhanced radiograph of abdomen (A) and images from upper gastrointestinal series (B–F) show abnormal positioning of small and large bowel loops, with small bowel loops seen within right side of abdominal cavity. Classic corkscrew sign (arrow, D) is suggestive of midgut volvulus. Abnormal displacement of duodenojejunal junction (arrow, F) is seen to right of left-sided pedicle of vertebral body.
Fig. 4A —60-year-old man with metastatic cecal leiomyosarcoma.
A, Axial (A) and coronal (B) CT images of abdomen show duodenum (arrow) remains to right and does not cross midline.
Fig. 4B —60-year-old man with metastatic cecal leiomyosarcoma.
B, Axial (A) and coronal (B) CT images of abdomen show duodenum (arrow) remains to right and does not cross midline.
Fig. 4C —60-year-old man with metastatic cecal leiomyosarcoma.
C, Axial CT image of abdomen shows inversion of relationship between superior mesenteric artery and superior mesenteric vein, with superior mesenteric artery (red arrow) on right and superior mesenteric vein (white arrow) on left. CT findings are consistent with intestinal malrotation.

Superior Mesenteric Artery Syndrome

SMAS is a rare cause of proximal intestinal obstruction that was first described by Carl von Rokitansky in 1861. In 1927, it was nicknamed Wilkie syndrome after a case series of 64 patients was reported by Wilkie [22]. SMAS results from vascular compression of the duodenum. The third part of the duodenum passes between the superior mesenteric artery (as it leaves the aorta at an acute downward angle [i.e., the aortomesenteric angle]) and the aorta, where the duodenum is at risk of external vascular compression between the superior mesenteric artery anteriorly and the abdominal aorta and vertebral column posteriorly [23]. The aortomesenteric angle and the aortomesenteric distance normally range from 28° to 65° and from 10 to 34 mm, respectively. In SMAS, they are reduced, having values of 6–15° and 2–8 mm, respectively [24]. Therefore, any condition associated with narrowing the aortomesenteric angle predisposes to the development of SMAS. Common causes include cachexia, weight loss, severe debilitating conditions, exaggerated lumbar lordosis, and external compression, such as the use of a cast for treatment of vertebral fracture [24, 25]. A short and hypertrophied ligament of Treitz can be a rare cause of SMAS. Contraction of the ligament pulls the duodenum upward into the vascular angle between the superior mesenteric artery and the aorta [9]. SMAS typically presents with symptoms of proximal bowel obstruction, including nausea, anorexia, bilious vomiting, and intestinal fullness after meals, with partial relief of symptoms with postural changes (e.g., placement in the prone position) [9].
Diagnosis of SMAS depends on the presence of three diagnostic criteria: a dilated duodenum, reduction of the aortomesenteric angle to less than 25°, and compression of the third part of the duodenum by the superior mesenteric artery. Barium studies can assist in diagnosis by showing characteristic duodenal dilatation with an abrupt vertical cutoff in the third part of the duodenum and a 4- to 6-hour delay in the gastroduodenal transit. In severe cases, marked to-and-fro peristalsis occurs [26, 27]. However, diagnosis can be confirmed by CTA that reveals compression of the third part of the duodenum by the superior mesenteric artery with subsequent proximal duodenal dilatation and a reduced aortomesenteric angle and aortomesenteric distance [2830] (Fig. 5).
Fig. 5A —29-year-old woman with history of familial adenomatous polyposis who presented with intermittent nausea, vomiting, and abdominal distention.
A, CT image of abdomen shows narrowing of angle between aorta and superior mesenteric artery that measured in range of 16–29° (circle).
Fig. 5B —29-year-old woman with history of familial adenomatous polyposis who presented with intermittent nausea, vomiting, and abdominal distention.
B, Axial CT image of abdomen shows compression of distal third portion of duodenum (circle) between aorta (black arrow) and superior mesenteric artery (white arrow).
Fig. 5C —29-year-old woman with history of familial adenomatous polyposis who presented with intermittent nausea, vomiting, and abdominal distention.
C, Axial CT image of abdomen shows mild proximal duodenal dilatation (arrows). These imaging findings are consistent with superior mesenteric artery syndrome.
Surgery is the standard of care for SMAS. Preferred options include release of the ligament with either duodenojejunostomy or gastrojejunostomy. However, gastrojejunostomy has been disfavored because of its higher rate of postoperative complications. Isolated division of the ligament is associated with a high failure rate [25, 31, 32].

