Structure and function if the GI system

Functions of the digestive system

o Productions of enzymes and hormones
o Storage and synthesis of vitamins
o Dismantling and reassembling of food
o Entrance of nutrients, vitamins, minerals, electrolytes, and water
through the GI tract
o Collection and elimination of wastes
Process of digestions and absorption of nutrients
o Requires an intact and healthy GI tract epithelial lining that can resist
the effects of its own digestive secretions
o Involves movement of materials through the GI tract at a rate that
facilitates absorption
o Required the presence of enzymes for the digestions and absorption of
nutrients
Parts of the digestive system
Upper portion - Acts as an intake and receptacle through which
food passes and which initial digestive processes take place
Mouth
Teeth for mastication of food
Tongue and other structures to help move food toward
pharyngeal structures
Receptacle for saliva
o Saliva produced by salivary glands
o Moistens and lubricates food
o Contains enzymes involved in the initial digestion
of lipids and starches
Esophagus
Straight, collapsible tube (~25 cm, 10 in)
Lies behind trachea
Connects the oropharynx with the stomach
Functions primarily as conduit for passage of food from
pharynx to stomach
Sphincters at either end
o Pharyngeoesophageal sphincter (upper sphincter)
Keeps air from entering esophagus during
breathing
o Gastroesophageal sphincter (lower sphincter)
Lies just above where esophagus meets the
stomach
Normally remains tonically contracted
creates zone of high pressure that serves to
prevent reflux into esophagus
During swallowing there is receptive
relaxation of this sphincter

Stomach
Lies in the left side of the abdomen
Serves as food storage reservoir during early stages of
digestion
Connects from the esophagus through an opening called
cardiac orifice
o Area of stomach that surround the cardiac orifice
called the cardiac region
Dome region that bulges above the cardiac region = the
fundus
Middle portion called the body
Funnel-shaped region that connects with the small
intestine = pyloric region
Ends in the pyloric sphincter
o Serves as a valve that controls the rate of stomach
emptying and prevents the regurgitation of
intestinal contents back into stomach
Middle portion - Most digestive and absorptive processes occur in the
small intestine
Small intestine
Duodenum
o Connects with the stomach and jejunum (~ 25
cm/10 in)
o Contains opening for the common bile duct and the
main pancreatic duct
Bile and pancreatic juices enter intestines
through these ducts
Jejunum food is digested and absorbed
Ileum food is digested and absorbed
o Combined length of jejunum and ileum is ~ 3m/9 ft
Lower portion total length ~1.5 m/4.5-5 ft; diameter ~6-7 cm/2.4-2.7
in
Cecum
Blind pouch that projects down at the junction of the
ileum and the colon
o Ileocecal valve lies at upper border of of cecum and
prevent the return of feces from the cecum into the
small intestine

Allows easy propulsion of contents

from esophagus into stomach
Passes through hiatus (opening) in the
diaphragm as it joins with stomach
The area of diaphragm that surround
this sphincter helps maintain the zone
of high pressure to prevent reflux

Colon
Ascending
o Extends from the cecum to the under surface of the
liver
o Turns abruptly there to form right colic (hepatic)
fixture
Transverse
o Crosses the upper half of the abdominal cavity from
right to left
o Curves sharply at left end beneath the lower end of
the spleen
Forms the left colic (splenic) fixture
Descending
o Extend from the left colic (splenic) fixture to the
rectum
Rectum
The rectum extends from the sigmoid colon to the anus
The anal canal passes between the two medial borders of
the levator ani muscles
Powerful sphincter protect against fecal incontinence
Serves as a storage channel for the efficient elimination of waste
Fourth part of digestive system
Accessory organs
Salivary glands
Liver
Pancreas
They all produce digestive secretions that help dismantle
foods and regulate the use and storage of nutrients
GI wall structure
The digestive tract below the upper third of the esophagus is
essentially a four layered tube
1st layer - Mucosal layer
Made up of:
o Lining epithelium
o Underlying connective tissue called lamina propria
o Muscularis mucosae
Numerous functions
o Production of the mucus that lubricates and
protects the inner surface of the alimentary canal
o Secretions of the digestive enzymes and
substances that break down food
o Absorption of the breakdown products of digestion
o Maintenance of a barrier to prevent the entry of
noxious substances and pathogenic organisms

