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GASTROINTESTINAL
Ivan Buntara
405120049
Learning Objective 1
Describes the anatomy, histology, physiology and biochemistry of stomach until
ileum; pancreas and gallbladder
ANATOMY OF STOMACH UNTIL ILEUM;
PANCREAS AND GALL BLADDER
STOMACH
• The stomach is a J-shaped, pouchlike organ, about 25-30 centimeters
long, which hangs inferior to the diaphragm in the upper left portion
of the abdominal cavity
• The stomach is divided into 4 parts
1. Cardia : surrounds the gastroesophageal sphincter
2. Fundus : is the rounded portion above and to the left of the cardia
3. The body : below the fundus is the large central portion of the stomach
4. Pylorus or Antrum : is the narrow inferior region that connects with the
duodenum of the small intestine via pyloric sphincter
• When there is no food in the stomach, the mucosa lies in large
folds called rugae, which are visible with the unaided eye
• The wider and more superior part of pyloric region, the pyloric
antrum narrows to form the pyloric canal, which terminates at the
pylorus
• The pylorus is continuous with the duodenum through the pyloric
valve or sphincter, which controls stomach emptying
• The convex lateral surface of the stomach is its greater curvature and
its concave medial surface is the lesser curvature
• Extending from these curvatures are two mesenteries, called omenta
help tether the stomach to other digestive organs and the body
wall
• The lesser omentum runs from the liver to the lesser curvature of the
stomach, where it becomes continuous with the visceral peritoneum
covering the stomach
• The greater omentum drapes inferiorly from the greater curvature of
the stomach to cover the coils of the small intestine
• Then runs dorsally and superiorly, wrapping the spleen and the transverse
portion of the large intestine before blending with the mesocolon
• The greater omentum is riddled with fat deposits that give it the
appearance of a lacy apron
• Also contain large collections of lymph nodes
• The stomach is served by the autonomic nervous system
• Sympathetic fibers from thoracic splanchnic nerves are relayed through the
celiac plexus
• Parasympathetic fibers are supplied by the vagus nerve
• The arterial supply of the stomach is provided by branches (gastric &
splenic) of the celiac trunk
• The corresponding veins are part of the hepatic portal system and
ultimately drain into the hepatic portal vein
SMALL INTESTINE
• The small intestine extends from the pyloric valve of the stomach
to the ileocecal valve, where it joins the large intestine
• It is named for its small diameter (compared to that of the large
intestine), but perhaps it should be called the long intestine
• The small intestine takes up a large portion of the abdominal
cavity, averaging about 6 m (18 ft) in length
REGIONS OF SMALL INTESTINE
The small intestine has the following regions :
• Duodenum
• The first 25 cm (10 in.) contain distinctive glands that secrete mucus and also
receive the pancreatic secretions and the bile from the liver through a common
duct. Folds and villi are more numerous at the end than at the beginning
• Jejunum
• The next 1 m (3 ft) contains folds and villi, more at the beginning than at the end
• Ileum
• The last 2 m (6–7 ft) contain fewer folds and villi than the jejunum
• Nerve fibers serving the small intestine include
• Parasympathetic from the vagus
• Sympathetics from the thoracic splanchnic nerves
• Both relayed through the superior mesenteric plexus
• The arterial supply is primarily from the superior mesenteric artery
• The veins parallel the arteries and typically drain into the superior
mesenteric vein
• From there, the nutrient-rich venous blood from the small intestine
drains into the hepatic portal vein, which carries it to the liver
PANCREATIC ANATOMY
• Gland with both exocrine and endocrine functions
• 15-25 cm long
• 60-100 g
• Location: retro-peritoneum, 2nd lumbar vertebral level
• Extends in an oblique, transverse position
• Parts of pancreas: head (caput), neck (collum), body (corpus) and tail
(cauda)
Ampulla of Vater
THE GALLBLADDER WITH BILIARY SYSTEM AND PANCREAS
HISTOLOGY OF STOMACH UNTIL ILEUM;
PANCREAS AND GALLBLADDER
ESOPHAGUS-GASTER JUNCTION
FUNDUS-TRANSVERSE SECTION
PYLORIC PART OF THE STOMACH-PYLORIC GLANDS
• In contrast to the gastric glands of the corpus and fundus of the stomach, the
tubules of the pyloric glands (pylorus = pars pylorica ventriculi) branch out
and form coils only deep in the mucous membrane
• The gastric foveolae are deeper than the foveolae in the mucous membrane
of the gastric corpus and fundus. The glandular tubules undulate considerably