Gastrointestinal Bleeding

Gastrointestinal bleeding is a common presentation in both outpatient and emergency settings and is associated with significant mortality. The ligament of Treitz represents an anatomic landmark, particularly during endoscopic procedures, for differentiating between the sources of upper gastrointestinal bleeding (i.e., originating proximal to the ligament) and lower gastrointestinal bleeding (i.e., originating distal to the ligament) [11]. It is of utmost importance to distinguish upper from lower gastrointestinal bleeding because the treatment measures for acute gastrointestinal bleeding primarily depend on the location and cause of the bleeding. Peptic ulcer disease is the most common cause of upper gastrointestinal bleeding, whereas diverticulosis is the most common cause of lower gastrointestinal bleeding [33].

Masses Involving the Ligament of Treitz

Primary malignancy of the small bowel is uncommon, representing only 1–2% of gastrointestinal tumors [3436]. Adeno-carcinoma involving the small bowel at the level of the ligament of Treitz is extremely rare [34] (Fig. 6). Most cases occur sporadically; however, some may occur in the context of familial syndromes such as familial adenomatous polyposis, Peutz-Jeghers syndrome, and Crohn disease [37, 38]. Metastatic deposits involving the ligament of Treitz are more common than primary small bowel neoplasms. These metastatic deposits can spread from surrounding structures, including the stomach, colon, and ovary, either by direct invasion or through peritoneal involvement [12]. Patients usually present with vague abdominal symptoms, and the lesions are incidentally discovered during the assessment and investigation of abdominal pain, anemia, or gastrointestinal bleeding [39]. The use of CT enteroclysis has improved the detection rate of these lesions, with an estimated sensitivity of 85–95% and a specificity of 96–100% [40, 41]. An inflammatory process can infiltrate the mesenteric fat surrounding the ligament of Treitz, causing a mass at the level of the ligament (Fig. 7).
Fig. 6A —39-year-old man who presented with nausea, vomiting, and abdominal pain.
A, Axial (A) and coronal (B) CT images of abdomen show ill-defined infiltrative duodenal mass (arrows) measuring approximately 3.6 cm in length at level of ligament of Treitz. Histopathologic analysis of tissue biopsy confirmed diagnosis of moderately differentiated adenocarcinoma of duodenum with invasion into lamina propria at very least.
Fig. 6B —39-year-old man who presented with nausea, vomiting, and abdominal pain.
B, Axial (A) and coronal (B) CT images of abdomen show ill-defined infiltrative duodenal mass (arrows) measuring approximately 3.6 cm in length at level of ligament of Treitz. Histopathologic analysis of tissue biopsy confirmed diagnosis of moderately differentiated adenocarcinoma of duodenum with invasion into lamina propria at very least.
Fig. 7 —58-year-old man with history of metastatic prostate and renal carcinoma who presented with fever and abdominal pain. Axial CT image of abdomen shows infiltration of mesenteric fat at ligament of Treitz with 2.6 × 1.7 cm peripherally enhancing mass (arrow) seen with relatively low-attenuation central necrotic components and surrounding inflammatory changes. Imaging findings are suggestive of inflammatory or infectious process. Imaging-guided fine-needle aspiration biopsy confirmed diagnosis of abscess at ligament of Treitz.

Conclusion

The ligament of Treitz, also known as the suspensory ligament of the duodenum, is one of the frequently forgotten structures within the abdomen, despite its importance as an anatomic landmark in the abdomen. The ligament of Treitz is an anatomic landmark between the foregut and the midgut and helps physicians differentiate between the sources of upper and lower gastrointestinal bleeding. In addition, the ligament of Treitz plays a pivotal role in the embryonic development of the gut by holding the duodenum during rotation of the gut around the superior mesenteric artery, thereby contributing to the development of intestinal malrotation and SMAS. Therefore, it is very important to understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 927 - 934
PubMed: 33566632

History

Submitted: March 30, 2020
Revision requested: May 4, 2020
Revision received: May 21, 2020
Accepted: May 23, 2020
Version of record online: February 10, 2021

Keywords

  1. anatomy
  2. cross-sectional imaging
  3. CT
  4. embryology
  5. ligament of Treitz
  6. superior mesenteric artery

Authors

Affiliations

Sameh Nassar, MD
Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX 77030
Christine O. Menias, MD
Department of Diagnostic Imaging, Mayo Clinic College of Medicine and Science, Scottsdale, AZ
Sarah Palmquist, MD
Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX 77030
Ayman Nada, MD
Department of Diagnostic Imaging, University of Missouri Health Care, Columbia, MO
Perry J. Pickhardt, MD
Department of Diagnostic Imaging, University of Wisconsin School of Medicine and Public Health, Madison, WI
Akram M. Shaaban, MD
Department of Diagnostic Imaging, University of Utah, Salt Lake City, UT
Ayman H. Gaballah, MD
Department of Diagnostic Imaging, University of Missouri Health Care, Columbia, MO
Khaled M. Elsayes, MD
Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX 77030

Notes

Address correspondence to K. M. Elsayes ([email protected]).
The authors declare that they have no disclosures relevant to the subject matter of this article.

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