frudensia-pemicu2GIT.ppt

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Frudensia Kristiana

405110031

Faculty of Medicine Tarumanagara University

Problem 2A Adult!

"rou# 1$ %



'earning (b)ectives*1+ Able to &no, and e-#lain about anatomy

of gaster. duodenum. )e)unum. ileum+

2+ Able to &no, and e-#lain about /istologyof gaster and duodenum+

3+ Able to &no, and e-#lain about #/ysiologyof gaster and duodenum+

4+ Able to &no, and e-#lain about

bioc/emistry of gaster and duodenum+5+ Able to &no, and e-#lain about dys#e#sia+



'(1+

Anatomy of gaster. duodenum.

)e)unum. ileum+





"aster enticulus tomac/• so#/agus uodenum• As s/elters of food to be digested become

6c/yme7

•

8egulate t/e 9o, of digested food into t/esmall intestine

• :a#acity* ; 1+5 liters. can be dilated un til2%3 liters

• T/e stomac/ ca#acity of ne,born baby* ;30 cc

• T/e most common is <%s/a#ed



urface Anatomy of t/etomac/=n t/e su#ine #osition. t/e stomac/

commonly lies in t/e right and left upperquadrants. or epigastric, umbilical, and lefthypochondriac and lumbar regions+





T/e surface mar&ings of t/e stomac/ in t/e su#ine #ositioninclude t/e*

:ardial ori>ce* ,/ic/ usually lies #osterior to t/e $t/ leftcostal cartilage. 2%4 cm from t/e median #lane at t/e level

of t/e T11 vertebra+Fundus* ,/ic/ usually lies #osterior to t/e left $t/ rib in t/e

#lane of t/e M:'+

"reater curvature* ,/ic/ #asses inferiorly to t/e left as faras t/e 10t/ left cartilage before turning medially to reac/

t/e #yloric antrum+'esser curvature* ,/ic/ #asses from t/e rig/t side of t/e

cardia to t/e #yloric antrum? t/e most inferior #art of t/ecurvature is mar&ed by t/e angular incisure. ,/ic/ lies )ustto t/e left of t/e midline+

Pyloric #art of t/e stomac/ in t/e su#ine #osition* ,/ic/usually lies at t/e level of t/e @t/ costal cartilages at t/elevel of '1 vertebra? t/e #yloric ori>ce is a##ro-imately 1+25cm left of t/e midline+

Pylorus in t/e erect #osition* ,/ic/ usually lies on t/e rig/tside? its location varies from t/e '2 t/roug/ '4 vertebra+



Parts of t/e tomac/ T/e stomac/ /as four #arts Fig+ 2+30A!* Cardia* t/e #art surrounding t/e cardial ori>ce+ Fundus* t/e dilated su#erior #art t/at is related to t/e left

dome of t/e dia#/ragm and is limited inferiorly by t/e/oriontal #lane of t/e cardial ori>ce+ T/e su#erior #art oft/e fundus usually reac/es t/e level of t/e left 5t/

intercostal s#ace+ T/e cardial notc/ cardial incisure! isbet,een t/e eso#/agus and t/e fundus+ T/e fundus may bedilated by gas. 9uid. food. or any combination of t/ese+

Body (corpus)* t/e ma)or #art of t/e stomac/ bet,een t/efundus and t/e #yloric antrum+

Pyloric part* t/e funnel%s/a#ed out9o, region of t/estomac/? its ,ide #art. t/e #yloric antrum. leads into t/e#yloric canal. its narro, #art+ T/e #ylorus "+ gate&ee#er!.t/e distal. s#/incteric region of t/e #yloric #art. is a mar&edt/ic&ening of t/e circular layer of smoot/ muscle. ,/ic/controls disc/arge of t/e stomac/ contents t/roug/ t/e#yloric ori>ce into t/e duodenum+





Figure 2+30+ Abdominal part of esophagus andstomach.A+ T/e stomac/ and t/e greater and lesser omenta are s/o,n+ T/e left#art of t/e liver is cut a,ay so t/at t/e lesser omentum and t/e omentalforamen entrance to omental bursa! can be seen+ T/e e-tent of t/eintact liver is indicated by a dotted line+ T/e stomac/ is in9ated ,it/ air+



