Professional Documents
Culture Documents
dr. Irwan
Blok IV
FAKULTAS KEDOKTERAN UNSRI
PALEMBANG
2007
Um feto de poucas semanas encontra-se
no interior do tero de sua me.
Content (1)
9. Small intestine
10. Large intestine (colon), rectum and anal
canal
11. Pancreas
12. Liver and biliary tract
13. Summary of digestion and absorption of
nutrients
Clinical correlations:
1. Periodontitis
2. Odontogenic abscesses
3. Acute follicular tonsillitis
4. Esophageal varicosis
5. Hiatus hernia
6. Diaphragmatic hernia
7. Cirrhosis hepatis
8. Cholelithiasis
9. Anorectal abscess & fistula
Clinical problems:
1. Perforated Appendicitis.
Digestive system:
1. Organs of digestion:
a. Alimentary canal (Fig. 12.1)
b. Accessory organs
2. Digestive processes
3. General structure (Fig. 12.2).
BASIC STRUCTURE OF THE ALIMENTARY CANAL
(Fig. 12.2)
Mucosa
Epithelium
cells firmly sealed by tight
junctions
secretes mucus, digestive
enzymes and hormones
Absorption
Lamina propria
Contains mucosa-
associated lymphatic
tissue
Muscularis mucosae
causes folds which
increase surface area
BASIC STRUCTURE OF THE ALIMENTARY CANAL
(Fig. 12.2)
Submucosa
Blood and lymphatic
vessels
Glands
Submucosal plexus
Regulates movement of
mucosa and
vasoconstriction of
blood vessels
BASIC STRUCTURE OF THE ALIMENTARY CANAL
(Fig. 12.2)
Muscularis
Mouth, pharynx, upper
esophagus and external anal
sphincter contain skeletal muscle
Rest of GI tract contains smooth
muscle
inner circular and outer
longitudinal layers
Myenteric plexus between layers
Controls motility
BASIC STRUCTURE OF THE ALIMENTARY CANAL
(Fig. 12.2)
serosa (visceral
peritoneum)
Forms portion of
peritoneum
BASIC STRUCTURE OF THE ALIMENTARY CANAL
(Fig. 12.2)
Peritoneum
Largest serous membrane in
body
Parietal layer
o Lines wall of abdomino-
pelvic cavity
Visceral layer
o Covers some organs in
cavity
Peritoneal cavity
o Contains serous fluid
Folds bind organs to each other
and to walls of abdominal cavity
MOUTH (Fig. 12.10)
Mucous membranes of
mouth and tongue secrete
small amount of saliva
Most saliva secreted by
major salivary glands which
lie outside the mouth
Parotid
Submandibular
Sublingual
Mouth - composition and functions of
saliva
Functions of saliva
Chemical digestion of polysaccharides.
Lubrication of food.
Cleansing and lubricating.
Non-specific defence.
Taste.
Mouth - control of salivation
Salivation under nervous control
salivary nuclei in brain stem
Receive input from cortex, taste buds, olfactory apparatus
Parasympathetic output increases salivation
Sympathetic output reduces salivation (dry mouth when
stressed)
Mouth digestion
Mechanical and chemical digestion occur in the mouth
Mechanical digestion results from mastication
Chemical digestion begins
Salivary amylase
Initiates breakdown of starch
Lingual lipase
Hydrolyses triglycerides into fatty acids and glycerol
Secreted in inactive form by glands in tongue
Becomes activated in acid environment of stomach
Mouth
Function of the tongue (Fig. 12.12)
The tongue plays an important part in:
mastication (chewing)
deglutition (swallowing)
speech
taste
Nerve endings of the sense of taste are present
in the papillae and widely distributed in the
epithelium of the tongue, soft palate,
pharynx and epiglottis.
