Skenario 1: Perjalanan makanan dalam saluran cerna

Untuk trigger tutorial 1, perhatikan video dibawah ini melalui link:

https://www.youtube.com/watch?v=5ufESc1bK78

Pertanyaan pemicu:

1. Proses apa saja yang dialami oleh makanan di dalam saluran cerna?
2. Bagaimanakah makanan dapat melewati satu bagian saluran cerna ke bagian berikutnya?
3. Bagaimanakah makanan bisa sampai ke jaringan target?

Keywords: motilitas, pencernaan, enzim, suplai darah, villi

Tujuan Belajar
Mahasiswa mampu menjelaskan prinsip dasar fungsi saluran gastrointestinal, termasuk:
1. Motilitas usus
• Menjelaskan prinsip umum motilitas usus
• Menyebutkan lapisan otot pada dinding saluran cerna dan fungsinya masing-masing
• Menjelaskan mekanisme pembangkitan aktivitas listrik pada otot saluran cerna
• Menjelaskan peran ion kalsium dalam kontraksi otot saluran cerna
• Memahami jenis-jenis gerakan fungsional saluran cerna: gerakan propulsif dan
mencampur
2. Proses pencernaan pada setiap bagian saluran gastrointestinal (pencernaan karbohidrat,
protein dan lemak)
• Menjelaskan proses pencernaan karbohidrat
• Menjelaskan proses pencernaan lemak
• Menjelaskan proses pencernaan protein
3. Mekanisme transportasi and absorpsi pada setiap bagian dalam saluran gastrointestinal
• Menjelaskan mekanisme transportasi dan absorpsi air dan elektrolit

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 4. Menjelaskan fisiologi defekasi
• Menjelaskan terjadinya proses defekasi (refleks defekasi)
• Menjelaskan komposisi fisiologis feses
5. Aktivitas flora usus: Fermentasi glukosa

Pembahasan:
1. Proses apa saja yang dialami oleh makanan di dalam saluran cerna?

Process that happened in gastrointestinal tract are:

a. Ingestion of food
The amount of food that a person ingests is determined principally by intrinsic desire for food
called hunger.The type of food that a person preferentially seeks is determined by appetite.
This proccess including mastication (chewing) and swallowing.

Mastication (chewing)

The teeth are admirably designed for chewing, the anterior teeth (incisors) providing a strong
cutting action and the posterior teeth (molars), a grinding action. All the jaw muscles
working together can close the teeth with a force as great as 55 pounds on the incisors and
200 pounds on the molars. Most of the muscles of chewing are innervated by the motor
branch of the fifth cranial nerve, and the chewing process is controlled by nuclei in the brain
stem. Much of the chewing process is caused by a chewing reflex. Chewing is important for
digestion of all foods, but especially important formost fruits and raw vegetables because
these have indigestible cellulose membranes around their nutrient portions that must be
broken before the food can be digested. Also, chewing aids the digestion of food for still
another simple reason: Digestive enzymes act only on the surfaces of food particles.

Swallowing (deglutition)

Swallowing is a complicated mechanism, principally because the pharynx sub-serves

respiration as well as swallowing. The pharynx is converted for only a few seconds at a time
into a tract for propulsion of food. It is especially important that respiration not be
compromised because of swallowing. In general, swallowing can be divided into (1) a
voluntary stage, which initiates the swallowing process; (2) a pharyngeal stage, which is
involuntary and constitutes passage of food through the pharynx into the esophagus; and (3)
an esophageal stage, another involuntary phase that transports food from the pharynx to the
stomach.

b. Digestion
The aim of this process is breaking down macronutrient (carbohydrates, lipid and protein)
becomes smaller then can be absorbed in GIT.
Digestion of carbohydrates in mouth and stomach

When food is chewed, it is mixed with saliva, which contains the digestive enzyme ptyalin (an
a-amylase) secreted mainly by the parotid glands. This enzyme hydrolyzes

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starch into the disaccharide maltose and other small polymers of glucose that contain three
to nine glucose molecules. However, starch digestion sometimes continues in the body and
fundus of the stomach for as long as 1 hour before the food becomes mixed with the
stomach secretions.