Figure 2+30+ Abdominal part of esophagus andstomach.B+ T/e internal surface mucous membrane! is demonstrated+ T/e longitudinal gastricfolds. or rugae. disa##ear on distension+ Along t/e lesser curvature. severallongitudinal mucosal folds e-tend from t/e eso#/agus to t/e #ylorus. ma&ing u# t/egastric canal along ,/ic/ ingested liCuids #ass+ :+ T/e #ylorus is t/e signi>cantly

constricted terminal #art of t/e stomac/+ T/e #yloric ori>ce is t/e distal o#ening of t/e#yloric canal into t/e duodenum+



T/e stomac/ also /as t,o curvatures*Lesser curvature* forms t/e s/orter concave border of t/e

stomac/? t/e angular incisure notc/! is t/e s/ar#indentation a##ro-imately t,o t/irds t/e distance along t/elesser curvature t/at indicates t/e )unction of t/e body andt/e #yloric #art of t/e stomac/+

reater curvature* forms t/e longer conve- border of t/estomac/+

=ntermittent em#tying of t/e stomac/ occurs ,/enintragastric #ressure overcomes t/e resistance of t/e#ylorus+ =t is normally tonically contracted so t/at t/e#yloric ori>ce is reduced. e-ce#t ,/en emitting c/yme+At irregular intervals. gastric #eristalsis #asses t/ec/yme t/roug/ t/e #yloric canal and ori>ce into t/esmall intestine for furt/er mi-ing. digestion. andabsor#tion+



T/e muscle layers of t/eoeso#/ageal and gastric ,alls



Peritoneal FormationsAn omentum is a double%layered e-tension or fold of

#eritoneum t/at #asses from t/e stomac/ and#ro-imal #art of t/e duodenum to ad)acent organs int/e abdominal cavity+!he greater omentum is a #rominent #eritoneal fold

t/at /angs do,n li&e an a#ron from t/e greatercurvature of t/e stomac/ and t/e #ro-imal #art of t/eduodenum Fig+ 2+1@A. :. D !+ After descending. it foldsbac& and attac/es to t/e anterior surface of t/etransverse colon and its mesentery+!he lesser omentum connects t/e lesser curvature of

t/e stomac/ and t/e #ro-imal #art of t/e duodenum tot/e liver Fig+ 2+1@B D !? it also connects t/e stomac/to a triad of structures t/at run bet,een t/e duodenumand liver in t/e free edge of t/e lesser omentum Fig+2+1E!+



Figure 2+1@+ Principal formations of peritoneum.



Figure 2+1@+ Principal formations of peritoneum.



Parts of t/e lesser omentum * T/e /e#atogastric ligaments

T/e /e#atoduodenal ligaments

T/e stomac/ is connected to t/e*

=nferior surface of t/e dia#/ragm by t/egastrophrenic ligament +

#leen by t/e gastrosplenic ligament gastrolienalligament!. ,/ic/ re9ects to t/e /ilum of t/e s#leen+

Transverse colon by t/e gastrocolic ligament . t/e

a#ron%li&e #art of t/e greater omentum. ,/ic/descends from t/e greater curvature. turns under.and t/en ascends to t/e transverse colon+







Figure 2+31+ "mental bursa and stomach bed.

A+ =n t/is anterior a##roac/ to t/e omental bursa. t/e greater omentum andgastros#lenic ligament /ave been cut along t/e greater curvature of t/estomac/. and t/e stomac/ /as been re9ected su#eriorly to o#en t/e bursaanteriorly+ At t/e rig/t end of t/e bursa. t,o of t/e boundaries of t/e omental

foramen can be seen* t/e inferior root of t/e /e#atoduodenal ligamentcontaining t/e #ortal triad! and t/e caudate lobe of t/e liver+



Figure 2+31+ "mental bursa and stomach bed.

