What is the primary blood supply to the duodenal bulb?

Blood Supply to the Duodenal Bulb

Primary Arterial Supply

The duodenal bulb receives its blood supply from two arterial pedicles—the supraduodenal and infraduodenal arteries—both of which approach the bulb on its posterior aspect, with each pedicle consisting of right and left arterial currents. 1

Anatomic Details and Clinical Significance

Vascular Architecture

• The supraduodenal and infraduodenal arterial pedicles constitute the dual blood supply system to the duodenal bulb (D1 segment) 1
• Both pedicles reach the bulb posteriorly, with the posterior aspect being the most heavily vascularized region 1
• Each pedicle contains both right-sided and left-sided arterial currents that create a rich collateral network 1
• The left-hand arterial currents predominate in the vascular supply, making them critical for maintaining bulb perfusion 1

Source Vessels

• The supraduodenal artery typically arises from the gastroduodenal artery or hepatic artery proper 1
• The infraduodenal artery originates from branches of the gastroduodenal artery system 1
• The gastroduodenal artery itself arises from the common hepatic artery (a branch of the celiac trunk) and travels inferiorly behind the duodenal bulb 2

Critical Clinical Implications

Hemorrhage Risk

• The rich posterior vascularization explains why posterior duodenal bulb ulcers have a high propensity for significant bleeding, even when the gastroduodenal artery itself is not directly eroded 1
• Large posterior duodenal ulcers that erode into the gastroduodenal artery represent the most common source of life-threatening upper GI bleeding requiring surgical intervention 3
• The extensive collateral blood supply from transverse pancreatic arteries complicates both surgical and angiographic management of bleeding 3

Surgical Considerations

• Interruption of the left-hand arterial currents during surgery can lead to ischemia of the duodenal bulb or rupture of the duodenal stump 1
• The duodenal bulb (D1) has a thicker wall compared to the descending duodenum (D2), providing some structural advantage but requiring careful vascular preservation 4, 5
• Triple-loop suturing is essential when controlling gastroduodenal artery bleeding due to the extensive collateral network 3

Angiographic Management

• Both the celiac axis and superior mesenteric artery must be interrogated during angiography to evaluate all potential bleeding sources and collateral pathways 3
• Superselective embolization should proceed in a distal-to-proximal fashion to minimize "back door" rebleeding through collaterals 3

Common Pitfalls to Avoid

• Do not assume that absence of gastroduodenal artery involvement excludes significant bleeding risk—the dual pedicle system with rich posterior collaterals can produce substantial hemorrhage from posterior bulb ulcers 1
• Avoid compromising the left-sided arterial currents during surgical procedures, as their predominance makes them critical for bulb viability 1
• During endovascular intervention, failure to evaluate both celiac and SMA territories may miss important collateral bleeding sources 3