Figure 1.3 Digestion of carbohydrates

Digestion of protein in stomach and upper small intestine

One of the important features of pepsin (the important peptic enzyme of the stomach)
digestion is its ability to digest the protein collagen, an albuminoid type of protein that is
affected little by other digestive enzymes. Collagen is a major constituent of the intercellular
connective tissue of meats; therefore, for the digestive enzymes of the digestive tract to
penetrate meats and digest the other meat proteins, it is first necessary that the collagen
fibers be digested. pepsin only initiates the process of protein digestion, usually providing
only 10 to 20 per cent of the total protein digestion to convert the protein to proteoses,
peptones, and a few polypeptides. This splitting of proteins occurs as a result of hydrolysis at
the peptide linkages between amino acids. Most protein digestion occurs in the upper small
intestine, in the duodenum and jejunum, under the influence of proteolytic enzymes from
pancreatic secretion. The last digestive stage of the proteins in the intestinal lumen is
achieved by the enterocytes that line the villi of the small intestine, mainly in the duodenum
and jejunum.These cells have a brush border that consists of hundreds of microvilli projecting
from the surface of each cell.

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Figure 1.4 Digestion of proteins

Digestion of lipid in small intestine

A small amount of triglycerides is digested in the stomach by lingual lipase that is secreted by
lingual glands in the mouth and swallowed with the saliva. This amount of digestion is less
than 10 per cent and generally unimportant. Instead, essentially all fat digestion occurs in
the small intestine as follows.

Emulsification of Fat by Bile Acids and Lecithin.The first step in fat digestion is physically to
break the fat globules into very small sizes so that the water-soluble digestive enzymes can
act on the globule surfaces.This process is called emulsification of the fat, and it begins by
agitation in the stomach to mix the fat with the products of stomach digestion. Then, most of
the emulsification occurs in the duodenum under the influence of bile, the secretion from the
liver that does not contain any digestive enzymes. However, bile does contain a large
quantity of bile salts as well as the phospholipid lecithin.

Digestion of Triglycerides by Pancreatic Lipase. By far the most important enzyme for
digestion of the triglycerides is pancreatic lipase, present in enormous quantities in
pancreatic juice, enough to digest within 1minute all triglycerides that it can reach. In
addition, the enterocytes of the small intestine contain still more lipase, known as enteric
lipase, but this is usually not needed. Most of the triglycerides of the diet are split by
pancreatic lipase into free fatty acids and 2-monoglycerides.

Figure 1.5 Digestion of fats

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 c. Absorption
Absorption in small and large intestine

Absorption from the small intestine each day consists of several hundred grams of
carbohydrates, 100 or more grams of fat, 50 to 100 grams of amino acids, 50 to 100 grams
of ions, and 7 to 8 liters of water. The absorptive capacity of the normal small intestine is far
greater than this: as much as several kilograms of carbohydrates per day, 500 grams of fat
per day, 500 to 700 grams of proteins per day, and 20 or more liters of water per
day.Thelarge intestine can absorb still additional water and ions, although very few
nutrients.

About 1500 milliliters of chyme normally pass through the ileocecal valve into the large
intestine each day. Most of the water and electrolytes in this chyme are absorbed in the
colon, usually leaving less than 100 milliliters of fluid to be excreted in the feces. Also,
essentially all the ions are absorbed, leaving only 1 to 5 milliequivalents each of sodium and
chloride ions to be lost in the feces. Most of the absorption in the large intestine occurs in the
proximal one half of the colon, giving this portion the name absorbing colon, whereas the
distal colon functions principally for feces storage until a propitious time for feces excretion
and is therefore called the storage colon.

The proccess in GI tract depends on these folowing :

(1) movement of food through the alimentary tract;
(2) secretion of digestive juices and digestion of the food;
(3) absorption of water, various electrolytes, and digestive products;
(4) circulation of blood through the gastrointestinal organs to carry away the absorbed
substances; and
(5) control of all these functions by local, nervous, and hormonal systems

2. Bagaimanakah makanan dapat melewati satu bagian saluran cerna ke bagian berikutnya?

Motilitas saluran cerna melibatkan gerakan peristaltik, segmentasi dan pengadukan

(peristalsis and segmentation & mixing). Terdapat 2 pola gerakan saluran cerna yakni: peristaltik dan
segmentasi – pencampuran (Guyton & Hall, 2006).

Peristaltic is a reflex response that is initiated when the gut wall is stretched by the contents of the
lumen, and it occurs in all parts of the gastrointestinal tract from the esophagus to the rectum. The
stretch initiates a circular contraction behind the stimulus and an area of relaxation in front of it. The
wave of contraction then moves in an oral-to-caudal direction, propelling the contents of the lumen
forward at rates thatvary from 2 to 25 cm/s. Peristaltic activity can be increased or decreased by the
autonomic input to the gut, but its occurrence is independent of the extrinsic innervation.

