Gastrointestinal Anatomy and Physiology Part 2: The stomach: initial digestion and absorption Lumen of the GI tract is outside

tside the body If you fed an object into your mouth, it would eventually come out the other side The lumen of the GI tract is continuous with the outside of the body Perforation of the lumen is equivalent to having a perforation (i.e. knife stab wound) in the abdominal wall from the outside A knife wound to the abdomen is no different and no less serious than a perforation of the lumen of the intestine into the peritoneal cavity

Objectives Know how the peritoneum supports the contents of the abdominal cavity, as well as the blood and neural supply. o Sac supports contents and provides route for the blood and neural supply Understand the roles of the layers within the intestinal wall. Understand the digestion processes that occur in the stomach, the cells that regulate them. Understand the process of gastric emptying Key Concepts Digestion depends on both mechanical (ie stretch) and chemical (such as pH) stimuli. o Response to mechanical change in the stomach food arrives and stretches the stomach and stimulates digestion o When food arrives in the stomach it dilutes the acid (causes the pH to rise) and this stimulates digestion as well Digestion is controlled by both extrinsic and intrinsic nervous and hormonal input o Digestive system has its own intrinsic nervous input, but it is also effected by extrinsic nervous and hormonal inputs We all wear an apron

The Omentum is a large sheet of the peritoneum The peritoneal sac is entirely analogous to the pericardial sac o Two layer serousal sac o parietal layer adjacent to the wall of the abdominal cavity o visceral layer on the surface of the viscera large flap of the peritoneum covering the entire front area of the abdominal cavity (left) the Omentum it has been flipped up in the right picture it hangs off the transverse colon of the large colon

Sagittal view of the abdomen

Q. Q.

The omentum hangs down at the front It is a 4 layered sac o Do not bother to try and track the layers since this an artistic rendition o (cannot see it as clearly as the pericardial sac where you could see the parietal portion against the inside of the fibrous pericardium and then you could see how it looped around the top and became the visceral layer of the heart) The sac wraps around and supports the stomach, the colon (immediately below the stomach) There is a portion of it, called the mesentery, which supports the small intestine (loops that come out around the small intestine) There are different names for portions of the peritoneal sac greater omentum, lesser omentum, mesentery o Called the lesser omentum where it narrows near the liver Parietal peritoneum along the abdominal wall; visceral peritoneum against the organs Not all of the GI tract and the organs within the abdomen are within the peritoneal sac o A number are plastered against the rear wall of the abdominal cavity pancreas and duodenum (below the pancreas) o (between the parietal layer and the wall retroperitoneal behind the peritoneal) What holds the abdominal contents in place? The peritoneum What structure supports the intestinal vascular supply?

The peritoneum The nerves and the blood vessels follow this tract down to the various parts of the small intestine and other parts of the intestine as well

How does everything fit in there?

This shows the location of things There is the large colon with the ascending, transverse, and descending portion which ends up at the rectum Theres the small intestine in the middle The stomach has part or the lesser omentum wrapping over it (as well as the liver and gull bladder) In one of the movies you can see a lesion in the stomach that has gone right through to the gallbladder o The gallbladder lies right against the stomach

Abdomen -tranverse section at the level of pancreas

Inferior view of a transverse section Shows a number of the contents of the abdominal cavity The pylorus is the structure out of which the contents of the stomach come to go to the small intestine The two top corners of the large intestine can be seen The top end of the kidney can be seen and a little bit of the small intestine The top end of the dark structure that wraps around the body of the vertebral column is the bottom edge of the muscular of the diaphragm This section is cut fairly high at the level of the pancreas and just caught the bottom end of the diaphragm

The intestine has specialized layers

The layers are essentially the same the whole way through o There is an extra layer in the stomach Mucosa o Made up of the epithelium (stratified squamous layer that provides the closure and ability withstand some abrasion for the lining of the GI tract) o Lamina propria connective tissue (underlies the same was as the epidermis has dermis underneath) o Muscular muscosa does not have role in peristalsis; has a role to move the endothelium around to help clear it of any material that may come to rest Submucosa o Connective tissue that carries the blood vessels (like layer underlying the skin) o Carries the first of the nerve plexuses that look after the operation of the GI tract submucosal plexus Nerves the run from one end of the GI tract to the other Provides communication in terms of sensory input (changes in stretch or pH) o two muscular layers are immediately above that inner layer is circular muscle (wraps around) outer layer is longitudinal between these two layers is the second plexus of nerves myenteric plexus muscle plexus myo = muscle; teric = GI tract communicates with the submusucosal plexus major role in controlling the peristaltic waves stimulates the muscle to contract Adventia is the connective tissue on the outside of an organ called the Serosa here o The adventia is also the visceral layer of the peritoneum o Mesentery that supports part of the GI tract with vessels and nerves arising and coming along it, so it is referred to as the Serosa (but is one in the same as the adventia)