and may therefore be sectioned in different planes relative to their axis
• The columnar surface epithelium also covers the funnel-shaped gastric
foveolae
• Pyloric glands exclusively consist of mucous cells
PYLORIC
PYLORIC-DUODENUM JUNCTION
SMALL INTESTINE-DUODENUM
• The tissue surface in the duodenum, as in the rest of the upper small intestine, shows
circular folds called plicae circulares or Kerckring’s folds. Circular folds form an
impressively articulated relief in the duodenum
• The surface of the Kerckring’s folds features intestinal villi in different shapes and sizes
(villi intestinales). They are 0.5–1.5mm high and about 0.15mm thick. Intestinal villi are
covered with a columnar epithelium (enterocytes, absorptive cells)
• Tubular canals extend from the cell surface at the bottom of the invaginations between
microvilli to the lamina muscularis mucosae. These are the intestinal glands of
Lieberkühn, also called crypts of Lieberkühn
• Brunner’s glands (duodenal glands) are characteristic of the duodenum. They are located
in the submucosal layer. The glands with their winding tubules remind of the pyloric
glands
DUODENUM
SMALL INTESTINE-JEJUNUM
• This longitudinal section of the jejunal wall from an adult human
shows six circular plicae (Kerckring’s folds)
• The villi of the small intestines are protrusions from the tunica
mucosa. Therefore, they consist of the surface epithelium, the
lamina propria mucosae and sporadic smooth muscle cells from
the lamina muscularis mucosae
• As the jejunum continues toward the ileum, the circular plicae
stand lower and become sparse
SMALL INTESTINE-ILEUM
• Compared with the adjacent small intestine, there is only little surface
enlargement in the ileum. This is the major difference between both
tissues. The circular plicae are lesser in height, and there are fewer and
fewer of them until they are completely absent
• In the process, the villi also become shorter and scarcer than in the
jejunum
• There are small crypts at the bottom of the spaces between the villi. The
development of the lymphoreticular organs in the form of lymphatic
nodules (noduli lymphatici aggregati)
PANCREATIC HORMONES, INSULIN AND GLUCAGON, REGULATE
METABOLISM
http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/ba
sics/gi_motility.html
SEGMENTATION
Trypsinogen Trypsin
Chymotrypsinogen Chymotrypsin
Proelastase Elastase
Procarboxypeptidase Carboxypeptidase
BICARBONATE FUNCTIONS
1. Neutralize gastric acid emptied into the duodenum
2. Provide a favorable alkaline environment for optimal activity of
pancreatic enzymes
CONTROL OF PANCREATIC FUNCTIONS
• Bicarbonate secretion stimulated by secretin
• Secretin released in response to acid in duodenum
• Zymogen secretion stimulated by cholecystokinin (CCK)
• CCK released in response to fat/amino acids in duodenum
• Also under neural control (vagal/local reflexes) - triggered by arrival of
organic nutrients in duodenum
CONTROL OF PANCREATIC FUNCTIONS
FUNCTIONS OF BILE
• Emulsification of fats
• Increased absorption of lipids into enterocytes (include vitamin A, D,
E, K)
• Cholesterol excretion (only route)
• Excretion of breakdown products of hemoglobin (bilirubin)
• Netralization of acid
SMALL INTESTINE
• Digestive enzymes not secreted from small intestine → from pancreas
or found on enterocytes
• Except enterokinase secreted from duodenal mucosa
• Mucus/alkali secretions → mucosal protection
• Aqueous secretions
SMALL INTESTINE
• Function
• Lubricate and protect intestinal surface (IgA)
• Dilute digestive products
• Digest specific food substances
• (enzymes in enterocytes: peptidase, sucrase, etc )
REGULATION OF SMALL INTESTINAL
SECRETIONS
• Local stimuli
• The presence of chyme in the intestine
• Hormonal regulation
• Secretin
• CCK
• Neuronal regulation
• Vagus nerve – excitatory
• Sympathetic nerve - inhibitory
Learning Objective 2
Describes about dyspepsia (definition, classification, etiology, pathophysiology,
clinical presentation, diagnosis, management, prognosis, complication and
prevention)
DYSPEPSIA
DYSPEPSIA
• Syndrome that consists of intermittent epigastric pain or discomfort,
nausea, bloating, vomiting, early satiation and flatus
• The symptoms characteristically develops after eating
DYSEPSIA ETIOLOGY
• Food or drug intolerance
• Functional dyspepsia
• Luminal GI tract dysfunction
• Helicobacter pylori infection
• Pancreas disease (pancreas carcinoma and pancreatitis)
• Other conditions (DM, thyroid disease, CKD, myocardial ischemia,
malignancy, gastric volvulus or paraesophageal hernia, pregnancy)
Harmon RC, Peura DA. Evaluation and management of
dyspepsia. Ther Adv Gastroenterol. 2010;3(2):87-98.