Segmentation and mixing is designed to retard the movement of the intestinal contents along the
length of the intestinal tract to provide time for digestion and absorption. It is promoted by enteric
nervous system when the meal is present. This motility pattern is known as segmentation, and it
provides for ample mixing of the intestinal contents (known as chyme) with the digestive juices. A
segment of bowel contracts at both ends, and then a second contraction occurs in the center of the

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segment to force the chyme both backward and forward. Unlike peristalsis, therefore, retrograde
movement of the chyme occurs routinely inthe setting of segmentation. This mixing pattern persists
for as long as nutrients remain in the lumen to be absorbed. It can occur independent of central
input, although the input from CNS can modulate it. In general, contraction and relaxation in motility
pattern are due to smooth muscle in gastrointestinal tract wall and neuronal innervation of the wall.

Figure 1.6 Patterns of gastrointestinal motility and propultion

GI smooth muscles work as a syncytium, that is, when an action potential is elicited anywhere within
the muscle mass, it generally travels in all directions since they are electrically connected with one
another through large numbers of gap junctions that allow low-resistance movement of ions from
one muscle cell to the next. Therefore, electrical signals that initiate muscle contractions can travel
readily from one fiber to the next within each bundle but more rapidly along the length of the bundle
than sideways. In addition to the gap junction, each bundle of smooth fuse with one another at many
points, so that in reality each muscle layer represents a branching latticework of smooth muscle
bundles.

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Cross sectioned figure of GI tract wall is showed in figure below :

Figure 1. 7 Typical cross-section of the gut.

Read also : electrical activity of smooth muscle wall in Guyton.

3. Bagaimanakah makanan bisa sampai ke jaringan target?

Transportation: Absorbed substances are carried away from gastrointestinal organs by means of
blood circulation and lymphatic circulation. The blood vessels of the gastrointestinal system are part
of a more extensive system called the splanchnic circulation. It includes the blood flow through the
gut itself plus blood flows through the spleen, pancreas, and liver.The design of this system is such
that all the blood that courses through the gut, spleen, and pancreas then flows immediately into the
liver by way of the portal vein. In the liver, the blood passes through millions of minute liver sinusoids
and finally leaves the liver by way of hepatic veins that empty into the vena cava of the general
circulation.

The nonfat, water-soluble nutrients absorbed from the gut (such as carbohydrates and proteins) are
transported in the portal venous blood to the same liver sinusoids. Here, both the reticuloendothelial
cells and the principal parenchymal cells of the liver, the hepatic cells, absorb and store temporarily
from one half to three quarters of the nutrients.

Almost all of the fats absorbed from the intestinal tract are not carried in the portal blood but instead
are absorbed into the intestinal lymphatics and then conducted to the systemic circulating blood by
way of the thoracic duct, bypassing the liver.

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Figure 1.8 Splanchnic circulation

Functions of GI system are regulated in an integrated manner to ensure efficient assimilation of

nutrients after meal. There are three main modalities of gastrointestinal regulation; endocrine,
paracrine and neuronal regulation.

a. Endocrine : Endocrine regulation is mediated by the release of hormones by triggers

associated with the meal. These hormones travel to the bloodstream to change the
activity of a distant segment of the gastrointestinal tract, an organ draining to it, or
both.
Gastrointestinal hormones are biologically active polypeptide that are secreted by nerve
cells and glands in the mucosa. They act in both paracrine and endocrine fashion to
regulate gastrointestinal secretion and motility. On the basis of structural and function
similarity, they can divided to two key hormones; Gastrin family (Gastrin and
Cholecystokinin) and Secretin family (Secretin, glucagon,glicentin, VIP, and GIP). There
are also other hormones that do not readily fall into these categories.
b. Paracrine : Substances or mediators that alter the function of cells in the local area
where they are released.

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Table 2.1. Hormones/paracrine involved in regulation of GI tract
Hormone Produced by Function Factors stimulate secretion Factors inhibit secretion
/Paracrine
Gastrin G cells (antrum) • To stimulate gastric acid secretion • Gastric content : peptide & Gastric content : Acid,
• To stimulate pepsin secretion amino acid, distention of Somatostatin
• To stimulate mucosal growth in stomach, small & large stomach
intestines Blood borne factor :
• Increased vagal discharge Secretin, GIP, VIP,
Glucagon, Calcitonin
• Blood borne factor :Ca ,
++

