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Physiology of the Colon and Defecation

8/22/2011 10:00 a.m.


I.

Large Intestine-Colon
A. Unique Features
1. Teniae Coli
a. Three bands of longitudinal smooth muscles in its muscularis
2. Haustra
a. Pocket like sacs caused by the tone of teniae coli
3. Epiploic Appendages
a. Fat filled pouches of visceral peritoneum
b. Functions as a cushion and blood reservoir
B. Histology
1. No villi or permanent circular folds in mucosa
2. Long thin intestinal glands
a. Columnar cells with microvilli for absorption
3. Solitary lymphatic nodules
C. Functions and Importance
1. Storage of ingestible food
a. Time Table for Food during Digestion
i. Stomach 2-6 hrs.
ii. Sm. Intestine 3-6 hrs.
iii. Lg. Intestine-12-72 hrs. longest
Chyme transitioned to feces
Water/Na+ absorbed
Egestion: removal of the feces through the anus by defecation
Indirect production of some vitamins, SCFAs
SCFAs are the energy source for the small intestine
2. Reabsorption of water and some electrolytes
a. Fluid and Electrolyte Transport in the Large intestine
i. < 90% of the fluid and Na+ entering the colon is absorbed
ii. Unlike small intestine, Na+ uptake under hormonal control (aldosterone)
Na+ sets up concentration gradient for water transport; this leads to solidification of
stools

3. Elimination of water products


4. Indirect production of some vitamins
5. Excretion of Feces

D. Bacterial Flora
1. Bacterial Flora of the Large Intestine Consist of
a. Bacterial surrounding the small intestine that enter the cecum and those entering via the
anus
2. Properties
a. Colonize the colon
b. Ferment ingestible carbohydrates
i. Undigested complex sugars are fermented by colonic bacteria Short Chain FA
Butyrate
Propionate
Acetate
ii. Utilize by colonic epithelium via beta oxidative pathways
Essential for nutrition for epithelial cells of large intestine
c. Release irritating acids and gases
d. Synthesize B complex vitamins and Vitamin K
e. Make up a large component of the feces
3. Commensalism relationship
E. Movement of Food and Waste
1. Sequence of Events
a. Chyme passage regulated by ileocecal sphincter valve generally closed
b. Slow passage following a mealGastroileal reflex
i. Gastroileal Reflex
Ileal motility increasessphincter relaxeschyme into cecumcecum becomes
fullsphincter contracts
ii. Colon movements start when chyme passes sphincter
Haustra relaxed: distended until full then contractsqueeze contents into next
haustrum
iii. Mass movements take over=Gastrocolic Reflex
During or immediately following a meal; 3-4 times day
They are strong peristaltic waves from middle of transverse colon that push contents
into the rectum
Rectum12 cm long, dilated near termination forming rectal ampulla
Entry of fecal matter into rectum triggers defecation reflex
2. Haustrations
a. Similar to segmentation but more marked and in anatomically pre-defined locations of
circular muscle layer
b. Governed by BER from interstitial cells ~6/min
3. Pelvic Floor Muscles: Levator Ani
a. Support the pelvic organs
b. Contraction causes urethral compressionhelps maintain continence during
c. Striated muscle fibersunder voluntary control
F. Defecation
1. Body Position
a. Sitting
i. To maintain continence the puborectalis muscle chokes the rectum
b. Squatting
i. Relaxes the puborectalis muscle and straightens the rectum
2. Normal Defecation
a. Full Rectum
i. Distention of the rectum stimulates stretch receptors in the rectal wall, pelvic floor and
upper anal canal
b. Adopt Correct posture
c. Raise intra-abdominal pressure
i. Exceeds that of the anal canal through straining
d. Internal and external anal sphincters relax
e. Rectum contract to expel stool
f. Should pass soft formed stool with minimal effort
i. Once initiated defecation either continuous or there is passage in bits preceded by
periodic straining
ii. Pattern influenced by stool consistency, size and individual habit
g. Sphincter

i. Snaps shut after completion


h. Normal
i. 3 times/day to 3 times/week
3. Control
a. Neural
i. Parasympathetic relaxes internal anal sphincter and puborectalis
b. Rectosphincteric Reflex and Defecation

