MICRO SGD 1. Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency.

For adults on a typical Western diet, stool weight >200 g/d can generally be considered diarrheal. Diarrhea may be further defined as acute if <2 weeks, persistent if 2 4 weeks, and chronic if >4 weeks in duration.

Signs and symptoms associated with diarrhea may include: y y y y y y Frequent loose, watery stools Abdominal cramps Abdominal pain Fever Bleeding Lightheadedness or dizziness from dehydration

2. MECHANISMS OF DIARRHEA a. Secretory Diarrhea - are due to derangements in fluid and electrolyte transport across the enterocolonic mucosa. They are characterized clinically by watery, large-volume fecal outputs that are typically painless and persist with fasting. Because there is no malabsorbed solute, stool osmolality is accounted for by normal endogenous electrolytes with no fecal osmotic gap. b. Osmotic diarrhea - occurs when ingested, poorly absorbable, osmotically active solutes draw enough fluid into the lumen to exceed the reabsorptive capacity of the colon. Fecal water output increases in proportion to such a solute load. Osmotic diarrhea characteristically ceases with fasting or with discontinuation of the causative agent. c. Exudative diarrhea- occurs in the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Chron s disease or ulcerative colitis and other severe infections such as E. coli or other forms of food poisoning. d. Deranged- Motility is caused by the rapid movement of food through the intestines (hypermotility). If the food moves too quickly through the gastrointestinal tract, there is not enough time for sufficient nutrients and water to be absorbed. e. Malabsorption is the inability to absorb food fully, mostly from disorders in the small bowel, but also due to maldigestion from diseases of the pancreas.

3. GASTROINTESTINAL MOTILITY

A. Oral Cavity -lined with stratified squamous epithelium, keratinized or nonkeratinized, depending on the region. The keratin layer protects the oral mucosa from damage during masticatory

function and is present mostly in the gingiva (gum) and hard palate. The lamina propria in these regions has several papillae and rests directly on bony tissue. Nonkeratinized squamous epithelium covers the soft palate, lips, cheeks, and the floor of the mouth. The lamina propria has papillae, similar to those in the dermis of the skin, and is continuous with a submucosa containing diffuse small salivary glands. In the lips, a transition from the oral nonkeratinized epithelium to the keratinized epithelium of the skin can be observed. B. Esophagus Esophagus is a muscular tube whose function is to transport foodstuffs from the mouth to the stomach and to prevent the retrograde flow of gastric contents. Transport is achieved by peristaltic contractions and relaxation of the esophageal sphincters (upper and lower), usually controlled by reflexes and by the autonomic nervous system. In humans the esophagus is covered by nonkeratinized stratified squamous epithelium. In general, it has the same layers as the rest of the digestive tract. In the submucosa are groups of small mucus-secreting glands, the esophageal glands, whose secretion facilitates the transport of foodstuffs and protects the mucosa. In the lamina propria of the region near the stomach are groups of glands, the esophageal cardiac glands, that also secrete mucus. At the distal end of the esophagus, the muscular layer consists of only smooth muscle cells that, close to the stomach, form the lower esophageal sphincter; in the mid portion, a mixture of striated and smooth muscle cells; and at the proximal end, only striated muscle cells. Only that portion of the esophagus that is in the peritoneal cavity is covered by serosa. The rest is covered by a layer of connective tissue, the adventitia, that blends into the surrounding tissue. C. Stomach- main function is to continue the digestion of food. The gastric mucosa consists of a surface epithelium that invaginates to various extents into the lamina propria, forming gastric pits. Emptying into the gastric pits are branched, tubular glands (cardiac, gastric, and pyloric) characteristic of each region of the stomach. The lamina propria of the stomach is composed of loose connective tissue interspersed with smooth muscle and lymphoid cells. Separating the mucosa from the underlying submucosa is a layer of smooth muscle, the muscularis mucosae. D. Small intestine The small intestine is the site of terminal food digestion, nutrient absorption, and endocrine secretion. The lining of the small intestine shows a series of permanent folds, plicae circulares (Kerckring's valves), consisting of mucosa and submucosa and having a semilunar, circular, or spiral form. The plicae are most developed in, and consequently a characteristic of, the jejunum. Intestinal villi are 0.5- to 1.5-mm-long outgrowths of the mucosa (epithelium plus lamina propria) projecting into the lumen of the small intestine.