Mouth
Chemical digestion
HCL
denatures proteins
Cephalic phase
Sight, smell, taste or thought of food recognised by cerebral cortex or
feeding centre in hypothalamus
Nerve impulses sent to medulla oblongata
Sends impulses to submucosal plexus (in submucosa)
Increases secretion from gastric glands and stomach motility (via gastrin
secretion)
Gastric phase
when food reaches stomach stimulates
Stretch receptors
Chemoreceptors (monitor pH)
Stimulate secretion of Gastrin (by G cells)
Maintains gastric secretion and motility
Intestinal phase
Stimulation of intestinal receptors as food enters small intestine
stimulates secretion of
Secretin reduces gastric secretion
CCK-inhibits gastric emptying
Slows exit of chyme from stomach into duodenum
Stomach
Blood supply
Arterial blood is supplied to the stomach by
branches of the coeliac artery and venous
drainage is into the portal vein. Figures 12.7
and 12.9
Nerve supply
The sympathetic supply to the stomach is mainly
from the coeliac plexus and the
parasympathetic supply is from the vagus
nerves. Sympathetic stimulation reduces the
motility of the stomach and the secretion of
gastric juice; vagal stimulation has the opposite
effect (Fig. 12.6).
Functions of gastric juice
Water further liquefies the food swallowed.
Hydrochloric acid:
acidifies the food and stops the action of salivary amylase
kills ingested microbes
provides the acid environment needed for effective digestion by
pepsins.
Pepsinogens are activated to pepsins by hydrochloric
acid and by pepsins already present in the stomach.
Intrinsic factor (a protein) is necessary for the absorption
of vitamin B12 from the ileum.
Mucus prevents
mechanical injury to the stomach wall by lubricating the contents.
chemical injury by acting as a barrier between the stomach wall
and the corrosive gastric juice.
Small intestine
Extends from pyloric
sphincter to ileocecal
valve
3 parts:
duodenum
jejunum
ileum
Small intestine
Structure of the small intestine
The walls of the small intestine are composed of the four
layers of tissue shown in Figure 12.2.
Peritoneum. A double layer of peritoneum called the
mesentery attaches the jejunum and ileum to the
posterior abdominal wall (Fig. 12.3A). The
attachment is quite short in comparison with the
length of the small intestine, therefore it is fan-shaped.
The large blood vessels and nerves lie on the posterior
abdominal wall and the branches to the small intestine
pass between the two layers of the mesentery.
Small intestine
Mucosa. The surface area of small intestine mucosa is
greatly increased by permanent circular folds, villi,
and microvilli.
The permanent circular folds, unlike the rugae of
stomach, are not smoothed out when the small
intestine is distended (Fig. 12.29). They promote
mixing of chyme as it passes along.
The villi are tiny finger-like projections of the mucosal
layer into the intestinal lumen, about 0.5 to 1 mm
long (Fig. 12.30).
Their walls consist of columnar epithelial cells, or enterocytes,
with tiny microvilli (1 m long) on their free border.
Small intestine
The intestinal glands are simple tubular glands situated below the
surface between the villi. The cells of the glands migrate
upwards to form the walls of the villi replacing those at the
tips as they are rubbed off by the intestinal contents. The
entire epithelium is replaced every 3 to 5 days. During
migration the cells form digestive enzymes that lodge in the
microvilli and, together with intestinal juice, complete the
chemical digestion of carbohydrates, protein and fats.
Numerous lymph nodes are found in the mucosa at irregular
intervals throughout the length of the small intestine. The
smaller ones are known as solitary lymphatic follicles, and
about 20 or 30 larger nodes situated towards the distal end of
the ileum are called aggregated lymphatic follicles (Peyers
patches).
Small intestine
Blood supply (Figs. 12.8 and 12.9)
The superior mesenteric artery supplies the whole
of the small intestine, and venous drainage is by
the superior mesenteric vein which joins other
veins to form the portal vein.
Nerve supply
Innervation of the small intestine is both
sympathetic and parasympathetic (Fig. 12.6).
Functions of the small intestine
onward movement of its contents which is produced by
peristalsis
secretion of intestinal juice
completion of chemical digestion of carbohydrates,
protein and fats in the enterocytes of villi
protection against infection by microbes that have
survived the antimicrobial action of the hydrochloric
acid in the stomach, by the solitary lymph follicles and
aggregated lymph follicles
secretion of the hormones cholecystokinin (CCK) and
secretin
absorption of nutrients.
Small intestine
Mechanical digestion
Segmentation mixes chyme
Control of secretion
Mechanical stimulation of the intestinal glands by
chyme is believed to be the main stimulus for
the secretion of intestinal juice, although the
hormone secretin may also be involved.
Small intestine
Absorption of nutrients (Fig. 12.31)
Absorption of nutrients occur by two possible processes
Diffusion. Monosaccharides, amino acids, fatty acids and
glycerol diffuse slowly down their concentration gradients
into the enterocytes from the intestinal lumen.