B+ T/e stomac/ and most of t/e lesser omentum /ave been e-cised. and t/e#eritoneum of t/e #osterior ,all of t/e omental bursa covering t/e stomac/bed is largely removed to reveal t/e organs in t/e bed+ Alt/oug/ ad/esions.suc/ as t/ose binding t/e s#leen to t/e dia#/ragm /ere. are common

#ostmortem >ndings. t/ey are not normal anatomy+



Posterior relations of t/e stomac/+



Artery of stomac/

T/e stomac/ /as a ric/ arterial su##lyarising from t/e celiac trun& and itsbranc/es+

Anastomoses formed along t/e lesser

curvature by t/e right and left gastricarteries. and along t/e greater curvature byt/e right and left gastro-omental arteries+

T/e fundus and u##er body receive bloodfrom the short and posterior gastricarteries+



Arterial u##ly to tomac/





eins of stomac/The right and left gastric veins drain into t/e portal vein

The short gastric veins and left gastro-omentalveins drain into t/e splenic vein. ,/ic/ )oins t/e

su#erior mesenteric vein M! to form t/e#ortal vein+

The right gastro-omental vein em#ties in t/eSMV +

A #re#yloric vein ascends over t/e #ylorus to t/erig/t gastric vein+ Because t/is vein is obvious inliving #ersons. surgeons use it for identifying t/e#ylorus+



eins of stomac/. duodenum. ands#leen



'ym#/atic drainage ofstomac/

T/e gastric lym#/atic vessels accom#any t/e arteriesalong t/e greater and lesser curvatures of t/e stomac/+ T/e follo,ing is a summary of t/e lym#/atic drainageof t/e stomac/*'ym#/ from t/e su#erior t,o t/irds of t/e stomac/drains along t/e rig/t and left gastric vessels to t/e

gastric lymph nodes? lym#/ from t/e fundus andsu#erior #art of t/e body of t/e stomac/ also drainsalong t/e s/ort gastric arteries and left gastro%omentalvessels to t/e pancreatico#splenic lymph nodes+'ym#/ from t/e rig/t t,o t/irds of t/e inferior t/ird oft/e stomac/ drains along t/e rig/t gastro%omental

vessels to t/e pyloric lymph nodes+'ym#/ from t/e left one t/ird of t/e greater curvaturedrains along t/e s/ort gastric and s#lenic vessels to t/epancreaticoduodenal lymph nodes+






=nnervation of stomac/

T/e parasympathetic nerve su##ly of t/estomac/ is from t/e anterior and posteriorvagal trunks and their branches. ,/ic/ entert/e abdomen t/roug/ t/e eso#/ageal /iatus+

T/e sympathetic nerve su##ly of t/estomac/ from t/e T6 through T segments ofthe spinal cord #asses to the celiac ple!ust/roug/ t/e greater s#lanc/nic nerve and is

distributed t/roug/ t/e #le-uses around t/egastric and gastro%omental arteries



=nnervation of stomac/ and smallintestine

istribution of t/e vagal nerves to t/e stomac/+ T/e t,o commonest variations in t/e anteriorvagus are s/o,n in #in&+ A. Multi#le main trun&s+

B. 'o, origin of t/e /e#atic#yloric branc/ lyingclose to t/e lesser curvature+





mall =ntestine

T/e small intestine. consisting of t/eduodenum. )e)unum. and ileum. is t/e#rimary site for absor#tion of nutrientsfrom ingested materials. and e-tends from

t/e #ylorus to t/e ileocecal )unction ,/eret/e ileum )oins t/e cecum t/e >rst #art oft/e large intestine!+ T/e #yloric #art of t/estomac/ em#ties into t/e duodenum.

duodenal admission being regulated by t/e#ylorus+







T/e duodenum is divisible into four#arts*a+ u#erior >rst! #art* s/ort

a##ro-imately 5 cm! and liesanterolateral to t/e body of t/e '1

vertebra+b+ escending second! #art* longer E%

10 cm! and descends along t/e rig/tsides of t/e '1%'3 vertebrae+

c+ Goriontal t/ird! #art* $%H cm longand crosses t/e '3 vertebra+

d+ Ascending fourt/! #art* s/ort 5 cm!and begins at t/e left of t/e '3vertebra and rises su#eriorly as far ast/e su#erior border of t/e '2 vertebra+





Pars ,uperior $uodeni

T/e >rst 2 cm of t/e su#erior #art of t/e duodenum.immediately distal to t/e #ylorus. /as a mesenteryand is mobile+ T/is free #art. called t/e ampulla(duodenal cap)+

T/e distal 3 cm of t/e su#erior #art and t/e ot/ert/ree #arts of t/e duodenum /ave no mesenteryand are immobile because t/ey are retro#eritoneal+

T/e su#erior #art of t/e duodenum ascends fromt/e #ylorus and is overla##ed by t/e liver andgallbladder+