The intestines have a special nervous system

Picture intended to emphasize the nervous system at the wall of the intestine Brain of the GI tract (component that can function on its own in terms of regulating the process that can go on) Pacemaker cells Interstitial cells of Cajal o Controls the frequency of contractions of the muscle o Major research going on at mac about this Its internal nervous system is impinged upon by the Autonomic Nervous System

Sympathetic innervation

Q. What is the role of the sympathetic innervation of the intestinal tract? A. Reduce activity for Fight, Fright or Flight In a stress situation, the liver does not do nothing! The liver is where a lot of the readily available carbohydrate energy is stored (glucose stored as glycogen)

Under sympathetic innervation, breakdown of the glycogen occurs to yield glucose to be distributed into circulation to maintain activity in fight, flight, fright situation It isnt completely a case of having everything slowed down Energy is diverted from process of digestion though Cant automatically say the entire GI tract shuts down under sympathetic control

The vagus nerve -parasympathetic

Q. What is the role of the parasympathetic innervation of the intestine? A. SLUDD Salivation, Lacrimation, Urination, Digestion, Defecation (Rest and Rumination) Liver will be storing sugar that you are getting from diet as glycogen

Blood supply -1

Descending (abdominal) aorta Celiac Trunk provides circulation to a number of the organs in the GI tract

Superior Mesenteric artery and Inferior mesenteric artery provide blood supply to the intestines

Blood supply -2

The stomach has been lifted in this image (normally sitting in front of the pancreas) The celiac trunk gives rise to the hepatic artery (supplies blood to the liver) and gives rise to the right gastric artery There are anastomoses everywhere to limit the risk of tissues becoming ischemic Left gastric artery comes off the celiac trunk ; right gastric artery comes off the hepatic artery Do not need to know all the names: o Know Gastric runs around the small curvature Gastroepiploic runs around the large curvature Splenic Pancreaticoduodenal supplies the pancreas and duodenum Recognize the fact that they almost all have anastomoses Superior mesenteric supplies all of the small intestine and the ascending and transverse portion of the large intestine Inferior mesenteric artery supplies the descending portion of the large intestine

The intestinal venous drainage

There are matching veins The Veins do not go back to the inferior vena cava They go to the Hepatic Portal You can see the superior mesenteric vein coming up and there is a contact between it, the inferior mesenteric and the splenic vein in behind o They combine and take the nutrient rich blood directly to the liver Q. Why do all intestinal veins drain through the liver? A. Processing Centre It is the place where all the nutrients that have been collected from the small intestine are either transported for storage (sugars) or processing (amino acids)

The stomach is a blender

Organs do not have air spaces in them this picture makes it look like there is a space in the stomach (makes you think food falls to the bottom) In reality, when the stomach is empty the two walls are against each other with a little bit of fluid in between them Parts of the stomach o Lower esophageal sphincter o Cardia enterance way o Fundus large area that has a lot of folds along its inner surface Where the food arrives to Capable of stretching maximally to hold food Can get 1L of food into our stomach (large part of that accommodated in the fundus) o Body main area where digestion occurs o Pyloric area Pyloric antrum Pyloric acal Pyloric sphincter o Duodenum is beyond the pyloric area There is a difference between the wall structure of the stomach and the rest of the GI tract has a third layer of muscle o It is inside the other two o Therefore, longitudinal, then circular, and oblique o Rather than just squeezing to mechanically break down the food, it can twist

The rugae of the stomach

Coronal section You can see the rugae (the folds) of the stomach, primarily in the area of the fundus o Allows the expansion of the stomach to accommodate large quantities of food o Gets much smoother as you move further down

Endoscopy of normal stomach

In order to do endoscopy, air must be pumped into the stomach once the endoscope is beyond the esophagus o This is what makes endoscopy uncomfortable This stomach has been inflated not what the stomach usually looks like You can see the folds (rugae) in the fundus part and it is smoother as you go further down