Epinephrine
Cholecystokinin Mucosal I cells in PRIMARY • Mucosal contact with Emptying of intestine
upper small peptides and amino acid lumen
intestines • To stimulate secretions of pancreatic enzymes • Presence of fatty acid
• To stimulate contraction of gallbladder (medium and long chain)
• To relax Sphicter of Oddi • CCk releasing peptide
ADDITIONAL • Monitor peptide
• Product of protein and fat
• To stimulate secretion of alkaline pancreatic juices digestion (positive
(augments action of secretin) feedback)
• To inhibit gastric emptying
• Tropic effect on pancreas
• To increase synthesis of Enterokinase,
• To enhance motility of small intestine and colon
Secretin S cells in upper small • To increase bicarbonate secretion by duct cells in pancreas • Product of protein
intestines and biliary tract digestion and bathing of
• To augment function of CCK in stimulating secretion of gastric acid in upper small
pancreatic enzyme intestine
• To decrease gastric acid secretion
• Causing contraction of pyloric sphincter
GIP K cells in duodenum Inhibition of gastric secretion and gastric motility Glucose and fat in duodenum
and jejunum mucosa Stimulate insulin secretion and jejunum

VIP Vasoactive Intestinal Peptide is not a hormon. It is found in nerves in

gastrointestinal tract, blood, brain and autonomous nerve. In gastrointestinal tract,

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 its function are:
• Stimulation secretion of electrolyte and water.
• Induction of relaxation of intestinal muscle (sphincter), dilatation of
peripheral blood vessels
• Inhibition gastric aacid secretion
• Potentiation action of Acetylcholine in salivary glands

Motilin Enterochromaffin • Production of smooth muscle contraction in stomach Ingestion of food

cells and Mo cells in and intestines
stomach, small • Regulation of Migrating Motor Complexes (MMC) that
intestine, and colon control gastrointestinal motility between meals
Somatostatin Paracrine D cells in Act in paracrine fashion to inhibit : Acid in the intestinal lumen
(GHIH, originally is pancreatic islet and • secretion of Gastrin,
found in D cells in • pancreatic exocrine secretion,
hypothalamus) gastrointestinal • gastric acid secretion and motility,
mucosa • gallbladder contraction,
• absorption of glucose, aminoacids and triglycerides

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Figure 1.9 Integrated action of gastrointestinal hormones in regulating digestion and
utilization of absorbed nutrients.

c. Neuronal : Neuronal control consists of extrinsic innervation and enteric innervation

Extrinsic innervation originated from central nervous system. The intestine receives a
dual extrinsic innervation from the autonomic nervous system, with parasympathetic
cholinergic activity generally increasing the activity of intestinal smooth muscle and
sympathetic noradrenergic activity generally decreasing it while causing sphincters to
contract.

The preganglionic parasympathetic fibers consist of about 2000 vagal efferents and
other efferents in the sacral nerves. They generally end on cholinergic nerve cells of the
myenteric and submucous plexuses.

The sympathetic fibers are postganglionic, but many of them end on postganglionic
cholinergic neurons, where the norepinephrine they secrete inhibits acetylcholine
secretion by activating α2 presynaptic receptors. Other sympathetic fibers appear to end
directly on intestinal smooth muscle cells. Still other fibers innervate blood vessels, where
they produce vasoconstriction. It appears that the intestinal blood vessels have a dual
innervation: They have an extrinsic noradrenergic innervation and an intrinsic
innervation by fibers of the enteric nervous system. VIP and NO are among the mediators
in the intrinsic innervation, which seems, among other things, to be responsible for the

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 hyperemia that accompanies digestion of food. It is unsettled whether the blood vessels
have an additional cholinergic innervation.

Autonomous enteric nervous system comprises both sensory and secreto-motor neuron.
This enteric nervous system can integrate central input to the gut, but also can regulate
gut function independently in response to changes in the luminal environment. Enteric
nervous system consist of themyenteric plexus (Auerbach’s plexus), located between the
outer longitudinal and middle circular muscle layers, and the submucous plexus
(Meissner’s plexus), between the middle circular layer and the mucosa. It is connected to
the CNS by parasympathetic andsympathetic fibers but can function autonomously
without these connections .

The myenteric plexus innervates the longitudinal and circular smooth muscle layers and
is concerned primarily with motor control, whereas the submucous plexus innervates the
glandular epithelium, intestinal endocrine cells, and submucosal blood vessels and is
primarily involved in the control of intestinal secretion.

Figure 1.10 Neural control of the gut wall.

Histologi dinding saluran pencernaan

Lapisan-lapisan dinding saluran pencernaan dari luar sampai ke dalam: lapisan serosa, lapisan otot
longitudinal, lapisan otot sirkuler, lapisan submukosa, lapisan mukosa. Selain itu, terdapat berkas
tipis serabut-serabut otot polos, yaitu otot mukosa yang terletak di lapisan paling dalam dari
mukosa. Fungsi motorik dari usus diselenggarakan oleh berbagai lapisan otot polos nadi (Guyton,
2007).