Peritoneum covers its anterior as#ect. but it is bare

of #eritoneum #osteriorly. e-ce#t for t/e am#ulla+ T/e #ro-imal #art /as t/e /e#atoduodenal ligament

#art of t/e lesser omentum! attac/ed su#eriorlyand t/e greater omentum attac/ed inferiorly+



Pars $escendens $uodeni

T/e descending #art of t/e duodenum runsinferiorly. curving around t/e /ead of t/e#ancreas+=nitially. it lies to t/e rig/t of and #arallel to t/e

=: inferior vena cava!+ T/e bile and main pancreatic ducts enter its

#osteromedial ,all+ T/ese ducts usually unite toform t/e hepatopancreatic ampulla. ,/ic/o#ens on t/e summit of an eminence. called t/e

maor duodenal papilla. located#osteromedially in t/e descending duodenum+ T/e descending #art of t/e duodenum is

entirely retro#eritoneal+





Pars -nferior (horiontal)$uodeni T/e inferior or /oriontal #art of t/e duodenum runs

transversely to t/e left. #assing over t/e =:. aorta. and'3 vertebra+

=t is crossed by t/e su#erior mesenteric artery and veinand t/e root of t/e mesentery of t/e )e)unum and ileum+

u#erior to it is t/e /ead of t/e #ancreas and its uncinate#rocess+

T/e anterior surface of t/e /oriontal #art is covered ,it/#eritoneum. e-ce#t ,/ere it is crossed by t/e su#eriormesenteric vessels and t/e root of t/e mesentery+

Posteriorly it is se#arated from t/e vertebral column byt/e rig/t #soas ma)or. =:. aorta. and t/e rig/t testicularor ovarian vessels+



Pars Ascendens $uodeni T/e ascending #art of t/e duodenum runs su#eriorly to

reac/ t/e inferior border of t/e body of t/e #ancreas+Gere it curves anteriorly to )oin t/e )e)unum at t/e

duodenoeunal unction. su##orted by t/eattac/ment of a suspensory muscle of theduodenum ligament of !reit!+

T/is muscle is com#osed of a sli# of s&eletal muscle fromt/e dia#/ragm and a >bromuscular band of smoot/muscle from t/e t/ird and fourt/ #arts of t/e duodenum+

:ontraction of t/is muscle ,idens t/e angle of t/eduodeno)e)unal 9e-ure. facilitating movement of t/e

intestinal contents+ T/e sus#ensory muscle #asses#osterior to t/e #ancreas and s#lenic vein and anterior tot/e left renal vein+



Artery of duodenum

T/e arteries of t/e duodenum arise from t/e celiac trunkand t/e superior mesenteric artery + T/e celiac trun&. via t/e gastroduodenal artery and its

branc/. t/e superior pancreaticoduodenal artery/ su##lies t/e duodenum #ro-imal to t/e entry of t/e bile ductinto t/e descending #art of t/e duodenum+

T/e su#erior mesenteric artery. t/roug/ its branc/. t/e

inferior pancreaticoduodenal artery/ su##lies t/eduodenum distal to t/e entry of t/e bile duct+

T/e #ancreaticoduodenal arteries lie in t/e curvebet,een t/e duodenum and t/e /ead of t/e #ancreasand su##ly bot/ structures+ T/e anastomosis of t/esu#erior and inferior #ancreaticoduodenal arteries. ,/ic/

occurs a##ro-imately at t/e level of entry of t/e bile ductor. according to some aut/ors. at t/e )unction of t/edescending and /oriontal #arts of t/e duodenum! isformed bet,een t/e celiac and t/e su#erior mesentericarteries+



An im#ortant transition in t/e blood su##ly oft/e digestive tract occurs /ere*Pro-imally. e-tending orad to,ard t/e mout/! to

and including t/e abdominal #art of t/eeso#/agus. t/e blood is su##lied to t/ealimentary tract by t/e celiac trun0.istally. e-tending aborad a,ay from t/e mout/!

to t/e left colic 9e-ure. t/e blood is su##lied byt/e ,A+

T/e basis of t/is transition in blood su##ly isembryological? t/is is t/e )unction of t/eforegut and midgut Moore and Persaud. 2003!+



Artery of duodenum



eins of duodenum

T/e veins of t/e duodenum follo, t/earteries and drain into t/e portal vein.some directly and ot/ers indirectly. t/roug/t/e su#erior mesenteric and s#lenic veins+



eins of stomac/. duodenum. ands#leen








=nnervation of duodenum

T/e nerves of t/e duodenum derive fromt/e vagus and greater and lesser(abdominopelvic) splanchnic nerves by,ay of t/e celiac and su#erior mesenteric

#le-uses. from ,/ic/ t/ey are conveyed tot/e duodenum via #eriarterial ple+usese+tending to the pancreaticoduodenalarteries.



