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Anatomy and Physiology of

the Gastrointestinal Tract

John P. Grant, MD, CNSP


Director Nutrition Support
Service
Professor of Surgery
Duke University Medical
Center
Durham, NC
Specialty Examination
Rule of thirds:

1/3 of questions are simple no study needed.

1/3 of questions you will answer from experience.

1/3 of questions you will not know, studying will

not help (with combination of studying and

experience you can make an educated guess in

1/3).
What are the Functions of the Gut?

Digestion

Process by which large molecules in


diet are broken down into smaller ones,
which are acceptable to the
enterocytes for absorption.
What are the Functions of the Gut?

Absorption

Process by which contents of the small


bowel enter the mucosal epithelial
cells, and eventually the portal vein or
lymphatics.
What are the Functions of the Gut?

Protection

Barrier to entry of pathogens and


toxins
Digestion and Absorption - ???
1. What digestive process does not occur
in the oropharynx?
A. Micelles are formed with fat
B. Salivary -amylase degrades starch
C. Pharyngeal lipase hydrolyzes triglycerides
to diglycerides and fatty acids
D. Food particles are mechanically broken up
Digestion and Absorption - ???
1. What digestive process does not occur
in the oropharynx?
A. Micelles are formed with fat
B. Salivary -amylase degrades starch
C. Pharyngeal lipase hydrolyzes triglycerides
to diglycerides and fatty acids
D. Food particles are mechanically broken up
Anatomy and Physiology of
Digestive System - Mouth
Mouth - Digestive Action
Food mechanically broken down

Saliva - normally about 25 ml/hr is


secreted, increases up to 300 ml per
hour with eating

Salivary -amylase degrades starch,


-amylase is deactivated by gastric acid
Anatomy and Physiology of
Digestive System - Mouth
Mouth - Protective Action
Preventive bacteria in the mouth are important
for defense against invading microorganisms
Contains specific antimicrobial proteins like
lysozyme, lactoferrin and lactoperoxidase, but
also mucin, IgA, and nitric oxide-donating
substances such as nitrates
Mucus covers food and follows it to colon. It can
attach to mucosal surfaces and forms protective
barrier
Anatomy and Physiology of
Digestive System - Mouth
Inhibition of Saliva
Anticholinergics, analgesics,
antispasmodics, antidiarrheals,
antidepressants, antihistamines,
antihypertensives, antipsychotics,
and diuretics

Stimulation of Saliva
Pilocarpine 5mg po tid
Anatomy and Physiology of
Digestive System - Esophagus

Esophagus

Transports food to stomach

Pharyngeal lipase hydrolyzes


triglycerides to diglycerides and fatty
acids
Anatomy and Physiology of
Digestive System - Stomach

Stomach: F
Gastroesophageal
Junction u
Cardia

Stores, mixes,
n
d
Incisura Body u

and grinds s

Pylorus Antrum
food to form
Duodenal
an emulsion Bulb
Anatomy and Physiology of
Digestive System - Stomach
Hydrochloric acid
from parietal cells Surface Epithelial Cell

denatures protein Mucous Cell

Pepsinogen Parietal Cell

(Pepsin) from
zymogen (chief) Zymogen Cell
Lymph Nodule
Argentaffine Cell

cells begins Muscularis Mucosae

Submucosa

proteolysis
Pyloric Glands
Gastric or Fundic Glands
Anatomy and Physiology of
Digestive System - Stomach

Pepsin Acid Gastric lumen


pH 1-3

Bicarbonate / Mucus Mucous gel


pH 7
layer

Gastric mucosa

Zymogen Mucous Parietal


Cell Cell Cell
Anatomy and Physiology of
Digestive System - Small
Bowel
Small Intestine - averages around
5 meters in length
Duodenum: ~10 long, 2 in
diameter
Jejunum: ~ 2/5 length of rest of
small bowel, 1 to 1 in
diameter, thick, many blood
vessels.
Ileum: ~3/5 length, 1 to 1
diameter, thin wall, large
Peyers patches
Anatomy and Physiology of
Digestive System - Small
Bowel
Small Intestine
Major organ for nutrient absorption