The appendix arises from the cecum ~2.5 cm/1 in from

the ileocecal valve

Contains: lymphatics within the mucosa

serves as the bodys first line of defense
Mucosal cells constantly turn over and move from outside
of the wall structure to the luminal face every 5 days
o Therefore injury to this layer heals rapidly and
without scar tissue
nd
2 layer Submucosa
Consists of dense connective tissue and aggregates of
adipose tissue
Contains blood vessels, nerves, and structures responsible
for secreting digestive enzymes
o Delivered either directly or via ducts
3rd layer muscularis externa
Consists of an inner layer of circularly arranged smooth
muscle cells and an outer layer of longitudinally arranged
smooth muscle cells
o Facilitate the movement of contents of GI tract
th
4 layer serosal layer
Serous membrane consisting of mesothelium (comprised
of squamous epithelium) and underlying connective tissue
Outermost layer commonly called visceral peritoneum
is continuous with the parietal peritoneum
The peritoneum is the largest serous membrane of the
body
o 2 layers
Visceral
Parietal lines the wall of the abdominal
cavity
o Between the 2 layers = peritoneal cavity potential
space containing fluid secreted from serous
membranes
o Prevents friction between continuously moving abd.
structures
o A mesentery is the double layer of peritoneum that
encloses a portion or all of one of the abd. viscera
and attaches it to the abd. wall
Contains blood vessels, nerves, and
lymphatic vessels
Holds organs in place
Stores fat
Movements of the GI tract
o Cells of Cajal and the generation of slow waves
All of the contractile tissue in GI is smooth muscle (except for
pharynx, upper third of esophagus, and external anal sphincter)
Smooth muscle cells in GI tract act as pacemaker cells

The interstitial Cells of Cajal found in groups between the

layers of smooth muscle tissue are thought to function as
pacemakers
They display rhythmic, spontaneous oscillations in
membrane potentials = slow waves (range of 3/min in
stomach and 12/min in duodenum)
Tonic movements
Continuous movements that last for minutes or even hours
Contractions occur at sphincters
Lower esophageal sphincter, upper region of the stomach,
the ileocecal valve, and the internal anal sphincter
Rhythmic movements
Intermittent contractions responsible for mixing and moving
food along the digestive tract
Peristaltic movements are rhythmic propulsive movements
ANS actions and the enteric nervous system
ANS modulation
Activation of the sympathetic nervous system
decreases the amplitude of the slow waves or abolishes
them all together (fight-or-flight)
Activation of the parasympathetic nervous system
increases the amplitude of the slow waves (rest-anddigest)
Enteric nervous system
Consists of the myenteric and submucosal plexus in GI
tract wall
Networks of nerve fibers and ganglion cell bodies
Myenteric (Auerbach) plexus consists mainly of a linear
chain of interconnecting neurons that is located between
the circular and longitudinal muscle layers
o Because it is between the 2 muscle layers, it
extends all the way down the intestinal wall
o Concerned mainly with motility along the length of
the gut
Submucosal (Meissner) plexus lies between the mucosal
and muscle layers of intestinal wall
o Mainly concerned with controlling secretions,
absorption, and contraction of each segment of the
intestinal tract
Both are regulated by local influences, by input from and
ANS, and by interconnecting fibers that transmit
information between the 2 plexuses
Mechanoreceptor monitor stretch and distention of the GI
tract wall

Chemoreceptors monitor the chemical composition (pH,

osmolality, digestive products of protein and fat
metabolism) of the GI tract contents
These receptors can communicate directly with ganglionic
cells in the intramural plexuses or with visceral afferent
fibers that influence ANS control of the GI tract
ANS innervation
Mediated by both sympathetic and parasympathetic
nervous systems
Parasympathetic innervation to the stomach, small
intestine, cecum, ascending colon, and transverse colon
through the vagus nerve
The remainder of the colon is innervated by
parasympathetic fibers that exit the sacral segments of
the spinal cord by way of pelvic nerves
Sympathetic innervation occurs through the thoracic
chain of sympathetic ganglia and the celiac, superior
mesenteric, and inferior mesenteric ganglia
o SNS controls the extent of mucous secretion by
mucosal glands
o Reduces motility by inhibiting activity of intramural
plexus neurons
o Enhances sphincter function
o Increases the vascular smooth muscle tone of the
blood vessels that supply the GI tract
The effect of sympathetic stimulation is to block the
release of excitatory neuromediators in the intramural
plexuses
Summary
Parasympathetic innervation
o Supplied mainly by vagus nerve with postganglionic
neurons located primarily in the myenteric and
submucosal plexuses
o Stimulation causes general increase in both
intestinal motility and secretory activity
Sympathetic innervation
o Supplied by nerves that run between the spinal
cord and the prevertebral ganglia and between
these ganglia and the intestine
o Stimulation is largely inhibitory
Producing decrease in intestinal motility and
secretory activity
Enteric nervous system
o Composed mainly of 2 plexuses
Myenteric (Auerbach) plexus
Located between longitudinal and
circular layers of smooth muscle cells