E. Large intestine The large intestine consists of a mucosal membrane with no folds except in its distal (rectal) portion. No villi are present in this portion of the intestine . The intestinal glands are long and characterized by a great abundance of goblet and absorptive cells and a small number of enteroendocrine cells. The absorptive cells are columnar and have short, irregular microvilli. The large intestine is well suited to its main functions: absorption of water, formation of the fecal mass, and production of mucus.

Question 4 Digestive enzymes are enzymes that break down polymeric macromolecules into their smaller building blocks, in order to facilitate their absorption by the body. Digestive enzymes are found in the digestive tract where they aid in the digestion of food as well as inside the cells, especially in their lysosomes where they function to maintain cellular survival. Digestive enzymes are diverse and are found in the saliva secreted by the salivary glands, in the stomach secreted by cells lining the stomach, in the pancreatic juice secreted by pancreatic exocrine cells, and in the intestinal (small and large) secretions, or as part of the lining of the gastrointestinal tract. Digestive enzymes are classified based on their target substrates:
   

proteases and peptidases split proteins into their monomers, the amino acids. lipases split fat into three fatty acids and a glycerol molecule. carbohydrases split carbohydrates such as starch and sugars into simple sugars such as glucose. nucleases split nucleic acids into nucleotides.

The main sites of digestion are the oral cavity, the stomach, and the small intestine. Digestive enzymes are secreted by different exocrine glands including:
   

Salivary glands Secretory cells in the stomach. Secretory cells in the pancreas. Secretory glands in the small intestine.

Oral Cavity Complex food substances that are taken by animals and humans must be broken down into simple, soluble, and diffusible substances before they can be absorbed. In the oral cavity, salivary glands secrete an array of enzymes and substances that aid in digestion and also disinfection. They include the following:

 

 

Potassium bicarbonate (KHCO3): The major role of bicarbonate is to neutralize acidity mainly in an attempt to preserve the dentin and tooth enamel and also to neutralize bacterial toxins. Bicarbonate also prevents acid damage to the esophageal lining before food enters the stomach. lingual lipase: Lipid digestion initiates in the mouth. Lingual lipase starts the digestion of the lipids/fats. amylase: Carbohydrate digestion also initiates in the mouth. Amylase produced by the salivary glands breaks complex carbohydrates to smaller chains, or even simple sugars. It is sometimes referred to as ptyalin. Mucin: Mucin functions to make food more pliable and also covers it facilitating its transfer in the esophagus to the stomach, by lubricating the content. lysozyme: Considering that food contains more than just the essential nutrients and bacteria or viruses, the lysozome offers a limited and non-specific, yet beneficial antiseptic function in digestion. IgA: This is a dimeric form of antibodies produced by the body. Gastrointestinal tract produces only IgA mainly to battle bacterial toxins, and also to tag certain recognizable molecular patterns in viruses and bacteria. IgA-coated pathogens are digested by white cells lining the gastrointestinal tract. Haptocorrin (also known as R-factor): Helps with the absorption of Vitamin B12. After Vitamin B12 is released from its original carrier protein in the stomach, it gets bound to Haptocorrin. Haptocorrin protects it from acidic conditions of the stomach but is cleaved in the duodenum by pancreatic proteases. Vitamin B12 can then bind to intrinsic factor (IF) that has been produced by parietal cells. Finally, the IF-Vitamin B12 complex is taken up by in ileum via the cubam receptor.

Of note is the diversity of the salivary glands. There are two types of salivary glands:
 

serous glands: These glands produce a secretion rich in water, electrolytes, and enzymes. A great example of a serous oral gland is theparotid gland. Mixed glands: These glands have both serous cells and mucous cells, and include sublingual and submandibular glands. Their secretion is mucinous and high in viscosity.

In addition, all salivary secretions are hypotonic with respect to the plasma concentration. This is because the duct cells of salivary cells are impermeable to water, yet there is a continuous abstraction of electrolytes such as sodium (Na) and potassium (K) from the initially secreted juice, causing it to be very dilute (hypotonic) by the time it is released into the mouth.