1&1%'% # -L&%

"e#unumbegins at t/e

duodeno)e)unal9e-ure ,/ere t/ealimentary tract

resumes anintra#eritoneal course

$leumends at t/e ileocecal

)unction. t/e union oft/e terminal ileum

and t/e cecum





Artery of <e)unum%=leum

T/e superior mesenteric artery su##liest/e )e)unum and ileum+

T/e MA usually arises from t/e abdominalaorta at t/e level of t/e '1 vertebra.

a##ro-imately 1 cm inferior to t/e celiactrun&. and runs bet,een t/e layers of t/emesentery. sending 15%1H branc/es to t/e

)e)unum and ileum+

T/e arteries unite to form loo#s or arc/es.called arterial arcades. ,/ic/ give rise tostraig/t arteries. called vasa recta.







eins of <e)unum%=leum

T/e superior mesenteric vein drains t/e )e)unum and ileum+ =t lies anterior and tot/e rig/t of t/e MA in t/e root of t/emesentery+ T/e M ends #osterior to t/e

nec& of t/e #ancreas. ,/ere it unites ,it/t/e s#lenic vein to form t/e #ortal vein+

' / ti d i f < )



'ym#/atic drainage of <e)unum%=leum

#ecialied lym#/atic vessels in t/e intestinal villi tiny#ro)ections of t/e mucous membrane! t/at absorb fat are calledlacteals+

T/ey em#ty t/eir mil&%li&e 9uid into t/e lym#/atic #le-uses int/e ,alls of t/e )e)unum and ileum+ T/e lacteals drain in turninto lym#/atic vessels bet,een t/e layers of t/e mesentery+Jit/in t/e mesentery. t/e lym#/ #asses seCuentially t/roug/t/ree grou#s of lym#/ nodes* 1u+ta#intestinal lymph nodes* located close to t/e intestinal ,all+esenteric lymph nodes* scattered among t/e arterial arcades+,uperior central nodes* located along t/e #ro-imal #art of t/e

MA+

Ierent lym#/atic vessels from t/e mesenteric lym#/ nodes

drain to t/e superior mesenteric lymph nodes+ 'ym#/aticvessels from t/e terminal ileum follo, t/e ileal branc/ of t/eileocolic artery to t/e ileocolic lymph nodes.



=nnervation of <e)unum%=leum

T/e MA and its branc/es are surrounded by aperivascular nerve ple+us t/roug/ ,/ic/ t/e nerves areconducted to t/e #arts of t/e intestine su##lied by t/isartery+

T/e sym#at/etic >bers in t/e nerves to t/e )e)unum andileum originate in t/e !2#!34 segments of the spinalcord and reac/ the superior mesenteric nerve ple+us

t/roug/ t/e sympathetic trunks and thoracicabdominopelvic greater. lesser. and least! splanchnicnerves+

T/e #resyna#tic sym#at/etic >bers syna#se on cell bodiesof #ostsyna#tic sym#at/etic neurons in t/e celiac andsuperior mesenteric %prevertebral& ganglia+

T/e #arasym#at/etic >bers in t/e nerves to t/e )e)unum andileum derive from t/e posterior vagal trun0s+ T/e #resyna#tic #arasym#at/etic >bers syna#se ,it/

#ostsyna#tic #arasym#at/etic neurons in t/e myenteric andsubmucosal ple!uses in t/e intestinal ,all+





'(2+

Gistology of gaster and duodenum+





"aster



Gistology of :ardia





uodenum

a+ 'ieber&/un gland

b+ Tunica mucosa

c+ Brunner gland

d+ Tunica submucosa

e+ Tunica muscularis



<e)unum

a+ illi

b+ Plica &erc&ringi

c+ Tunica muscularismucosa

d+ Tunica submucosa


=leum



=leum

a+ illib+ 'ym#/onodus

aggregati

c+ Tunica muscularis

mucosad+ Tunica submucosa




a+ 'iber&/un glandb+ "oblet cell

c+ Panet/ cell



'(3+

P/ysiology of gaster and duodenum+





tomac/

3 main functionstore ingested food until it can be em#tied

into t/e small intestine

ecretes G:l D enymes. begin #rotein

digestiontomac/Ks mi-ing movement ingested

food #ulveried D mi-ed ,it/ gastricsecretions t/ic& liCuid mi-ture c/yme!