Controls mainly intestinal movements

along length of the gut
Submucosal (Meissner) plexus (inner)
Lies between the mucosal and muscle
layers
Controls mainly the function within
each segment of the intestine
Fibers in this plexus also use signals
originating from intestinal epithelium
to control secretion and blood flow
Swallowing and esophageal motility
o Three phases of swallowing
Oral phase initiated as a voluntary activity
The bolus is collected at the back of the mouth
The tongue lifts the food upward until it touched the
posterior wall of the pharynx
Pharyngeal phase becomes involuntary as food of fluids
reaches the pharynx
The soft palate is pulled upward
The palatopharyngeal folds are pulled together so that
food does not enter the nasopharynx
The vocal cords are pulled together
The epiglottis covers the larynx
Respiration in inhibited
The bolus is moved backward into the esophagus by
constrictive movements of the pharynx
Esophageal phase
As food enters the esophagus and stretches its walls, local
and central nervous system reflexes that initiate
peristalsis are triggered
Sensory impulses for swallowing begin at tactile receptors in
pharynx and esophagus and are integrated with the motor
components of the response in an area of the reticular formation
of the medulla and lower pons (called the swallowing center)
Motor impulses for oral and pharyngeal phases of swallowing are
carried in these cranial nerves:
Trigeminal (V)
Glossopharyngeal (IX)
Vagus (X)
Hypoglossal (XII)
Motor impulses for esophageal phase carried by the vagus (X)
cranial nerve
o Tonic contractions vs. peristaltic contractions
Tonic
Constant without period of relaxation
Peristaltic

Rhythmic waves of contraction

Defined rest periods
Two types of peristalsis
o Primary
Controlled by the swallowing center in the
brain stem when food enters the esophagus
o Secondary
Partially mediated by smooth muscle fibers
in esophagus
Occurs when primary is inadequate to move
food through esophagus

Gastric motility
o Chemical breakdown of protein begins in stomach and converted to
creamy mixture called chime
o Motility of stomach results in the churning and mixing of solid foods
and regulated emptying of the gastric contents (chyme) into the
duodenum (empties between peristaltic contractions)
o Peristalsis moves chime from fundus to pyloric sphincter which
prevents back flow
Peristaltic waves occur ~3-5/min and last 2-20 seconds
Also important because bile from duodenum can back into the
antrum of the stomach and damage the mucosal surface
causing gastric ulcers
Also the duodenal mucosa can also be damages by the rapid
influx of highly acidic gastric contents
o Emptying of the stomach is regulated by hormonal and neural
mechanisms
Hormones
CCK and glucose-dependent insulinotropic polypeptide
(GIP) are released in response to the pH, osmolality, and
fatty acid composition of chyme
Small intestine motility
o The major site for digestion and absorption
o Mixing and propulsive movements
2 patterns of contractions
Segmentation contractions
o Slow contractions of circular muscle layer occlude
the lumen and dive the contents forward and
backward
o Function mainly to mix chyme with digestive
enzymes and to ensure that the chyme comes in
contact with most of the small intestine surface
area for absorption
Peristaltic contractions
o Rhythmic contractions to propel chyme along the
small intestine toward the large intestine
Colonic motility and defecation

Two types of movement

Segmental mixing movements (haustral churning)
Ensures that all portions of the fecal mass are exposed to
the intestinal surface
Propulsive mass movements
A large segment of colon (>/= 20 cm) contracts as a unit
moving the fecal contents forward as a unit
Mass movements last ~30 seconds followed by a 2-3
minute period of relaxation
o Normal colonic movement time is 24 to 48 hours
o Normal stool is comprised of ~75% water and ~25% solid matter
o Defecation is controlled by 2 sphincters
Internal sphincter
Several long circular thickening of smooth muscle that lies
inside the anus
Under reflexive control of the enteric nervous system
External sphincter
Composed of striated voluntary muscle
Surround the internal sphincter
Controlled by nerve fibers in the pudendal nerve (part of
the somatic nervous system = voluntary control)
Water and electrolytes
o Each day appox. 7,000 mL of fluid is secretes into the GI tract
o These secretions are mainly water and have sodium and potassium
concentrations similar to those of extracellular fluid
o They are derived from the extracellular fluid component in blood work
Control of secretory functions
o Local
pH, osmolality, and chyme
Act as stimuli of neural and humoral mechanisms
o Humoral
o Neural influences
Mediated though the ANS
Increased with parasympathetic stimulation
Inhibited with sympathetic activity
Saliva
o Saliva is rich in mucus that acts as a buffer protecting the oral mucosa
and coats the food as it passed through the mouth, pharynx, and
esophagus
o Contains ptyalin and amylase which initiate the digestions of dietary
starches
o It cleans the mouth and contains the enzyme lysozyme which has
antibacterial action
Secretions of the GI tract
o Secretory glands have 2 basic functions
Production of mucous to lubricate and protect the mucosal layer
of GI tract wall
o