Absorptive surface enhanced by plicae


circulares, foldings called villi with surface
projections called microvilli
Final surface area about 1.7 m cm2

About 800 cm2 to absorb 1 Kcal (100-200


cm2/Kcal minimum)
Anatomy and Physiology of
Digestive System - Small
Bowel
Plica circularis or
Valve of Kerckring

Villus

Jejunum Ileum
Digestion and Absorption - ???
Poor question

2. The absorptive surface of the normal


small intestine is equal to:

A. 3 tennis courts
B. 5 tennis courts
C. 1 tennis court
D. 10 tennis
courts
Digestion and Absorption - ???
Poor question

2. The absorptive surface of the normal


small intestine is equal to:

A. 3 tennis courts
B. 5 tennis courts
C. 1 tennis court
D. 10 tennis
courts
Digestion and Absorption - ???
Poor question

3. How much small intestine can be


removed before a patient will develop
short bowel syndrome?

A. 1/3 C. 2/3
B. 1/2 D. 3/4
Digestion and Absorption - ???
Poor question

3. How much small intestine can be


removed before a patient will develop
short bowel syndrome?

A. 1/3 C. 2/3
B. 1/2 D. 3/4
Digestion and Absorption - ???
It is always better to know the amount of bowel
remaining following surgical resection rather than
the amount resectedBetter question:
A patient is likely to, but not always, require
HTPN if only the following amount of small
bowel can be saved at the time of surgery:

A. 10 feet C. 3 feet
B. 5 feet D. 1 foot
Digestion and Absorption - ???
It is always better to know the amount of bowel
remaining following surgical resection rather than
the amount resectedBetter question:
A patient is likely to, but not always, require
HTPN if only the following amount of small
bowel can be saved at the time of surgery:

A. 10 feet C. 3 feet
B. 5 feet D. 1 foot
Digestion and Absorption

There is a high probability of transitioning


patients off HTPN if the ratio of remaining
intestinal length to body weight is: > 0.5
cm/kg

ie: > 40 cm for an 80 kg patient

Wilmore, et al., Ann. Surg., 226:288-293, 1997


Anatomy and Physiology of
Digestive System - Colon
Absorbs water and
electrolytes
Stores waste
Organ within an Organ
Colonic microflora
ferment malabsorbed
nutrients and soluble
fiber to a form the
colonic mucosa can
Nutrient Absorption
Sites of Nutrient
Absorption
Sites of Nutrient
Absorption
Good question

5. What nutrient
deficiency might be
expected if 3 feet
of the terminal
ileum is resected?

A. Iron C. Vit B-12


B. D.
Magnesium Calcium
Sites of Nutrient
Absorption
Good question

5. What nutrient
deficiency might be
expected if 3 feet
of the terminal
ileum is resected?

C. Vit B-
A. Iron
12
B. D.
Magnesium Calcium
Sites of Nutrient
Absorption
Much harder
question
6. What nutrient
deficiency might be
expected if 3 feet
of the terminal
ileum is resected?

C. Vit B-
A. Iron
12
B.
D. Fat
Magnesium
Absorption of Water

8 L/day fluid reaches the small intestine


of which about 2 L is dietary in origin

Small bowel absorbs about 7 L/d,


mainly in jejunum, colon absorbs 1 to
1.5 L/d (can increase absorption up to 4
L/d)
Digestion and Absorption - ???