DIFFERENTIAL DIAGNOSIS OF DYSPEPSIA
COMPLAINTS
Krenitsky JS, Decher N. Medical nutrition therapy for upper gastrointestinal tract
disorders. In Mahan LK, Stump SE, Raymond JL, editors. Krause’s food and nutrition
care process (chapter 28). 13th ed. St Louis: Saunders; 2012: p. 592-608.
NUTRITION CARE GUIDELINES FOR REDUCING
GASTROESOPHAGEAL REFLUX AND ESOPHAGITIS
• Stay upright and avoid vigorous activity soon after eating
• Avoid tight-fitting clothing, especially after a meal
• Consume a healthy, nutritionally complete diet with adequate fiber
• Avoid acidic and highly spiced foods when inflammation exists
• Lose weight if overweight
Krenitsky JS, Decher N. Medical nutrition therapy for upper gastrointestinal tract
disorders. In Mahan LK, Stump SE, Raymond JL, editors. Krause’s food and nutrition
care process (chapter 28). 13th ed. St Louis: Saunders; 2012: p. 592-608.
Learning Objective 4
Describes the physiology and pathophysiology of bloating, vomiting and alarm
symptoms
ALARM SYMPTOMS
• Age older than 55 with new-onset dyspepsia
• Unintended weight loss
• Persistent/continuous vomiting
• Progressive dysphagia
• Odynophagia
• Unexplained anemia or iron deficiency
• Jaundice
ALARM SYMPTOMS
• Palpable abdominal mass or lymphadenopathy
• Hematemesis, melena, hematochezia (chronic GI bleeding)
• Anorexia
• Family history of upper GI cancer
• Previous gastric surgery
• Suspicious barium meal
VOMITING (EMESIS)
• Forceful expulsion of gastric contents through the mouth
• Not accomplished by reverse peristalsis
• The force for expulsion comes from :
• The diaphragm
• The abdominal muscles
• Coordinated by vomiting center in the medulla of brain stem
VOMITING (EMESIS)
1. Deep inspiration, closure of glottis
2. Contracting diaphragm + abdominal muscles → the intra-abdominal
pressure ↑
3. Flaccid stomach is squeezed
4. Gastric contents forced upward through relaxed sphincters till
mouth
CAUSES OF VOMITING (EMESIS)
• Tactile (touch) stimulation of the back of the throat
• Irritation or distention of stomach and duodenum
• Elevated intracranial pressure (e.g. cerebral hemorrhage)
• Rotation or acceleration of the head → dizziness
• Chemical agents (drugs, noxious substances)
• Psychogenic (emotional factors)
EFFECTS OF VOMITING (EMESIS)
• Reduction in plasma volume → dehydration, circulatory problems
• Loss of acid → metabolic alkalosis
REFERENCES
• Netter FH. Atlas of human anatomy. 6th ed. Philadelphia: Saunders Elsevier;
2014.
• Eroschenko VP. Atlas histologi diFiore: dengan korelasi fungsional. Ed 11.
Jakarta: EGC; 2008.
• Sherwood L. Introduction to human physiology. 5th ed. United States:
Brooks/Cole-Thomson Learning; 2007.
• Sherwood L. Introduction to human physiology. 8th ed. United States:
Brooks/Cole-Cengage Learning; 2013.
• Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders.
REFERENCES
• Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada J, et al.
Functional gastroduodenal disorders. Gastroenterology. 2006;130:1466-79.
• Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiadi S, editor. Buku ajar
ilmu penyakit dalam. Edisi 5. Jilid I. Jakarta: Pusat Penerbitan Ilmu Penyakit
Dalam FKUI; 2008.
• Rani AA, Simadibrata M, Syam AF, editors. Buku ajar gastroenterologi. Edisi
1. Jakarta: Pusat Penerbitan Ilmu Penyakit Dalam; 2011.
• Krenitsky JS, Decher N. Medical nutrition therapy for upper gastrointestinal
tract disorders. In Mahan LK, Stump SE, Raymond JL, editors. Krause’s food
and nutrition care process (chapter 28). 13th ed. St Louis: Saunders; 2012:
p. 592-608.
REFERENCES
• Harmon RC, Peura DA. Evaluation and management of dyspepsia. Ther Adv
Gastroenterol. 2010;3(2):87-98.
• Vojvodic M, Young A, editors. Toronto notes 2014. Toronto: Toronto Notes
for Medical Students Inc.; 2014.
• Papadakis MA, McPhee S, Rabow MW, editors. Current medical diagnosis
and treatment. 52nd ed. New York: The McGraw-Hill Companies Inc.; 2013.