Secretion of fluids and enzymes to aid in the digestion and

absorption of nutrients
Salivary
Salivary glands consist of the:
Parotid gland
Submaxillary gland
Sublingual gland
Buccal glands
3 functions of saliva
1.) Protections and lubrication
o Saliva is rich in mucus that acts as a buffer
protecting the oral mucosa and coats the food as it
passed through the mouth, pharynx, and
esophagus
2.) Protective antimicrobial action
o It cleans the mouth and contains the enzyme
lysozyme which has antibacterial action
3.) Initiation of digestion of dietary starches
o Contains ptyalin and amylase which initiate the
digestions of dietary starches
Regulated by the ANS primarily
Parasympathetic increase salivary flow
Sympathetic decreases salivary flow (Ex: dry mouth with
anxiety)
Gastric
Mucous-secreting epithelial cells line the luminal surface and
gastric pits of the stomach
Serve as protective barrier
Parietal (oxyntic) cells
Secrete HCl and intrinsic factor
o 2 major functions of gastric acid
Chemically breakdown ingested food
Chemically disinfect ingested food
o Intrinsic factor is necessary for absorption of B 12
vitamin
Chief cells
Secrete pepsinogen which is rapidly converted to pepsin
when exposed to the low pH of the stomach
Pepsin is an enzyme the initiates proteolysis (breakdown
of proteins)
G cells
Secrete gastrin
Together the epithelial, parietal, chief, and G cells in the
stomach mucosa secrete ~20 mEq of HCl each hour
Gastric acid secretions

Pancreatic
Biliary
Intestinal
The small intestine secretes digestive juices and receives
secretions from the liver and pancreas
Many mucous-producing glands (called Brunner glands)
are concentrated where stomach contents and secretions
from liver and pancreas enter the duodenum
o They secrete large amounts of alkaline mucous to
protect duodenum
o Activity of Brunner glands largely influenced by
ANS activity
Serous fluid secretions
o Secreted by specialized cells in intestinal mucosa
o Acts as a vehicle for absorption
Surface enzyme secretions
o Aid in absorption
o They are peptidases (enzymes that separate amino
acids) and disaccharidases (enzymes that split
sugars)
The large intestine only secrete mucous
ANS strongly influences the secretion of mucous in the
bowel
Major GI hormones
o Cholecystokinin (CCK)
The primary function of CCK is the stimulation of pancreatic
enzyme secretion
Potentiates the action of secretin, increasing the
pancreatic bicarbonate response to low circulating levels
of secretin,
Regulates gallbladder contraction
Regulates gastric emptying
o
o
o

Cellular mechanism for HCl secretion by the parietal cells

involces the hydrogen/potassium adenosine
triphosphatase (H+/K+ ATPase) transporter and chloride
(Cl-) channels
3 substances stimulate the secretion of HCl by parietal
cells
o Acetylcholine (ACh) released from vagal nerves
innervating the stomach and binds to ACh
receptors on the parietal cells
o Gastrin
o Histamine H2-receptor blockers used in tx of
peptic ulcers and gastroesophageal reflux
o All serve to stimulate an increase in H+ secretion
through the H+/K+ ATPase transporter
o

Has also been shown to inhibit food intake

Important mediator of appetite and control of meal size
Source is in the intestine
Secreted by I cells in the intestinal mucosa
o Secretin
Stimulates secretion of bicarbonate-containing solution by the
pancreas and liver
Inhibits gastric secretion
Source is in the intestine
Secreted by S cells in the mucosa of the duodenum and
jejunum
Secreted in response to duodenal pH which stimulates the
pancreas to secrete large amounts of fluid with high
bicarbonate concentration
o The entry of an acidic chyme stimulates the release
of secretin which inhibits the release of gastrin
o Gastrin
Primary function is to stimulate gastric acid secretion and
pepsinogen
Increases gastric blood flow
Stimulates gastric smooth muscle contraction
Stimulates growth (trophic effect) of the gastric, small intestine,
and colonic mucosa
Source is the stomach
G cells located mostly in antrum of stomach produce
gastrin
Ghrelin
A peptide hormone produced by endocrine cells in the
mucosal layer of the fundus of the stomach
Stimulates the secretion of growth hormone
Appetite-stimulating signal from stomach when an
increase in metabolic efficiency is necessary
Released during periods of fasting
Released when there are decreased levels of growth
hormone
May have effects on blood sugar regulation and
cardiovascular responses
Requirements for digestion
o Hydrolysis
o Enzyme cleavage
A series of protease enzymes reduce the peptides into amino
acids for easy absorption
o Fat emulsification
Pancreatic lipase breaks down fat to simple fatty acids and bile
salts provide an emulsification to allow for absorption
o Parietal cells Gastric acid

o Chief cells Pepsin

o Liver and gallbladder
o Brunner glands
Enzymes that breakdown proteins
o Trypsin
o Chymotrypsin
o Carboxypeptidase
o Elastase
Enzymes used in the digestions of carbs
o Lactase
o Sucrase
o Amylase
o Maltase
o -dextrinase
Characteristics of digestion in:
o Small intestine
Large surface area
Surface area of small intestine in an adult ~250m 2
Villi
o The distinguishing characteristic of the small
intestine is its large surface area and villi
Villi are finger-like projections of mucous
membrane that line the small intestine
Each villus is covered with cells called
enterocytes that contribute to the absorptive
and digestive functions of the small bowel
Artery, vein, lymph ducts
Goblet cells
Provide mucous
Brush border enzymes
Enterocyte secrete enzymes that aid in digestions of
carbs, proteins, and fats
o Brush border enzymes convert polysaccharides to
monosaccharides so that can be absorbed
o Pancreatic lipase breaks down fat to simple fatty
acids and bile salts provide an emulsification to
allow for absorption
o A series of protease enzymes reduce the peptides
into amino acids for easy absorption
Called brush border enzymes because they adhere to the
border of the villus structures
Gut flora
o The gut is the natural habitat of a large and diverse bacterial
community
o Major functions of the gut microflora:
Metabolic activities that salvage energy and absorbable
nutrients