7. Water absorption by the small bowel may be


enhanced by adding the following to the enteral
formula:

C. Magnesium
A. Zinc Sulfate
Chloride
B. Sodium Chloride D.Medium-Chain Fat
Digestion and Absorption - ???

7. Water absorption by the small bowel may be


enhanced by adding the following to the enteral
formula:

C. Magnesium
A. Zinc Sulfate
Chloride
B. Sodium Chloride D.Medium-Chain Fat
Absorption of Water

Water absorption is entirely passive - follows


absorption of solutes (can move in either
direction, depending on osmotic gradients)
Particularly true of the solute Na +
High sodium enteral diets enhance water
absorption
Low sodium diets predispose to diarrhea
Absorption of Sodium and
Chloride - Small Bowel
Sodium absorption
is directly coupled
to absorption of
organic solutes
such as glucose,
amino acids, water-
soluble vitamins,
and bile salts
Absorption of Sodium and
Chloride - Small Bowel
Once inside cell,
sodium is extruded
against chemical and
electrical gradient
via a basolateral
membrane-
associated
Na+-K+-ATPase
Absorption of Sodium and
Chloride - Small Bowel

Chloride passively
follows absorption
of sodium
Absorption of Sodium and
Chloride Distal Ileum and
Colon
Neutral NaCl co-transport, Na+ for H+ and
Cl for HC03
Absorption of Potassium
in Small Bowel

Overall K+ movement is result of


solvent drag and is potential-
dependent
K+ actively secreted in colon

Rectosigmoid colon has active K+


absorption - exchanges K+ for H+
Absorption of Calcium
Passive - throughout the small intestine
Predominates at concentrations 10
mmol/L

Active - primarily in the duodenum


Below 10 mmol/L, active transport
occurs with 1,25 dihydroxy vitamin D 3
Absorption of Calcium
Absorption of Magnesium

Absorbed from distal small intestine and


all of colon by passive diffusion
Digestion and Absorption - ???
Good question

8. What mineral will be depleted if a


patient has a draining T-tube in the
common bile duct ?

A. Zinc C. Magnesium

B. Sodium D. Copper
Digestion and Absorption - ???
Good question

8. What mineral will be depleted if a


patient has a draining T-tube in the
common bile duct ?

A. Zinc C. Magnesium

B. Sodium D. Copper
Absorption of Copper
Dietary copper is absorbed in stomach
and duodenum
Active process requires energy and
involves absorption of complexes of
copper and amino acids
Copper is excreted by bile
urine losses = ~1-2% of intake
Digestion and Absorption - ???
Good question

8. What mineral will be depleted if a


patient has marked diarrhea ?

A. Zinc C. Magnesium

B. Sodium D. Copper
Digestion and Absorption - ???
Good question

8. What mineral will be depleted if a


patient has marked diarrhea ?

A. Zinc C. Magnesium

B. Sodium D. Copper
Absorption of Zinc

Major loss of zinc is in the feces - during


intravenous nutrition it is suggested to
give:
2 mg Zn
+ 17.1 mg Zn/kg stool lost
+ 12.2 mg Zn/kg of gastric/duodenal/or
jejunal fluid lost
Absorption of Zinc

Zinc is absorbed primarily in jejunum


Binds to a ligand in lumen transports to mucosa
Transferred to binding site on cell
Active process requiring energy, oxygen, and Na +
Absorption stimulated by glucose
Digestion and Absorption - ???
Good question

9. Even in Short Bowel Syndrome, oral


iron supplementation can be effective.

A. True
B. False
Digestion and Absorption - ???
Good question

9. Even in Short Bowel Syndrome, oral


iron supplementation can be effective.

A. True
B. False
Absorption of Iron
Iron is absorbed in duodenum
ferrous salt > ferric salt
At brush border, ferrous ion oxidized to
ferric and transported by various brush
border carrier proteins - regulated by
bodys need for iron
At pharmacologic doses, passive
diffusion occurs
Digestion and Absorption - ???
Good question

10. The major source of carbohydrate in


the diet is:

A. Starch C. Lactose

B. Sucrose D. Fructose
Digestion and Absorption - ???
Good question

10. The major source of carbohydrate in


the diet is:

A. Starch C. Lactose

B. Sucrose D. Fructose
Average Carbohydrate Intake
Saccharides Intake (gm) % Total
Polysaccharides
Starch 200 64
Glycogen 1 0.5
Disaccharides
Sucrose 80 26
Lactose 20 6.5
Monosaccharide
Fructose 10 3
Carbohydrate Digestion and
Absorption