Stomach The enzymes that are secreted in the stomach are called gastric enzymes. The stomach plays a major role in digestion, both in a mechanical sense by mixing and crushing the food, and also in an enzymatic sense, by digesting it. The following are the enzymes produced by the stomach and their respective function:

Pepsinogen is the main gastric enzyme. It is produced by the stomach cells called "chief cells" in its inactive form pepsinogen, which is a zymogen. Pepsinogen is then activated by the stomach acid into its active form, pepsin. Pepsin breaks down the protein in the food into smaller particles, such as peptide fragments and amino acids. Protein digestion, therefore, first starts in the stomach, unlike carbohydrate and lipids, which start their digestion in the mouth. Hydrochloric acid (HCl): This is in essence positively charged hydrogen atoms (H), or in layterms stomach acid, and is produced by the cells of the stomach called parietal cells. HCl mainly functions to denature the proteins ingested, to destroy any bacteria or virus that remains in the food, and also to activate pepsinogen into pepsin. Intrinsic factor (IF): Intrinsic factor is produced by the parietal cells of the stomach. Vitamin B12 (Vit. B12) is an important vitamin that requires assistance for absorption in terminal ileum. Initially in the saliva, haptocorrin secreted by salivary glands binds Vit. B, creating a Vit B12-Haptocorrin complex. The purpose of this complex is to protect Vitamin B12 from hydrochoric acid produced in the stomach. Once the stomach content exits the stomach into the duodenum, haptocorrin is cleaved with pancreatic enzymes, releasing the intact vitamin B12.Intrinsic factor (IF) produced by the parietal cells then binds Vitamin B12, creating a Vit. B12-IF complex. This complex is then absorbed at the terminal portion of the ileum. Mucin: The stomach has a priority to destroy the bacteria and viruses using its highly acidic environment but also has a duty to protect its own lining from its acid. The way that the stomach achieves this is by secreting mucin and bicarbonate via its mucous cells, and also by having a rapid cell turn-over. Gastrin: This is an important hormone produced by the "G cells" of the stomach. G cells produce gastrin in response to stomach stretching occurring after food enters it, and also after stomach exposure to protein. Gastrin is an endocrine hormone and therefore enters the bloodstream and eventually returns to the stomach where it stimulates parietal cells to produce hydrochloric acid (HCl) and Intrinsic factor (IF).

Of note is the division of function between the cells covering the stomach. There are four types of cells in the stomach:
   

Parietal cells: Produce hydrochloric acid and intrinsic factor. Gastric chief cells: Produce pepsinogen. Chief cells are mainly found in the body of stomach, which is the middle or superior anatomic portion of the stomach. Goblet cells: Produce mucin and bicarbonate to create a "neutral zone" to protect the stomach lining from the acid or irritants in the stomach chyme. G cells: Produce the hormone gastrin in response to distention of the stomach mucosa or protein, and stimulate parietal cells production of their secretion. G cells are located in the antrum of the stomach, which is the most inferior region of the stomach.

Secretion by the previous cells is controlled by the enteric nervous system. Distention in the stomach or innervation by the vagus nerve (via the parasympathetic division of the autonomic nervous system) activates the ENS, in turn leading to the release of acetylcholine. Once present, acetylcholine activates G cells and parietal cells.

Pancreas Pancreas is both an endocrine and an exocrine gland, in that it functions to produce endocrinic hormones released into the circulatory system (such as insulin, and glucagon), to control glucose metabolism, and also to secrete digestive/exocrinic pancreatic juice, which is secreted eventually via the pancreatic duct into duodenum. Digestive or exocrine function of pancreas is as significant to the maintenance of health as its endocrine function. Two population of cells in the pancreatic parenchyma make up its digestive enzymes:


Ductal cells: Mainly responsible for production of bicarbonate (HCO3), which acts to neutralize the acidity of the stomach chyme entering duodenum through the pylorus? Ductal cells of the pancreas are stimulated by the hormone secretin to produce their bicarbonate-rich secretions, in what is in essence a bio-feedback mechanism; highly acidic stomach chyme entering the duodenum stimulates duodenal cells called S cells to prouduce the hormone secretin and releases it to the bloodstream. Secretin having entered the blood eventually comes into contact with the pancreatic ductal cells, stimulating them to produce their bicarbonate-rich juice. It is interesting to note that secretin also inhibits production of gastrin by "G cells", and also stimulates acinar cells of the pancreas to produce their pancreatic enzyme. Acinar cells: Mainly responsible for production of the inactivate pancreatic enzymes (zymogens) that, once present in the small bowel, become activated and perform their major digestive functions by breaking down proteins, fat, and DNA/RNA. Acinar cells are stimulated bycholecystokinin(CCK), which is a hormone/neurotransmitter produced by the duodenal cells called the "I cells." CCK stimulates production of the pancreatic zymogens.