Trophic effects on intestinal epithelial cells

Protections against invasion by pathogenic organisms
Questions
o 1.) Which of the following is an accurate statement regarding digestion
and absorption?
A. Digestion involves movement of materials through the
gastrointestinal tract at a rate that facilitates absorption.
B. The regulation of secreted enzymes is controlled by the
hypothalamus via trophic hormones.
C. Digestion is the active transport of proteins, carbohydrates,
and fats into the blood stream
o 2.) Is the following statement true or false?
Gastrointestinal hormones function in the digestive tract to
facilitate the absorption of essential nutrients.
Answers
o 1.) A
Rationale: Digestion involves movement of materials through
the gastrointestinal tract at a rate that facilitates absorption.
o 2.) False
Rationale: The hormones stimulate gland that will directly
secrete enzymes into the digestive tract.

GI Disorders

Clinical manifestations of GI disorders

o Anorexia
Represents loss of appetite
Hypothalamus and other associated centers in the brain
regulate appetite
o Nausea
An ill-defined and unpleasant subjective sensation
o Vomiting
Involves 2 functionally distinct medullary center
The vomiting center
o The act of vomiting is thought to be a reflex
integrated in the vomiting center
Chemoreceptor trigger zone
o This is thought to mediate the emetic effects of
blood-borne drugs and toxins because of its
location and contact with blood and cerebrospinal
fluid
Projectile vomiting is spontaneous and does not follow nausea or
retching
o Retching

The rhythmic spasmodic movements of the diaphragm, chest

wall, and abdominal muscles
o Constipation, diarrhea, abdominal pain
o GI bleeding
o These responses are protective to the extent that they signal the
presence of disease and in the case of vomiting remove noxious agents
from the GI tract
o They can also contribute to impaired intake or loss of fluids and
nutrients
Swallowing Disorders
o Mechanism
Depends on the coordinated action of the tongue and pharynx
These structures are innervated by cranial nerves V, IX, X, and
XII
o Alterations
Dysphagia: difficulty swallowing
Can result from neuromuscular or structural causes
o Can produce narrowing of the esophagus, lack of
salivary secretion, weakness of the muscular
structures that propel the food bolus toward the
stomach, or disruption of the neural networks
coordinating the swallowing mechanism
o Cancer of the esophagus and structures resulting
from scarring (a structural cause) can reduce the
size of the esophageal lumen and make swallowing
difficult
o Lesions of the CNS such as a stroke which often
involves cranial nerves that involve swallowing (a
neuromuscular cause)
Odynophagia: painful swallowing
Achalasia: failure of the esophageal sphincter to relax
Due to a disruptions in the input from the enteric neural
plexus and the vagus nerve
Results in difficulty passing food into the stomach and the
esophagus above the lower esophageal sphincter
becomes enlarged
Danger of aspiration when pt lies down
Gastroesophageal reflux
o The term reflux refers to the backward or return movement of gastric
contents into the esophagus
Causes heartburn or pyrosis
Most common GI disorder
Associated with time soon after eating
Usually short-lived
Seldom cause more serious problems
GERD

A disorder involving the reflux of stomach contents that causes

unfavorable symptoms or complications (like regurgitation or
heartburn)
Thought to be associated with transient relaxations of weak or
incompetent lower esophageal sphincter
This allows reflux to occur but also is associated with
DECREASED CLEARANCE of the refluxed contents back into the
stomach
Delayed gastric emptying may also be a cause by increasing
gastric volume and pressure = greater risk of reflux
The refluxate (refluxed contents) leads to esophageal mucosa
damage
Persistent reflux can lead to Barrett Esophagus which is a
precursor for adenocarcinoma
GERD is chronic
Treated with
Clinical manifestations
Heartburn (most frequent symptom)
Frequently severe
Occurs 30-60 minutes after eating
Belching
Chest pain
Usually epigastric or retrosternal location
Often radiates to throat, shoulder, or back
This pain may be confused with angina
Respiratory symptoms
Asthma
Chronic cough
Laryngitis
These symptoms, however, are usually multifactorial in
nature in addition to the GERD dx
Gurgling
Foul-smelling breath
The food stops before it reaches the stomach
Evening onset (usually our biggest meal of the day is dinner in
the evening)
Advise to avoid large meals
Treatments
Usually focused on conservative measures
Avoid positions that reflux is made worse by
o Remain in sitting position for several hours after
eating
o Sleep with head elevated
Avoid large meals
Avoid foods that reduce lower esophageal sphincter tone
o Caffeine, fats, chocolate