Primarily absorbed in duodenum and


proximal jejunum (75% in first 70 cm of
jejunum)

Carbohydrate intolerance is nearly always


related to a defect in intestinal surface
digestion of a polysaccharide or
disaccharide
Carbohydrate Digestion and
Absorption

Luminal phase

Hydrolysis of starch by salivary and


pancreatic -amylases

Cleaves starches to yield -


limit dextrans, maltotriose, and
maltose
Carbohydrate Digestion and
Absorption

Brush-border phase

Hydrolysis by glycosidases to
monosaccharides:

glucose, galactose, and fructose


Carbohydrate Digestion and
Absorption

Cellular phase - transport to venous


system

Glucose and galactose transported via


SGLT1 Na+-linked active transporter
Fructose via GLUT5 facilitated diffusion
Carbohydrate Digestion and
Absorption
SGLT1

Galactos
GLUT2
e
GLUT5 Fructose

GLUT2 Glucose
SGLT1
Fiber Digestion and
Absorption
Non-starch carbohydrate of plant origin
that escapes enzymatic digestion in the
small intestine

Two types
Cellulosic: high molecular weight, non-
soluble (cellulose, wheat bran)
Noncellulosic: soluble (hemicelluloses,
pectin, gums, mucilages)
Digestion and Absorption - ???
Good question

11. Which type of fiber can contribute to


the energy needs of the colon?

A. Cellulosic
B. Non Cellulosic
Digestion and Absorption - ???
Good question

11. Which type of fiber can contribute to


the energy needs of the colon?

A. Cellulosic
B. Non Cellulosic
Fiber Digestion and
Absorption
Non Cellulosic fiber is degraded rapidly
by anaerobic microflora of cecum and
colon (fermentation) to give short-chain
fatty acids:

Acetate, Propionate, N-butyrate


Fiber Digestion and
Absorption
Non Cellulosic fiber

Enhances colonic blood flow


Serves as fuel for colonocyte (70% )
Increases colonocyte proliferation
Enhances Na+ absorption
Preserves colonic mucosal barrier
Fiber Digestion and
Absorption
Cellulosic fiber

Contributes to fecal mass and water


content
Reduces mean stool transit time
Fat Digestion and Absorption

96% of ingested
fat is absorbed daily

90% of ingested fat


is triglycerides, 10%
is cholesterol,
phospholipids, and
plant sterols
Triglycerides

Majority of triglycerides contain long-


chain fatty acids (16 -18 C)

A few dietary triglycerides contain


medium-chain fatty acids (8 -12 C)
Lipid Absorption

Lipids in diet are emulsified in the


stomach by mechanical grinding
Pancreatic lipase in duodenum digests to
free fatty acids and 2-monoglycerides
Bile acids form water soluble micelles
which diffuse easily across the unstirred
water layer
Fat Digestion and Absorption
Digestion and Absorption - ???
Good question
12. Which of the following fatty acid(s) is
absorbed directly into the enterocyte without
micelle formation?

C. Chenodeoxycholic
A. Arachidonic acids
acids
B. Medium-chain fatty
D. Picric acids
acids
Digestion and Absorption - ???
Good question
12. Which of the following fatty acid(s) is
absorbed directly into the enterocyte without
micelle formation?

C. Chenodeoxycholic
A. Arachidonic acids
acids
B. Medium-chain fatty
D. Picric acids
acids
Fat Digestion and Absorption

Medium-chain triglycerides, which are


more water soluble, may be absorbed
intact with direct transport to the portal
system as free fatty acids
Protein Digestion and
Absorption
Derived from animal and vegetable
sources and make up to 11 to 14% of
average caloric intake (70 to 100 gm/day)

Primarily absorbed in the duodenum and


proximal jejunum, yet some does pass
into and is absorbed by the colon
Protein Digestion and
Absorption
Luminal gastric digestion

Acid denaturation makes protein


susceptible to proteolysis by pepsin
resulting in large soluble
oligopeptides, peptones, and some
amino acids
Protein Digestion and
Absorption
Luminal duodenal phase