Pancreatic juice, composed of the secretions of both ductal and acinar cells, is made up of the following digestive enzymes:


     

Trypsinogen, which is an inactive(zymogenic) protease that, once activated in the duodenum, into trypsin, breaks down proteins at the basic amino acids. Trypsinogen is activated via the duodenal enzyme enterokinase into its active form trypsin. Chymotrypsinogen, which is a inactive(zymogenic) protease that, once activated by duodenal enterokinase, breaks down proteins at their aromatic amino acids. Chymotrypsiongen can also be activated by trypsin. Carboxypeptidase, which is a protease that takes off the terminal amino acid group from a protein Several elastases that degrade the protein elastin and some other proteins. Pancreatic lipase that degrades triglycerides into fatty acids and glycerol. Cholesterol esterase Phospholipase Several nucleases that degrade nucleic acids, like DNAase and RNAase

Pancreatic amylase that breaks down, besides starch and glycogen, most other carbohydrates. Humans lack the enzyme to digest the carbohydrate cellulose, mainly due to its special hydrogen-bonding structure.

Pancreas's exocrine function owes part of its immaculate function to bio-feedback mechanisms controlling secretion of its juice. The following significant pancreatic bio-feedback mechanisms are essential to the maintenance of pancreatic juice balance/production:


Secretin, a hormone produced by the duodenal "S cells" in response to the stomach chyme containing high hydrogen atom concentration (high acidicity), is released into the blood stream; upon return to the digestive tract, secretion decreases gastric emptying, increases secretion of the pancreatic ductal cells, as well as stimulating pancreatic acinar cells to release their zymogenic juice. Cholecystokinin (CCK) is a unique peptide released by the duodenal "I cells" in response to chyme containing high fat or protein content. Unlike secretin, which is an endocrine hormone, CCK actually works via stimulation of a neuronal circuit, the end-result of which is stimulation of the acinar cells to release their content. CCK also increases gallbladder contraction, resulting in bile squeezed into the cystic duct, common bile duct and eventually the duodenum. Bile of course helps absorption of the fat by emulsifying it, increasing its absorptive surface. Bile is made by the liver, but is stored in the gallbladder. Gastric inhibitory peptide (GIP) is produced by the mucosal duodenal cells in response to chyme containing high amounts of carbohydrate, proteins, and fatty acids. Main function of GIP is to decrease gastric emptying. Somatostatin is a hormone produced by the mucosal cells of the duodenum and also the "delta cells" of the pancreas. Somatostatin has a major inhibitory effect, including on pancreatic juice production.

Small Intestine The small intestine is traditionally divided into three anatomic sections defined from their distance from the pyloric sphincter:


duodenum: It is the first portion of the small bowel that is itself divided into four distinct anatomic positions called first, second, third, and fourth sections of duodenum. Duodenum is the only portion of the small bowel that is partially retroperitoneal, and peritoneal. Duodenum is a secretary portion of the small intestine. jejunum: This is the section of the small intestine that begins immediately from the insertion point of the ligament of Treitz, and is the longest of the three sections. Jejunum is an absorptive surface. ileum This is the terminal portion of the small intestine and as such has a limited but vital role in absorption. Vitamin B12 and bile are absorbed at this portion.

The following enzymes/hormones are produced in the duodenum:

 

  

secretin: This is an endocrine hormone produced by the duodenal "S cells" in response to the acidity of the gastric chyme. Cholecystokinin (CCK): This is not by definition a hormone; there is new evidence suggesting that CCK works by a very complex neuronal bi-directional pathway. Regardless of its pathway, its eventual role is to increase secretion of acinar cells and increased production of pancreatic juice. CCK also increases gallbladder contraction, causing release of pre-stored bile into the cystic duct, and eventually into the common bile duct and via the ampulla of Vater into the second anatomic position of the duodenum. CCK also decreases the tone of thesphincter of Oddi, which is the sphincter that regulates flow through the ampula of Vater. CCK also decreases gastric activity and decreases gastric emptying, thereby giving more time to the pancreatic juices to neutralize the acidity of the gastric chyme. Gastric inhibitory peptide (GIP): This peptide decreases gastric motility and is produced by duodenal mucosal cells. motilin: This substance increases gastro-intestinal motility via specialized receptors called "motilin receptors." somatostatin: This hormone is produced by duodenal mucosa and also by the delta cells of the pancreas. Its main function is to inhibit a variety of secretory mechanisms.