The Stomach Is normally a very, very acid environment (pH 1.5-3.5) o Usually more down towards 1.5

Digests proteins. Breaks down, mixes and puts chyme into duodenum. o Mechanically o (ex. Hamburger is mashed up and the meat itself is broken down but fats will undergo very little breakdown) Produces one essential protein: intrinsic factor used in Vitamin B12 absorption o Important in the iluim to take up Vitamin B12 o Necessary for synthesis of red cells o Without Vitamin B12 you get Pernicious anemia Absorbs some drugs like alcohol and ASA (some drugs). o Well vascularized so you would expect some absorption

The gastric wall

The wall of the stomach is specialized to do its role Everything in the muscularis and submucosa is the same as the rest of the GI tract (but has an additional oblique muscle layer) The Mucosa varies There are pits with glands in the muscoa

In the pit

There is an upper portion where there are columnar cells o Unlike the esophagus which was just a transfer tube and had stratified squamous cells It is a simple layer of columnar cells o Columnar cells are classically cells that secrete something In the neck of the pit, they secrete a mucous which is rich in bicarbonate o The mucous protects the cells that line the stomach from the acid o It is a thick layer o The presence of the bicarbonate prevents the acid from affecting the cells below o These cells undergo rapid turnover constant flow of movement of cells up cells on the surface are constantly replenished to replace cells damaged by the acid The working part of the pit is in the area identified as the gastric gland o Contains three types of cells Parietal cell produced intrinsic factor and HCl Chief cells produce pepsinogen (inactive form of pepsin) Pepsinogen converted to pepsin in the presence of HCl You dont want an active protease inside the cell or it would break down the cell It is exposed to acid in the lumen and converted to pepsin so it can become active and break down the proteins Enteroendocrine Cells Major one is gastrin Produced in situations where the pH has risen Gastrin goes into the blood and stimulates the parietal cells to secrete more acid Gastrin Hormone used by the stomach to control the production of acid

Gastrin goes into the blood because in the area of the stomach, there is primarily parietal cells in the fundus In the area of the stomach towards the pylorus the proportion of enteroendocrine cells increases o Sends a message based on what its seeing in terms of the contents of the stomach and sending a message back up to the top of the stomach

How does the parietal cell make acid?

Gastrin produced by enteroendocrine cells stimulates the parietal cells to produce acid The receptors are on the basal side (adjacent to blood vessels) ACh arrives transmitter for parasympathetic nervous system in cases for rumination/digestion is required, parasympathetic system can turn on production of acid Internal second messenger transduction signaling gets an acid pump going Carbon dioxide and water forms carbonic acid which dissociates to a proton and bicarbonate (like it respiratory lecture)

The easiest way to get acid is to produce carbonic acid which will disassociate uses carbonic anhydrase which catalyzes the condensation of water and carbon dioxide to yield carbonic acid o Parietal cells are rich in carbonic anhydrase and produce large quantities of protons and bicarbonate o Protons are pumped by a specific pump requiring ATP energy into the lumen of the stomach in exchange for potassium which comes in o Potassium builds up in the cell and leaves through channels in the cell wall There is a lot of bicarbonate in the cell, it will follow the concentration gradient and move into blood and extracellular fluid through facilitated transport in exchange for chloride coming into the cell o The concentration of chloride builds up in the cell and there are channels in the parietal cells which allow the chloride to move out into the lumen Hydrogen and Chloride are both in the lumen so they form hydrochloric acid The apical surface (surface facing the stomach lumen) of the cells is very invaginated to maximize the surface area for these processes to occur The bicarbonate ends up in the blood and alcholonizes the blood (makes it more basic) o This doesnt matter because pancreatic fluid ends up putting protons into the blood and it balances out

Q. What is the role of the stomach in digestion? Three processes in terms of what goes on in the stomach o Cephalic Phase When we taste, smell, think about food a message is sent via the sympathetic nervous system to the stomach to tell it to get ready Starts the production of acid and gets things ready for food to arrive o Gastic Phase Stretch and rise in pH (dilution of acid) is detected Stimulates the production of gastin which stimulates the production of acid Based on the food arriving o Intestinal Phase Intestines only want to deal with so much at a given time

Feedback from the intestines as food moves from the stomach into the intestines which limits the amount of food that enters the intestine at any given time Handled by feedback with cholecystokinin