Three pancreatic endopeptidases and


two pancreatic exopeptidases reduce
oligopeptides to free amino acids and
di- and tripeptides
Protein Digestion and
Absorption
Luminal enterocyte phase

Enterocyte brush border membrane


hydrolase produces amino acids,
dipeptides and tripeptides
Protein Digestion and
Absorption
There are 4 major Na+ dependent,
group specific, active transport systems

Neutral amino acids


Glycine, proline, hydroxyproline
Dibasic amino acids and cystine
Dicarboxylic amino acids
Digestion and Absorption - ???
Good question

13. What is the di- and tri-peptide H+


dependent transport system in the small
intestine?

A. GLUT5 C. PepT1

B. Endopeptidase D. SGLT1
Digestion and Absorption - ???
Good question

13. What is the di- and tri-peptide H+


dependent transport system in the small
intestine?

A. GLUT5 C. PepT1

B. Endopeptidase D. SGLT1
Protein Digestion and
Absorption
There is a H+ dependent di- and
tripeptide transport system (PepT1
Transporter)

Cephalosporin antibiotics, containing a


peptide bond, share the same transport
system
Protein Digestion and
Absorption
Amino acids absorbed by either route
efflux from the basolateral membrane
via transporters whose kinetic
characteristics are sensitive to
circulating amino acid concentrations
Protein Digestion and
Absorption
Mucosal uptake of peptides has an
important role in protein absorption -
absorption of
amino nitrogen is greater during perfusion
of di- and tripeptides

Yet have less effect on Na + and water uptake


than free amino acids or complex proteins
(diarrhea)
Protein Digestion and
Absorption
Although theoretical advantages may
exist for enteral products containing
peptides vs intact protein or free amino
acids, little experimental data exists to
support their advantage. Any advantage
would be more apparent with increased
protein load as during cyclical feedings
Malabsorption

Clinical symptoms include unexplained


weight loss, steatorrhea, diarrhea,
anemia, tetany, bone pain, pathologic
fractures, bleeding, dermatitis,
neuropathy, glossitis, and edema
Malabsorption
Normal Stool Composition
Water 100 ml
Sodium 4 mEq
Potassium 9 mEq
Chloride 2 mEq
Bicarbonate 0 mEq
From 3/week to 3/day considered normal
Diarrhea = stool weight > 200 to 500 g/24 h
Digestion and Absorption - ???
Good question

13. Each of the following are screening


tests for intestinal absorption except:

A. Gross inspection of stool


B. Fat content of stool in random collection
C. Microscopic examination of stool
D.Lactose tolerance test
Digestion and Absorption - ???
Good question

13. Each of the following are screening


tests for intestinal absorption except:

A. Gross inspection of stool


B. Fat content of stool in random collection
C. Microscopic examination of stool
D.Lactose tolerance test
Malabsorption - Screening
Tests
Gross inspection of stool
Microscopic examination of stool
Fat content of stool in random
collection
Protein content of stool in random
collection
Malabsorption - Screening
Tests
Serum carotene
D-xylose absorption
Radiologic evaluation of transit
time, motility, mucosal diseases,
fistulas, strictures/obstructions
Malabsorption - Specific Tests

Lactose tolerance test (Lactase


deficiency, short gut, mucosal disease)

Schilling test (B12 absorption, tests


terminal ileum and gastric production
of intrinsic factor)
Malabsorption - Specific Tests

Small bowel biopsy (celiac disease,


tropical sprue, Whipples disease, etc.)

Radioactive compounds (iron, calcium,


amino acids, folic acid, pyridoxine, vit
D, bile salts, and others)
Malabsorption - Balance Tests

3-5 day timed stool collection for


quantitative fat absorption (standard
fat intake = 100 g/d)

Usually less than 5% lost in stool


Malabsorption - Balance Tests
Radioactive tracer studies

14C-triolein and 13C-trioctanion breath


tests for neutral fat absorption

131I-albumin, 51Cr-albumin given IV with


stool measurement of radioactivity for
protein-losing enteropathies
Specialty Examination

Good Luck !!