Throughout the lining of the small intestine there are numerous "brush border" enzymes whose function is to further cleave the already-broken-down products of digestion into absorbable particles. Some of these enzymes include:
 

 

Sucrase Lactase: This is a significant brush border enzyme in that a majority of Middleastern and Asian population lack this enzyme and also this enzyme decreases with age, and as such lactose intolerance is often a common abdominal complaint in the Middleastern, Asian, and older population, manifesting with bloating, abdominal pain, and osmotic diarrhea. Maltase Other disaccharidases

Large Intestine The colon is the main reservoir for feces (mainly in rectum) before defecation. It is also where the liquid stool becomes solid, by losing its water, and electrolytes. The colon also actively secretes bicarbonate and potassium, which explains why severe diarrhea can cause metabolic acidosis as well as hypokalemia. The colon also houses symbiotic bacteria that produce vitamin by-products and are essential to the human health and homeostasis. Oesophagus or gullet
Osmotic Diarrhea Osmotic diarrhea occurs when too much water is drawn into the bowels. This can be the result of maldigestion (e.g., pancreatic disease or Coeliac disease), in which the nutrients are left in the lumen to pull in water. Osmotic diarrhea can also be caused by osmotic laxatives (which work to

alleviate constipation by drawing water into the bowels). In healthy individuals, too much magnesium or vitamin C or undigested lactosecan produce osmotic diarrhea and distention of the bowel. A person who has lactose intolerance can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who have fructose malabsorption, excess fructose intake can also cause diarrhea. High-fructose foods that also have high glucose content are more absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugarfree foods) are difficult for the body to absorb and, in large amounts, may lead to osmotic diarrhea. Osmotic diarrhea stops when offending agent (e.g. milk, sorbitol) is stopped Absorption of water in the intestines is dependent on adequate absorption of solutes. If excessive amounts of solutes are retained in the intestinal lumen, water will not be absorbed and diarrhea will result. Osmotic diarrhea typically results from one of two situations:
y

Ingestion of a poorly absorbed substrate: The offending molecule is usually a carbohydrate or divalent ion. Common examples include mannitol or sorbitol, epson salt (MgSO4) and some antacids (MgOH2). Malabsorption: Inability to absorb certain carbohydrates is the most common deficit in this category of diarrhea, but it can result virtually any type of malabsorption. A common example of malabsorption, afflicting many adults humans and pets islactose intolerance resulting from a deficiency in the brush border enzyme lactase. In such cases, a moderate quantity of lactose is consumed (usually as milk), but the intestinal epithelium is deficient in lactase, and lactose cannot be effectively hydrolyzed into glucose and galactose for absorption. The osmoticallyactive lactose is retained in the intestinal lumen, where it "holds" water. To add insult to injury, the unabsorbed lactose passes into the large intestine where it is fermented by colonic bacteria, resulting in production of excessive gas.

A distinguishing feature of osmotic diarrhea is that it stops after the patient is fasted or stops consuming the poorly absorbed solute. Secretory Diarrhea Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a charge balance in the lumen, sodium is carried with it, along with water. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting. It continues even when there is no oral food intake. Large volumes of water are normally secreted into the small intestinal lumen, but a large majority of this water is efficienty absorbed before reaching the large intestine. Diarrhea occurs when secretion of water into the intestinal lumen exceeds absorption. Many millions of people have died of the secretory diarrhea associated with cholera. The responsible organism, Vibrio cholerae, produces cholera toxin, which strongly activates adenylyl cyclase, causing a prolonged increase in intracellular concentration of cyclic AMP within crypt enterocytes. This change results in prolonged opening of the chloride channels that are instrumental in secretion of water from

the crypts, allowing uncontrolled secretion of water. Additionally, cholera toxin affects the enteric nervous system, resulting in an independent stimulus of secretion. Exposure to toxins from several other types of bacteria (e.g. E. coli heat-labile toxin) induce the same series of steps and massive secretory diarrhea that is often lethal unless the person or animal is aggressively treated to maintain hydration. In addition to bacterial toxins, a large number of other agents can induce secretory diarrhea by turning on the intestinal secretory machinery, including:
y y y y

some laxatives hormones secreted by certain types of tumors (e.g. vasoactive intestinal peptide) a broad range of drugs (e.g. some types of asthma medications, antidepressants, cardiac drugs) certain metals, organic toxins, and plant products (e.g. arsenic, insecticides, mushroom toxins, caffeine)