Pembungkus jaringan ikat di sebelah luar saluran cerna adalah serosa, yang mengeluarkan cairan
serosa encer yang meluminasi dan mencegah gesekan antara organ-organ pencernaan dan visera di
sekitarnya. Di sepanjang saluran pencernaan, serosa berhubungan dengan mesenterium, yang
menggantung organ-organ pencernaan ke dinding dalam rongga abdomen seperti sebuah ayunan
(Sherwood, 2001).

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Lapisan muskularis eksterna, lapisan otot polos utama di saluran pencernaan, mengelilingi
submukosa. Di sebagian besar saluran pencernan, lapisan isi terdiri dari bagian lapisan sirkuler dalam
dan lapisan longitudinal luar. Bersama-sama aktivitas kontraksi otot polos menghasilkan gerakan
propulsif dan mencampur (Sherwood, 2001).

Submukosa adalah lapisan tebal jaringan ikat yang menyebabkan saluran pencernaan memiliki
elastisitas dan distensibilitas. Lapisan ini memiliki pembluh darah dan limfe yang besar, juga terdapat
jaringan saraf yang dikenal sebagai pleksus submukosa, yang membantu mengontrol aktivitas lokal
masing-masing bagian usus (Sherwood, 2001). Mukosa melapisi permukaan luminal saluran
pencernaan. Bagian ini dibagi menjadi tiga lapisan:
a. Komponen utama mukosa adalah membran mukosa, suatu lapisan epitel bagian dalam yang
berfungsi sebagai permukaan protektif serta mengalami modifikasi di daerah-daerah
tertentu untuk sekresi dan absorbsi. Membran mukosa mengandung sel eksokrin untuk
sekresi getah pencernaan, sel endokrin untuk sekresi hormon saluran pencernaan dan sel
epitel yang khusus untuk penyerapan nutrien.
b. Lamina propia adalah lapisan tengah jaringan ikat tipis tempat epitel melekat. Lapisan ini
mengandung gut assosiated lymphoid tissue (GALT).
c. Mukosa muskularis adalah lapisan otot polos di sebelah luar yang terletak di sebelah lapisan
sub mukosa (Sherwood, 2001).

Pada bagian lambung lapisan dindingnya tersusun atas empat lapisan:

a. Tunika serosa atau lapisan luar merupakan bagian dari peritonium viseralis.
b. Tunika muskularis, tersusun atas tiga lapis otot polos, yaitu lapisan longitudinal bagian luar,
lapisan sirkuler di tengah dan lapisan oblik di bagian dalam.
c. Lapisan submukosa, tersusun atas jaringan areolar longga yang membungkus lapisan
mukosa dan lapisan muskularis.
d. Lapisan mukosa, tersusun atas lipatan-lipatan longitudinal (rugae), memungkinkan
terjadinya distensi lambung sewaktu diisi makanan. (Wilson et al, 2007).

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Referensi:

Guyton, A. C., J. E. Hall. (2007) Buku Ajar Fisiologi Kedokteran. Edisi 11. Terjemahan Irawati, et.al.
Jakarta : Penerbit Buku Kedokteran EGC.

Guyton, A. C., J. E. Hall. (2006) Textbook of Medical Physiology, 11th edition. Elsevier Saunders,
Philadelphia. Chapter 62: General Principles of Gastrointestinal Function – Motility, Nervous
Control, and Blood Circulation, p771-80.

Guyton, A. C., J. E. Hall. (2006) Textbook of Medical Physiology, 11th edition. Elsevier Saunders,
Philadelphia. Chapter 63: Propulsion and Mixing of Food in the Alimentary Tract, p781-90.

Guyton, A. C., J. E. Hall. (2006) Textbook of Medical Physiology, 11th edition. Elsevier Saunders,
Philadelphia. Chapter 64: Secretory Function of the Alimentary Tract, p791-807.

Lynn S. Bickley. (2009) “Bates” Buku Ajar Pemeriksaan Fisik dan Riwayat Kesehatan. Jakarta : EGC

Price, Sylvia, Lorraine M. Wilson. (2006) Patofisiologi Konsep Klinis Proses Penyakit, Vol. 1, Ed. 6,
Penerbit Buku Kedokteran EGC, Jakarta

Saladin (2007) Anatomy & Physiology: The Unity of Form and Function, 4th edition. McGraw Hill Co,
New York. Chapter 25: The Digestive System, p940-68 and p974-79.

Sherwood, Lauralee. (2001) Fisiologi Manusia dari Sel ke Sistem, Ed. 2, Penerbit Buku Kedokteran
EGC

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