4. Summary of Defecation
a. Sensation of stool in rectum
b. Internal anal sphincter relaxes
c. External anal sphincter relaxes
d. Puborectalis muscle relaxes
e. Rectum contracts
f. Abdominal muscles contract
g. Stool is expelled
5. Continence
a. Anal Sphincters
i. Provide structural integrity
ii. Internal Anal Sphincter
Passive stool retention
iii. External Anal Sphincter
Control of urge to stool
b. Pelvic floor contraction
c. Sensory function and co-ordination
d. Stool consistency (e.g. diet)
e. Gut motility
f. Emotional factors
g. Lifestyle and toilet access
6. The Sampling Reflex
a. Local, transient, relaxation of the internal anal sphincter allows recognition of rectal contents
by proximal anal mucosa
b. Sampling occurred between 4-10 times per hour in ambulatory studies of healthy individuals
G. Flatus
1. Emissions
a. 200-2000 ml/day
2. Composed of five gases
a. Nitrogen
b. Oxygen
c. Carbon dioxide
d. Hydrogen
e. Methane
3. Most swallowed air is eructed
4. Gases produced in the bowels lumen=CO2, H2, CH4

5. Odor
a. Ultimately governed by the kinds of bacteria that colonize within hours of newborns delivery
and persist throughout life
6. Noise
a. Loudness depends on volume of gas, the force of expulsion and the presence of hemorrhoids
or other resonating anatomic structures
7. Clinical complaints of re flatus promoted by disordered motility causing more gas to reflux back
into stomach as well as abdominal pain response to bowel distention
8. Rectal Valves
a. Separate feces from flatus, thus allowing gas to be passed
H. Feces
1. Brown due to bilirubin
a. Dark if blood or from foods high in Fe
b. Pale if high fat content
2. Odor due to indole, skatole, H2S
a. Result from decomposition of undigested food residue, unabsorbed AA, dead bacteria, cell
debris
3. In an upright person, gravity causes stools within the rectum to exert pressure on the anal
sphincter
a. But this effect of gravity is negated in supine patients, especially those confined to bed for
long periods of time, reducing the urge to defecate
II. GI Reflexes
A. Anal Wink
1. Reflexive contraction of external anal sphincter on touching/stimulation
2. Detected by nociceptors in perineal skinPudenal nerve
a. Response via S1-S3
B. Gastrocolic
1. Increase in colonic activity after a meal
2. Distention of the stomach stimulates evacuation of the colon
C. Enterogastric
1. Distention and irritation of the small intestine results in suppression of secretion and motor
activity in the stomach
D. Intestino-intestinal reflex
1. When a part of the intestine becomes overdistended or its mucosa becomes excessively
irritated, activity in other parts of the intestine is inhibited as long as the distention persists
E. Gastroileal Reflex
1. An increase in ileal motility and opening of the ileocecal valve when food enters the empty
stomach
III. Clinical Conditions
A. Diarrhea: an Osmotic Catastrophe
1. Watery stool resulting from any condition that rushes food residue through the large intestine
too quickly
2. Any condition that blocks water absorption
3. Causes
a. Malabsorbtion Diarrhea
i. Unabsorbable osmolytes in lumen
b. Genetics
i. E.g. Sugar Enzyme Disorder
c. Disease
i. E.g. Pancreatitis/Stones
d. Secretory Diarrhea (most common)
i. E.g. bacterial toxins
B. Incontinence
1. Loss of control of bowels retentive functionresulting in passive leakage
C. Ileus
1. Prolonged total GI transit times
D. Constipation
1. Prolonged colonic transit times, passage of small hard stool, painful passage (straining)
2. Physiologically Related Causes
a. Too dry feces due to absorption of water
b. Prolonged distention of the lg intestine

c.
d.
e.
f.
g.
h.