Why doesnt the stomach autodigest? The bicarbonate rich mucous secreted by the cells at the neck of the gland that prevent the acid from interacting with the cells at the surface If this mucous is damaged or effected you will get damage to the surface of the stomach Diseases of the stomach related to acid Acute gastritis (alcohol, NSAIDS non-steroidal anti-inflammatories [like cheap asprin]): loss of mucus layer/ bicarbonate Helicobacter pylori infection: loss of gastric function. Treatment is 85-95% effective to prevent recurrent ulcers o Buries itself in the mucous layer and effects the mucous o Treated with antibiotics and in many cases relieves ulcers The risk of ulcer formation is worsened by smoking, alcohol and stress. Acute Gastritis

The red dots are small bleeds in the wall due to the mucous layer not being continuous and acid getting through

Gastric ulcer

Probably caused by aspirin sitting on stomach wall The stomach wall has been eroded The green at the bottom is bile leaking in

Erosion has gone through stomach wall and through the wall of the gallbladder This is an emergency situation

Bleeding gastric ulcer

Blood spurting due to the erosion of the stomach wall down to the submucosa and blood vessels

Gastric Cancer

Gastric Emptying

Once the contents (ex. Of a hamburger) of have been turned around to physically break up the structure and the pepsin and acid have substantially broken down the protein it is time for the chyme that results to move to the small intestine and into the duodenum for absorption of the nutrients

Initially a new set of peristaltic waves occurs in the stomach to push the chyme towards the pylorus If the small intestine is ready to receive chyme the pyloric valve will open and a small amount of chyme will go into the first part of the duodenum The pyloric valve will close again and feedback from the duodenum will reduce the motility in the stomach until that batch of chyme has been processed in the duodenum at which point the process will occur again

Regulation of gastric emptying

Gives outline of process of initiation of the peristaltic wave that moves the material into the duodenum (combination of food being almost digested and parasympathetic input) The right side shows feedback from the duodenum that slows the activity and reduces motility of the stomach until the chyme has been moved through and processed

Control of gastric emptying Neural: the presence of neuronal NO allows the stomach to relax to accommodate up to 1 litre of food o Muscularature of pyloric valve is controlled by NO not nerves o Plays a central role in opening pyloric valve and relaxing the stomach Hormonal: gastrin and serotonin stimulate, VIP, GIP and somatostatin inhibit o Dont worry about VIP o GIP (Gastric Inhibitory Peptide) is a source of confusion used to be considered a hormone produced by the duodenum that fed back to inhibit gastric activity; turns out that that isnt what it is renamed it to glucose-dependent insulinotropic peptide (a hormone that is

produced by the duodenum when it has carbohydrates in it to stimulate insulin production by the pancreas switch that turns on insulin production in anticipation of blood glucose level rising) Somatostatin does inhibit gastric acivity

The duodenum controls the emptying based on content: o Carbohydrates, water easy (i.e. pasta, bread) easily processed by the small intestine material moves rapidly through the stomach into the intestine o Small amounts of acid Moves quickly If amount of acid is larger it will move more slowly o Fats enter very slowly Leaves stomach slowly This is what the fast food industry is based on The fattier the food is, the longer it will take the stomach to enter You need one relatively small-fatty hamburger and your stomach will be full for a long time (and therefore satisfied) Chinese food which is low in fat moves on quickly so you need to eat a much larger amount to remain satisfied for the same amount of time

Q. What common disease is associated with problems in gastric emptying? Vomiting goes the other way if it cant empty!

Why do we vomit? Extreme stretch, or irritants (bacterial toxins, excessive EtOH, certain foods, drugs) Under the above conditions, there is efferent stimulation of medulla. Afferent signals (from the medulla) to stimulate contraction of diaphragm and abdominal muscles, relaxation of Lower Esophageal Sphincter, closing of soft palate and epiglottis Pyloric stenosis Unless the inhibitory fibers at the pylorus develop and produce the inhibitory neurotransmitter NO (nitric oxide) the sphincter does not relax. o If the NO production is slow in developing the sphincter will not open and food will come flying out If it doesnt then the only place for gastric contents to go is up the esophagus and out (Stand back the projectile vomiting will cross the room). It is most common in first male babies (young boys) o Gives rise to projectile vomiting If mild wait; if severe treated by slitting the pyloric sphincter