In most cases, secretory diarrheas will not resolve during a 2-3 day fast. Inflammatory and Infectious Diarrhea Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis. The epithelium of the digestive tube is protected from insult by a number of mechanisms constituting thegastrointestinal barrier, but like many barriers, it can be breached. Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species. Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results. Examples of pathogens frequently associated with infectious diarrhea include:
y y y

Bacteria: Salmonella, E. coli, Campylobacter Viruses: rotaviruses, coronaviruses, parvoviruses (canine and feline), norovirus Protozoa: coccidia species, Cryptosporium, Giardia

The immune response to inflammatory conditions in the bowel contributes substantively to development of diarrhea. Activation of white blood cells leads them to secrete inflammatory mediators and cytokines which can stimulate secretion, in effect imposing a secretory component on top of an inflammatory diarrhea. Reactive oxygen species from leukocytes can damage or kill intestinal epithelial cells, which are replaced with immature cells that typically are deficient in the brush border enyzmes and transporters necessary for absorption of nutrients and water. In this way, components of an osmotic (malabsorption) diarrhea are added to the problem. Diarrhea Associated with Deranged Motility

In order for nutrients and water to be efficiently absorbed, the intestinal contents must be adequately exposed to the mucosal epithelium and retained long enough to allow absorption. Disorders in motility than accelerate transit time could decrease absorption, resulting in diarrhea even if the absorptive process per se was proceeding properly.

Exudative Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections such as E. coli or other forms of food poisoning.

Dysentery Generally, if there is blood visible in the stools, it is not diarrhea, but dysentery. The blood is trace of an invasion of bowel tissue. Dysentery is a symptom of, among others, Shigella,Entamoeba histolytica, and Salmonella.

5. salivary glands - exocrine glands, glands with ducts, that produce saliva. They also secrete amylase, an enzyme that breaks down starch into maltose. Stomach- is located between the esophagus and the small intestine. It secretes proteindigesting enzymes and strong acids to aid in food digestion,through smooth muscular contortions before sending partially digested food to the small intestines. Bolus enters the stomach through the oesophagus via the oesophageal sphincter. The stomach releases proteases (protein-digesting enzymes such as pepsin) and hydrochloric acid, which kills or inhibits bacteria and provides the acidic pH of two for the proteases to work. small intestine- is the part of the gastrointestinal tract following the stomach and followed by the large intestine, and is where much of the digestion and absorption of food takes place. small intestine is where most chemical digestion takes place. Most of the digestive enzymes that act in the small intestine are secreted by the pancreas and enter the small intestine via the pancreatic duct. The enzymes enter the small intestine in response to the hormone cholecystokinin, which is produced in the small intestine in response to the presence of nutrients. The hormone secretin also causes bicarbonate to be released into the small intestine from the pancreas in order to neutralize the potentially harmful acid coming from the stomach.

pancreas - is a gland organ in the digestive and endocrine system ofvertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, and a digestive organ, secreting pancreatic juice containing digestive enzymes that assist the absorption of nutrients and the digestion in the small intestine. These enzymes help to further break down the carbohydrates, proteins, and lipids in the chyme. biliary tract - is the common anatomical term for the path by which bile is secreted by the liver then transported to the first part of the small intestine, also known as the duodenum. The duct, the branches of the hepatic artery and theportal vein form the central axis of the portal triad. Bile flows in the direction opposite to that of the blood present in the other two channels. large intestine is the third-to-last part of the digestive system invertebrate animals. Its function is to absorb water from the remaining indigestible food matter, and then to pass useless waste material from the body. 6. Stomach- is located between the esophagus and the small intestine. It secretes proteindigesting enzymes and strong acids to aid in food digestion,through smooth muscular contortions before sending partially digested food to the small intestines. colon is the last part of the digestive system in most vertebrates; it extracts water andsalt from solid wastes before they are eliminated from the body, and is the site in which flora-aided (largely bacterial) fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a major role in absorption of foods and nutrients. However, the colon does absorb water, sodium and some fat soluble vitamins. rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long. Its caliber is similar to that of thesigmoid colon at its commencement, but it is dilated near its termination, forming the rectal ampulla. anus is the external opening of the rectum. Like other animals, its closure is controlled by sphincter muscles. Feces are expelled from the body through the anus during the act of defecation, the primary function of the anus.