Avoid alcohol and smoking

Combination of antacids and alginic acid are also used to
treat mild forms
Histamine-2 receptor-blocking antagonists
o Inhibit gastric acid production
Proton pump inhibitors
o Inhibit the gastric proton pump which regulates the
final pathway for acid secretion

Esophageal Cancer
o 2 types
Squamous cell carcinoma
Most cases of this are attributable to alcohol use and/or
tobacco use
Adenocarcinoma
Barrett esophagus and GERD are the 2 most common risk
factors
o This is not easily caught especially because the most indicative
symptom of it is a late stage sign
o Clinical manifestations
Most common complaint: progressive dysphagia
BUT this is usually a late sign
Need to adjust diet accordingly
Seen in bulky foods to soft foods to liquids
Unintentional weight loss
Anorexia
Fatigue
Pain upon swallowing
o Treatments
Depends of stage of tumor
Surgical resection may provide a cure if done early
May provide palliation in late stage
Radiation may be an alternative to surgery
Chemotherapy may be used before surgery to reduce size of
tumor
o Poor prognosis
Disorders of the stomach
o Gastritis
Gastritis refers to the inflammation of the gastric mucosa
Causes can be grouped in acute and chronic
Acute gastritis
o Usually transient gastric mucosa inflammation
o May be accompanies by emesis, pain, and in severe
cases, hemorrhage and ulcerations
o Acute gastritis is an important cause of GI bleeding
o Most commonly associated with local irritants

Aspirin or other NSAIDs, alcohol, or bacterial

toxins
Oral administration of corticosteroids may
also be complicated by acute hemorrhagic
gastritis
o Any kind of stress that requires substantial medical
or surgical treatment renders the gastric mucosa
more vulnerable to acute hemorrhagic gastritis
because of mucosal injury
o Uremia, treatment with cancer chemotherapy
drugs, and gastric radiation are other causes of
acute gastritis
o Symptoms
Complaints vary
Those with aspirin-related gastritis may be
completely unware and only complain of
heartburn or sour stomach
Associated with excessive alcohol
consumption: often causes transient gastric
distress which may lead to vomiting and in
more severe cases to bleeding and
hematemesis
Caused by toxins: usually has abrupt, violent
onset
Vomiting and gastric distress occurs
appox. 5 hours after the ingestion of
contaminated foods
o Acute gastritis is usually a self-limiting disorder,
with complete regeneration and healing occurring
within several days of removal of inciting agent
Chronic gastritis
o Characterized by the absence of grossly visible
erosions and presence of inflammatory changes
leading eventually to atrophy of the glandular
epithelium of the stomach
o There are 3 types of chronic gastritis
H. pylori
Helicobacter pylori infection is the
most common cause of chronic
gastritis
Prevalence in U.S. associated with
socioeconomic status, increased age,
and Hispanic and African American
ethnicities
H. pylori is transmitted person-toperson via bodily fluids as well though
contaminated water

Chronic infection with H. pylori can

lead to gastric atrophy and peptic
ulcers
Also associated with increased risk of
gastric adenocarcinoma and creation
of mucosa-associated lymphoid tissue
which can progress to lymphoma
H. pylori move through the mucous
layer of stomach and secrete urase
o This allows it to produce
sufficient ammonia to buffer the
acidity of the stomach acid
Have the capacity to interfere with the
local protection of the gastric mucosa
against acid, produce inflammation,
and elicit an immune response
Increase production of
proinflammatory cytokines (IL-6, IL-8)
that serve to recruit neutrophils
Also is immunogenic and invoke a
immune response in the mucosa
Tx: difficult to eradicate, use of
antibiotics and proton pump inhibitors
used in combination
H. mutate rapidly and develop
resistant strains
Autoimmune and multifocal atrophic gastritis
Autoimmune
o Limited to the body and fundus
of the stomach
o Results from the presence of
autoantibodies in the parietal
cells and intrinsic factor
o Severe cases: intrinsic factor is
lost leading to B12 deficiency
and pernicious anemia
Multifocal atrophic
o Uncertain etiology
o Affect the antrum and adjacent
areas
o Associated with reduces gastric
acid secretion
Chemical gastrophy
Results from the reflux of alkaline
duodenal contents, pancreatic
secretions, and bile into the stomach

Ulcerative disorders
Peptic ulcer disease
Term used to describe a group of ulcerative disorders that
occur in upper GI tract that are exposed to acid-pepsin
secretions
Peptic ulcers
o Most common forms are duodenal and gastric
ulcers
o Can affect one or all layers of the stomach or
duodenum
o Causes
Two causes both affect the mechanisms that
protect the gastric mucosa from destructive
effects of gastric acid
H. pylori infections
Induces inflammation and stimulate
release of cytokines and other
mediators of inflammation that
contributes to mucosal damage
NSAIDs
Involve mucosal injury and inhibition
of prostaglandin synthesis
Dose dependent
Also age, warfarin, and smoking are causes
o Clinical manifestations
Spontaneous remissions and exacerbations
are comon
Uncomplicated peptic ulcer
Discomfort and pain which is
described as burning, gnawing, or
cramplike usually rhythmic and
occurs when stomach is empty
o Pain over epigastric midline and
radiates
Superficial and deep epigastric
tenderness with more extensive
lesions
Pain usually relieved by antacids or
food
Complications
Hemorrhage
o Bleeding from granulation tissue
or from erosion of an ulcer into
an artery or vein
o Acute post hemorrhagic anemia
Perforation and penetration