Ignoring the urge


Reduced intestinal motility
Obstruction (tumor or spasm)
Impairment of the defecation reflex
History of painful defecation and fear are contributing factors especially in children
Impaction with overflow diarrhea
i. Most common in frail dependent individuals
3. Pregnancy
a. High frequency
b. Progesterone decreases the motility of the gut
c. Stomach and intestines are displaced
d. More water and nutrients absorbed (gastric overloading and transit times increased
4. Diseases that involve Autonomic Neuropathology
a. Diabetes
b. Spinal cord disease
c. Chemotherapy
E. Nausea
1. Conscious Recognition of subconscious excitation in an area of the medulla closely associated
with the vomiting center
2. A Psychic Experience associated with
a. Decreased gastric motility and tone
b. Increased tone in the small intestine
c. There is often reverse peristalsis in the proximal small intestine with reflux of intestinal
contents into the stomach
d. Often perspiration, salivation, tachycardia, anorexia, headache
F. Retching
1. Dry heaves
2. Spasmodic inspiration against a closed airway or glottis
3. The effort decreases intrapulmonary and intrathoracic pressures
4. Antrum of the stomach contracts; fundus and cardia relax
5. Mechanics of Retching
a. Inspiration on partially closed glottis
b. LOW intrathoracic pressure
c. HIGH intraabdominal pressure
d. CLOSED hypopharyngeal sphincter
e. RELAXED lower esophageal sphincter
f. RELAXED body of stomach
g. SPASM antrum and duodenum
G. Vomiting
1. Two major cerebral centers: **** BOTH cause vomiting when stimulated
a. Chemoreceptor trigger zone (CTZ)
i. Near the medulla
ii. Receives impulse from drugs, toxins and vestibular center
iii. Dopamine stimulates the CTZ which stimulates the vomiting center
b. Vomiting Center
i. In the medulla
ii. Stimulated by CTZ
iii. When triggered motor neuron respondcontraction of diaphragm, anterior abdominal
muscles & stomach.
iv. Glottis closes the abdominal wall moves upward and vomiting occurs
v. Other Inputs to the vomiting center
Higher cortical centers
Disturbed vestibular function
Stimulation of CN VIIIstimulation of vomiting center
2. Triggered by one or more of the following stimuli
a. Excessive gastric or duodenal distension
b. Noxious substances in stomach
c. Certain smells or sights
d. Emotional factors
e. Endocrine factors
i. E.g. estrogen morning sickness

f.
g.
h.
i.
3.

4.

5.

6.

Migraine
Touch receptors at back of throat
Reflexes involving semi-circular canals motion sickness
Stimulation of the chemoreceptor trigger zone by circulating emetics
i. Near to the GI vagal nuclei
Sequence of Events
a. Deep Inspiration
b. Closure of Glottis
c. Relaxation of LES
d. Contraction of diaphragm an abdominal muscles causes increased intra-thoracic and intraabdominal pressure
i. Diaphragm descends
e. Rapid rise in intragastric pressure causes reverse expulsion of gastric contents
f. Accompanied by generalized autonomic effects
i. Sympathetic effects
Sweating, pallor, increased respiration, and heart rate, dilation of pupils
ii. Parasympathetic Affects
Profuse salivation, pronounced motility of the esophagus, stomach and duodenum
Relaxation of the esophageal sphincters
Complications of Vomiting
a. Acid base derangements
b. Volume and electrolyte depletion
c. Malnutrition
d. Aspiration pneumonia
Classifications
a. By Nature
i. Projectile Forceful Vomiting
Increased intracranial pressure, pyloric stenosis
ii. Nonprojectile
b. Quality
i. Bilious (dark green indicating bile)
ii. Bloody (hematemesis)
iii. Clear or yellow with remnant of food
Related Body Changes with Vomiting
a. Marked changes in the circulatory system and interference with respiration
i. A sudden drop in blood pressure with cardiac inhibition at the moment of emesis (Vagal)
ii. A feeling of fainting or light headiness