7. Major causes of the specific mechanism of the diarrhea diseases

To be able to identify and understand the specific target or involved structure of the etiology of diarrhea diseases in the following organs 7.1 stomachBolus (masticated food) enters the stomach through the oesophagus via the oesophageal sphincter. The stomach releases proteases (protein-digesting enzymes such as pepsin) and hydrochloric acid, which kills or inhibits bacteria and provides the acidic pH of two for the proteases to work. Food is churned by the stomach through muscular contractions of the wall reducing the volume of the fundus, before looping around the fundus and the body of stomach as the boluses are converted into chyme (partially digested food). Chyme slowly passes through the pyloric sphincter and into the duodenum, where the extraction of nutrients begins. Depending on the quantity and contents of the meal, the stomach will digest the food into chyme anywhere between forty minutes and a few hours. The hormone gastrin causes an increase in the secretion of HCl from the parietal cells, and pepsinogen from chief cells in the stomach. It also causes increased motility in the stomach. Gastrin is released by G-cells in the stomach in response to distenstion of the antrum, and digestive products(especially large quantities of incompletely digested proteins). It is inhibited by a pH normally less than 4 (high acid), as well as the hormone somatostatin. Cholecystokinin (CCK) has most effect on the gall bladder, causing gall bladder contractions, but it also decreases gastric emptying and increases release of pancreatic juice which is alkaline and neutralizes the chyme. In a different and rare manner, secretin, produced in the small intestine, has most effects on the pancreas, but will also diminish acid secretion in the stomach. 7.2 intestine- waste moves along too fast and the large intestine can t absorb the water before the waste is pushed through After being processed in the stomach, food is passed to the small intestine via the pyloric sphincter. The majority of digestion and absorption occurs here after the milky chyme enters the duodenum. Here it is further mixed with three different liquids:


 

Bile, which emulsifies fats to allow absorption, neutralizes the chyme and is used to excrete waste products such as bilin and bile acids. Bile is produced by the liver and then stored in the gallbladder. The bile in the gallbladder is much more concentrated. Pancreatic juice made by the pancreas. Intestinal enzymes of the alkaline mucosal membranes. The enzymes include maltase, lactase and sucrase (all three of which process only sugars), trypsin and chymotrypsin.

The pH level increases in the small intestine. A more basic environment causes more helpful enzymes to activate and begin to help in the breakdown of molecules such as fat globules. Small, finger-like structures called villi, each of which is covered with even smaller hair-like structures called microvilli improve the absorption of nutrients by increasing the surface area of the intestine and enhancing speed at which nutrients are absorbed. Blood containing the

absorbed nutrients is carried away from the small intestine via the hepatic portal vein and goes to the liver for filtering, removal of toxins, and nutrient processing. The small intestine and remainder of the digestive tract undergoes peristalsis to transport food from the stomach to the rectum and allow food to be mixed with the digestive juices and absorbed. The circular muscles and longitudinal muscles are antagonistic muscles, with one contracting as the other relaxes. When the circular muscles contract, the lumen becomes narrower and longer and the food is squeezed and pushed forward. When the longitudinal muscles contract, the circular muscles relax and the gut dilates to become wider and shorter to allow food to enter. After the food has been passed through the small intestine, the food enters the large intestine. Within it, digestion is retained long enough to allow fermentation due to the action of gut bacteria, which breaks down some of the substances that remain after processing in the small intestine; some of the breakdown products are absorbed. In humans, these include most complex saccharides (at most three disaccharides are digestible in humans). In addition, in many vertebrates, the large intestine reabsorbs fluid; in a few, with desert lifestyles, this reabsorbtion makes continued existence possible. In humans, the large intestine is roughly 1.5 meters long, with three parts: the cecum at the junction with the small intestine, the colon, and the rectum. The colon itself has four parts: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon. The large intestine absorbs water from the bolus and stores feces until it can be egested. Food products that cannot go through the villi, such as cellulose (dietary fiber), are mixed with other waste products from the body and become hard and concentrated feces. The feces is stored in the rectum for a certain period and then the stored feces is eliminated from the body due to the contraction and relaxation through the anus. The exit of this waste material is regulated by the anal sphincter. 7.3 biliary 7.4 pancreas The pancreas as an exocrine gland helps out the digestive system. It secretes pancreatic fluid that contains digestive enzymes that pass to the small intestine. These enzymes help to further break down the carbohydrates, proteins, and lipids (fats) in the chyme. In humans, the secretory activity of the pancreas is regulated directly via the effect of hormones in the blood on the islets of Langerhans and indirectly through the effect of the autonomic nervous system on the blood flow.