Ulcer erodes through all layers

of stomach or duodenum
o GI contents enter peritoneum
and cause peritonitis
Gastric outlet obstruction
o Caused by edema, spasm, or
contraction of scar tissue and
interference with the free
passage of gastric contents
through the pylorus or adjacent
tissue
o

Treatment
Eradicate H. pylori if present
Acid-inhibiting (H2 receptor antagonists or
proton pump inhibitors) and acid-neutralizing
(antacids) drugs used for symptoms
Mucosa-protective drugs
Acid content reduction drugs Zollinger-Ellison
Rare condition caused by a gastrin-secreting tumor
(gastrinoma)
Increased gastric secretions results in GERD or severe
peptic ulcer disease
Autosomal dominant disorder
Symptoms
o Diarrhea from hypersecretion or from inactivation
of intestinal lipase and impaired fat digestion that
occur with decrease in intestinal pH
Treatment
o Control of gastric acid secretions by proton pump
inhibitors
o Treatment of malignant neoplasm
Surgical removal if not metastasized
Stress Ulcers
GI ulcerations that develop in relation to major
physiological stress
Risks:
o Those with large-surface-area burns (Curlings
ulcer)
o Trauma
o Sepsis
o ARDS
o Severe liver failure
o Major surgical procedures
Occur most often in fundus and body of the stomach
Thought to occur from ischemia to the mucosal tissue and
alterations in the gastric mucosal barrier
o

Cushings ulcer
o Gastric, duodenal, and esophageal ulcers arising in
people with intracranial injuries, operations, or
tumors
o May be caused by hypersecretion of gastric acid
resulting from stimulation of vagal nuclei by
increased intracranial pressure
ICU pts are at risk for this
Proton pump inhibitors are first line treatments
o Stomach cancer
Risk factors
Genetics
Carcinogenic factors in diet
Autoimmune gastritis
Gastric adenomas or polyps
Chronic H. pylori infections
Clinical manifestations
Often asymptomatic
Usually vague and nonspecific symptoms if they occur at
all
o Indigestion
o Anorexia
o Weight loss
o Epigastric pain
o Vomiting
o Abdominal mass
Treatment
Depends on location and extend of tumor progression
Surgery of radical subtotal gastrectomy is usually tx of
choice
Irradiation and chemotherapy have not been proved
useful as primary txs
Conditions causing altered intestinal function
Irritable bowel disease
Dont really know what causes it
o Maybe stress/anxiety related
o GI studies seem normal, but with a cascade of
symptoms
Persistent or recurrent symptoms of abdominal pain
o Visceral pain that comes and goes
Altered bowel function
Varying complaints of flatulence, bloatedness
Nausea
Anorexia
Constipation or diarrhea
Anxiety or depression

Mostly just treat symptoms

Inflammatory bowel disease
Crohns disease
o A recurrent granulomatous type of inflammatory
response that can affect any area of the GI tract
from the mouth to the anus
o May have fistula formations
Ulcerative colitis
o A nonspecific inflammatory condition of the colon
Diverticulitis
Commonly occurs in the distal descending colon and
sigmoid colon
Mucosal layer of the colon herniates through the
muscularis layer
There are often multiple diverticula
Diverticulitis is a complication of diverticulosis in which
there is inflammation and gross or microscopic perforation
of the diverticulum
Symptoms
o Pain in the lower left quadrant
o Nausea and vomiting
o Tenderness in the LLQ
o A slight fever
o Elevated WBC count = infection INFLAMMATORY
CASCADE
Treatment
o Tx symptoms and prevent complications
o Sometimes surgical tx
o Diet is very important with these pts
Some things that we eat we cant fully digest
This things may get stuck in the
outpourings
This may be where diverticulitis
becomes diverticulosis
Appendicitis
The appendix becomes inflamed, swollen, and
gangrenous
o It eventually perforates if not treated become
septic inflammatory cascade
Appendicitis is related to intraluminal obstruction with a
fecalith (hard piece of stool), gallstones, tumors,
parasites, or lymphatic tissue
Kind of like diverticulitis because the appendix is really
just an pouch off the side of the intestine
Alterations in bowel motility
Diarrhea