Active transport. Monosaccharides, amino acids, fatty acids
and glycerol may be actively transported into the villi; this is
faster than diffusion. Disaccharides, dipeptides and
tripeptides are also actively transported into the enterocytes
where their digestion is completed before transfer into the
capillaries of the villi.
LARGE INTESTINE (COLON), RECTUM AND ANAL CANAL
Blood supply
Arterial supply is mainly by the superior and inferior mesenteric
arteries (Fig. 12.8).
The superior mesenteric artery supplies the caecum. ascending and
most of the transverse colon.
The inferior niesenteric artery supplies the remainder of the colon
and the proximal part of the rectum.
The distal section of the rectum and the anus are supplied by
branches from the internal iliac arteries.
Mass movement
The large intestine does not exhibit peristaltic movement as it is
seen in other parts of the digestive tract. Only at fairly long
intervals (about twice an hour) does a wave of strong peristalsis
sweep a long the transverse colon forcing it contents into the
descending and sigmoid colons. This is known as mass
movement and it is often precipitated by the entry of food into
stomach. This combination of stimulus and response is called the
gastrocolic reflex.
Defaecation
Usually the rectum is empty, but when a mass movement forces
the contents of the sigmoid colon into the rectum the nerve
endings in its walls are stimulated by stretch.
LARGE INTESTINE (COLON), RECTUM AND ANAL CANAL
Mechanical digestion
Movements of large intestine begin when substances pass
iliocecal sphincter
Haustral churning
distention of haustra as chyme enters LI initiates haustral churning
Peristalsis occurs at slower rate than in SI
Mass peristalsis
Strong peristaltic wave that begins at mid-transverse colon drives
contents into rectum
Occurs during or immediately after meal when food enters
stomach
Chemical digestion
Final stage of digestion occurs in LI through activity of bacteria
Produces gases and other by-products
Eg vitamins
Pancreas
Pancreas connected to
duodenum
Secretes pancreatic juice into
duodenum
Structure
Learning outcomes
After studying this section, you should be
able to:
list the main organs of the alimentary tract
list the accessory organs of digestion.
BASIC STRUCTURE OF THE ALIMENTARY
LO:
CANAL
Learning outcomes
After studying this section, you should be able to:
describe the distribution of the peritoneum
explain the function of smooth muscle in the walls
of the alimentary canal
discuss the structures of the alimentary mucosa
outline the nerve and blood supply of the
alimentary canal.
LO: Mouth & Salivary glands
Learning outcomes
After studying this section, you should be able to:
list the principal structures associated with the mouth
describe the structure of the mouth
describe the structure and function of the tongue
describe the structure and function of the teeth
outline the arrangement of normal primary and secondary dentition.
describe the structure and the function of the principal salivary
glands
explain the role of saliva in digestion.
LO: Pharynx
Learning outcomes
After studying this section, you should be able to:
describe the structure of the pharynx.
LO: Oesophagus
Learning outcomes
After studying this section, you should be able to:
describe the location of the oesophagus
outline the structure of the oesophagus
explain the mechanisms involved in swallowing, and
the route taken by a bolus.
LO: Stomach
Learning outcomes
After studying this section, you should be able to:
describe the location of the stomach with reference to
surrounding structures
explain the physiological significance of the layers of
the stomach wall
discuss the digestive functions of the stomach.
LO: Small intestine
Learning outcomes
After studying this section, you should be able to:
describe the location of the small intestine, with
reference to surrounding structures
sketch a villus, naming its component parts
discuss the digestive functions of the small intestine
and its secretions
explain how nutrients are absorbed in the small
intestine.
LO:Large intestine (colon), rectum and anal
canal
Learning outcomes
After studying this section, you should be able to:
identify the different sections of the large intestine
describe the structure and functions of the large
intestine, the rectum and the anal canal.
LO: Pancreas
Learning outcomes
After studying this section, you should be able to:
differentiate between the structures and functions of
the exocrine and endocrine pancreas.
LO: Liver & Biliary tract
Learning outcomes
After studying this section, you should be able to:
describe the location of the liver in the abdominal
cavity
describe the structure of a liver lobule
list the functions of the liver.
describe the route taken by bile from the liver, to the
gall bladder, and then to the duodenum
outline the structure and functions of the gall bladder.
LO: Summary of digestion and absorption of nutrients
Learning outcomes
After studying this section, you should be able to:
list the principal digestive enzymes, their sites of
action, their substrates and their products
describe the sites of absorption of the main nutrient
groups.