8. Structural sources of the contents of the feces for fecalysis To be able to know the genera; etiology and the altered structure/s responsible for the diarrhea 8.1 microscopic ( quantity, ferm, consistency, and color) 8.2 mucus

8.3 microscop

Fecalysis is also known as stool analysis. It refers to a series of laboratory tests done on fecal samples to analyze the condition of a person's digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as white blood cells (WBCs), sugars, or bile and signs of poor absorption as well as screen for colon cancer. To properly check for inadequate absorption, a fecal fat test may be required. This is a diagnostic procedure used to recognize problems with fat absorption. A quantitative fecal fat test is usually completed in three days and able to verify the amount of fat within a person's body.

STOOL ANALYSIS NORMAL: y y y y y y the stool appears brown ( varies from light brown-dark brown) soft and well formed in consistency no blood, mucus, pus, bacteria, viruses, or parasite are present in the stool the shape of the stool is tubular, reflecting its passage through the colon normal pH of stool is about 6 less than 2 milligram per gram (mg/g) of certain sugars called reducing factors are present in the stool ABNORMAL o Increase vol. of stool may indicate poor absorption of fats o Blood, mucus, pus, bacteria, viruses, or parasite are present in the stool o Low levels of enzymes ( such as trypsin or elastase) may be present o Reducing factors levels between 2 and 5 mg/g are considered borderline. Level s greater than 5 mg/g are abnormal Abnormal values may mean Parasites or eggs present in the stool indicate a parasitic infestation, such as, amebiasis High levels of fat in the stool may indicate chronic pancreatitis, Crohn's disease, or cysticfibrosis. The presence of undigested meat fibers in the stool may indicate pancreatitis. An abnormal pH may indicate poor absorption of carbohydrates or fat. Low levels of certain enzymes (such as trypsin or elastase) may indicate digestivecomplications of cystic fibrosis or pancreatic insufficiency.

The presence of blood in the stool indicates bleeding in the digestive tract. The presence of white blood cells in the stool may indicate bacterial diarrhea. A specificorganism may be identified. Rotaviruses are a common cause of diarrhea in young children. If diarrhea is present,testing may be done to determine the presence of rotaviruses in the stool. High levels of reducing factors in the stool may indicate a problem digesting certainsugars (especially sucrase and lactase).

10. Organs and tissues affected by the complication of diarrhea 10.1 To be able to identify the specific structures involved in the compensatory mechanism during diarrhea 10.1.1 skin Due to low water volume in the body, there is prevention of water loss for compensation which is done by the skin by preventing sweating. 10.1.2 pituitary gland The posterior pituitary secretes ADH or antidiuretic hormone which aids in water reabsorption specifically in the distal convoluted tubule to increase water volume in the body. 10.1.3 heart and blood vessels During Diarrhea, there is low blood pressure due to low blood volume. The heart compensates by increasing heart rate and the blood vessels vasoconstrict with the aid of vasoconstrictors such as the angiotensin II of RAAS to increase blood pressure. 10.1.4 kidneys The Renin-Angiotensin-Aldosterone system is the mechanism done by the kidney to increase water retention. compensatory

10.2 To be able to identify specific structures of the primary organ/s or tissues affected by the physiologic alteration during the occurrence of diarrhea complication.

10.2.1 blood Prolonged and severe diarrhea can lead to kidney failure, diminished urine output, shock and acidosis (too much of acid in the blood). 10.2.2 kidneys The body loses electrolytes along with water, in cases of prolonged diarrhea. This can lead to deficiency of minerals, especially sodium and potassium. A person suffering from diarrhea can notice abnormalities of chloride and bicarbonate. Prolonged and severe diarrhea can lead to kidney failure, diminished urine output, shock and acidosis (too much of acid in the blood)

10.2.3 heart and blood vessels A person can faint upon standing, due to orthostatic hypotension. This occurs due toreduction in the volume of blood, which causes a drop in blood pressure upon standing. Severe diarrhea can lead to heart complications in some cases. 10.2.4 brain If not treated immediately, diarrhea can lead to severe complications like affected brainfunction in infants and young children. Infants are more prone to become severelydehydrated and thus, suffer from such problems 10.2.5 skin and soft tissues The skin has a decreased turgor which is shown by still remaining elevated after being pulled up and released.