Constipation
o Common causes:
Failure to respond to the urge to defecate
Inadequate fiber intake in diet
Inadequate fluid intake
Weakness of abd. muscles
Inactivity and bed rest
Pregnancy
Hemorrhoids
Fecal impaction
o Painful anorectal disease
o Tumors
o Neurogenic disease
o Use of constipating antacids or bulk laxatives
o Low-residue diet
o Drug-induced colonic stasis
o Prolonged bed rest and debility
o If digitally disimpacted, you can stimulate the
vagus nerve and the HR will drop significantly
Intestinal obstruction
o Mechanical obstruction can result from postop
causes like external hernia and postop adhesions
o Paralytic or adynamic obstruction results from
neurogenic or muscular impairment of peristalsis
o Will have watery stools because formed stool
cannot get passed the obstruction and the liquids
are going around the obstruction
Peritonitis
o Muscles of the abd. wall tighten to protect the
inflamed bowel
Board-like abd.
No tympanic sounds
o Pain and sympathetic nervous stimulation cause
the bowel to freeze in position
Reflex paralysis or paralytic ileus
o Diaphragm and accessory breathing muscle
movement
Shallow breathing
o Peritoneal dialysis can have peritonitis as a
complication
o Permits rapid absorption of bacterial toxins
o Favors the dissemination of contaminants
o Great inflammatory response
Thick, fibrous protective substance
o Causes
Perforated peptic ulcer
Ruptured appendix

Perforated diverticulum
Gangrenous bowel
Pelvid inflammatory disease
Gangrenous gall bladder
Abd. trauma and wounds
Intestinal Malabsorption
Failutre to transport dietary constituents from the lumen
of the intestine to the extracellular fluid
Causes
o Celiac disease
o Inflammatory reaction
o Neoplasm
o Colorectal cancer
Symptoms
o Diarrhea
o Steatorrhea
o Flatulence
o CBloating
o Abd. pain
o Cramps
o Weakness, muscle wasting
o Weight loss and abd. distention
Malabsorption syndrome
Failure to break down things to get nutrients
Gastric bypass surgery can cause malabsorption
o Dumping syndrome
Celiac disease
Gluten sensitivity
One of the most common genetic diseases
o Affected share the MHCII allele
T-cell mediated reaction to gluten component
Antibodies inflammatory reaction loss of small
intestine villi malabsorption
Usually found early in life
Will have abnormal liver function tests if they have had it
for a while
Cancer of the colon and rectum
Colorectal cancers
o Risk factors
Age
Family hx
Chron disease
Ulcerative colitis
Familial adenomatous polyposis
Diet
o Diagnosis
Stool occult blood tests

Digital rectal exam

X-ray studies using barium (like barium
enema)
Flexible sigmoidoscopy and colonoscopy
Colorectal neoplasm
o Adenomas = adenomatous polyps
Benign
Tubular, villous, tubulovillous
o Adenocarcinoma
Malignant/cancerous
Early screening important for prognosis
o Slow-growing, but symptomatic late
Infections of the intestine
Viral infections
o Rotavirus
Worldwide, the leading cause of severe diarrhea
Live vaccines available
Incubation period of 1-3 days with mild to
moderate fever and vomiting (these usually
disappear on the second day)
Followed by onset of frequent watery stools for
5-7 days
Dehydration develops rapidly especially in
infants
Avoiding and treating dehydration are the
main goals
Bacterial infections
o C-diff colitis
Associated with antibiotic therapy
Broad-spectrum antibiotics predisposes
disruption of the normal protective flora
and c-diff is opportunistic and takes over
It releases toxins that damage the
mucosa
o Interfere with protein synthesis and
attract inflammatory cells leads
to hemorrhage, inflammation, and
necrosis
Spore-forming bacillus
Spores are resistant to acid enviro of
stomach
Convert to vegetative forms in the colon
Passed oral-fecal route
Pseudomembranous colitis more severe form
Characterized by an adherent
inflammatory membrane overlying the
area of mucosal injury

E-coli

Treatment
Metronidazole is the drug of choice
Vanco reserved for those who cant
tolerate metron.
O157:H7
Found in the feces and contaminated milk of
healthy dairy and beef cattle but also found in
contaminated pork, poultry, and lamb
Ingesting undercooked meats
Symptoms
May have none
Acute, nonbloody diarrhea
Hemorrhagic colitis
Hemolytic uremic syndrome
Thrombotic thrombocytopenia purpura
Abdominal cramping
Watery diarrhea may become bloody
(usually lasts 5-10 days)
Treatment
No specific therapy available
Tx largely focused on symptoms
Antibiotic use in early stages of infection
Antimotility/antidiarrheal drugs early, but
shown to increase risk of HUS
EDUCATION
o How to cook meat
o Do not cross contaminate foods
o Hygiene in daycare settings and
nursing homes

Protozoal
o 2 distinct stages
The trophozoites (ameboid form)
Thrive in the colon and feed on bacteria
and human cells
Can colonize any portion of large bowel
but especially the cecum
Cysts
Only cysts are infections because they
survive gastric acidity
Humans pass both trophozoites and cysts
in stool but they both quickly dies when
exposed to air
o Symptoms
Diarrhea 2-4 weeks after infected
o Treatment

Antimicrobial agents (tinidazole and

metronidazole) act against trophozoites
Diloxanide (not available in U.S.) is effective
against cysts