Fig. 16
Fig. 15
Fig. 14
Fig. 13
Fig. 12.37
Fig. 12.38
Fig. 12.24
Fig. 12
Fig. 12.31
Fig. 12.35
Fig. 12.34
Fig. 12.33
Fig. 12.42
Fig. 12.29
Fig. 12.30
Fig. 12.3
1. A 45-year-old man was admitted to the emergency
room complaining of severe pain in the right lower
quadrant. He had repeatedly vomited, and his
temperature and pulse rate were elevated. His history
indicated that he had been suffering from acute
appendicitis and that the pain had suddenly increased,
On examination, the muscles of the lower part of the
anterior abdominal wall in the right lower quadrant
showed rigidity. The diagnosis of peritonitis
following perforation of the appendix was made.
Can you explain the rigidity of the abdominal
muscles in anatomical terms?
What anatomical structure helps the body to
localize inflammatory lesions of the pentoneum?
Answers to Anatomical-Clinical Problems
1. The sudden increase in pain in the right lower quadrant would
suggest that the appendix suddenly perforated, and the
infected intestinal contents gushed out into the peritoneal cavity
The infecting organisms quickly multiplied and spread the
inflammation to the parietal peritoneum in the right iliac region,
and the pain was intensified. The parietal peritoneum, the
muscles of the anterior abdominal wall, and the overlying skin
are all supplied by the same segmental nerves (T12 and L1).
The irritation of the parietal peritoneum reflexly produced an
increase in the tone of the muscles in this region, which, when
felt by the examiners hand, was interpreted as rigidity. This is
an attempt by the body to reduce movement in this area and so
help localize the infection. If the perforation is a slow process,
the greater omentum becomes stuck down to the appendix by
inflammatory exudate (infiltrate), and its presence considerably
restricts the spread of infection.
2. The diagnosis in a 50-year-old woman was
carcinoma of the greater curvature of the
stomach. What is the lymphatic drainage of the
greater curvature of the stomach? Describe
briefly the extent of the operation necessary to
treat cancer of the stomach, and give your
anatomical reasons.
Answers to Anatomical-Clinical Problems
2. Lymph from the right inferior part of the greater curvature of the
stomach drains into nodes lying along the right gastroepiploic artery,
the gastroduodenal artery, the root of the hepatic artery, and the nodes
around the celiac artery Lymph from the left superior part of the
greater curvature drains into nodes lying along the short gastric and
the left gastroepiploic arteries and the splenic artery and Hnally
drains into nodes around the celiac artery. Cancer of the stomach
initially spreads locally by the lymphatic vessels in the mucous
membrane, and for this reason the entire stomach must be removed.
The best chance one has of removing all the cancer cells is to remove
all the lymphatic vessels and nodes that drain the stomach. A total
gastrectomy is therefore performed, and this includes removal of the
lower end of the esophagus and the first part of the duodenum; the
spleen and the gastrosplenic and lienorenal ligaments and their lymph
nodes; the splenic vessels; the tail and body of the pancreas, and their
associated nodes; and the nodes along the lesser and greater
curvatures of the stomach, along with the greater omentum. The
continuity of the gut is restored by anastomosing the esophagus to the
jejunum.
Fig. 12.6
Fig. 12.7
Fig. 12.8
Fig. 12.9
Fig. 11
Fig. 12.23
Fig. 12.12
Fig. 12.16
Fig. 10 Pharynx - deglutition
Fig. 12.1
Fig. 12.1 Organs of digestion
Gastrointestinal tract
(alimentary canal)
mouth
pharynx
esophagus
stomach
small intestine
large intestine
Fig. 12.1 Organs of digestion
Accessory organs of
digestive system
Salivary glands
Liver and
gallbladder
Pancreas
Fig. 12.2
Fig. 12.10
Fig. 01
Fig. 02
Fig. 03
Fig. 04
Fig. 05
Fig. 06
Fig. 07
Fig. 08
Fig. 09
Digestive processes
Ingestion
Taking of food and liquid into the mouth (eating)
Secretion
Cells secrete ~7 litres of fluids per day
Mixing and Propulsion
Mixing and movement of material along GI tract is termed
motility
Digestion
Mechanical
Chemical
Absorption
Defecation
Indigestible material eliminated as feces during defacation