"astricKs motilityFilling. storage. mi-ing. em#tying



"astric >lling

olume about 50 ml? can e-#and to 1lduring a meal

Folds of gastric get smaller D nearly 9attenout as stomac/ rela-es slig/tly receptive

rela!ation! en/ance stomac/ toaccomodate t/e e-tra volume of food ,it/little rise in stomac/ #ressure Triggered by t/e act of eating D mediated by

t/e vagus nerve

"astric storage body of



"astric storage body ofstomac/!=nterstitial cells of :a)al generates slo,

,ave #otential Basic electrical r/yt/m! occurs continuously ,it/ or ,it/out musclecontraction food is stored in t/e

relatively Cuite body ,it/out being mi-ed

Fundus contains only #oc&et of gas

"astric mi-ing antrum of



"astric mi-ing antrum ofstomac/!trong antral #eristaltic mi- food D

gastric )uice c/yme! #ro#els t/ec/yme to,ards #yloric s#/incter

Tonic contraction of #yloric s#/incter &ee#s

it almost closed bul& of t/e antral c/ymetumbled bac& into t/e antrum #ro#eledfor,ard tumbled bac& again as t/e ne,#eristaltic ,ave advances





"astric em#tying

"astric factorAmount of c/yme? stomac/ distention

strect/ of smoot/ muscle. intrinsic #le-uses.vagus nerve. gastrin gastric motility LL

egree of 9uidityuodenum factorFat. acid. /y#ertonicity. D distention



Mec/anism of G D :l ions



Mec/anism of G D :l ionssecretion

Function of G:l*Activate #e#siongen #e#sin

Aids brea&do,n ofconnective tissue Dmuscle >bers.reducing food intosmaller #articles

enaturates #rotein

Along ,it/lysoyme &ills

microorganism

Pe#sinogen activated #rotein



Pe#sinogen. activated #roteindigestion

Pe#sinKs autocatalytic activity



Mucus

'ubricating #ro#erties. #rotects gastricmucosa

Protect t/e stomac/ ,all from self%digestionbecause of #e#sin

doesnKt aIect #e#sin activity in t/e lumenBeing al&aline neutraliing G:loesnKt interfere ,it/ t/e function of G:l in

t/e lumen

8egulatory #at/,ays #arietal D



8egulatory #at/,ays #arietal Dc/ief cells

Acetylc/oline s/ort local re9e-es D vagalstimulation #arietal D c/ief cells. " D :'cells

" cells secrete gastrin

Main factor for increased G:l secretion bystimulating :' cells to release /istamine

nteroc/roman li&e cells #aracrine/istamine#eed u# G:l secretion. #otentiates A:/ D gastrin

cells #aracrine somatostatinNegative feedbac& fas/ion



:ontrol of gastric secretion



ll = t ti



mall =ntestine

T/e site ,/ere most digestion andabsorbtion ta&e #lace+

ivided into 3 segments* duodenum.

)e)unum and ileum =ts motility includes*

egmentation

Migrating motility com#le-

t ti



egmentation

egmentation consists of oscillating. ring%li&econtraction of t/e circular smoot/ muscle along t/esmall intestineKs lengt/? bet,een t/e contractedsegments are rela-ed areas containing a small bolusof c/yme+

After a brief #eriod of time. t/e contracted segmentsrela-. and ring%li&e contraction a##ear in t/e#reviously rela-ed area+

T/e ne, contraction forces t/e c/yme in a #reviouslyrela-ed segment to move in bot/ direction into t/eno, rela-ed ad)acent segments. s/ortly t/ereafter.

t/e areas of contraction and rela-ation is alternateagain+ =n t/is ,ay. t/e c/yme is c/o##ed. c/urned and

t/oroug/ly mi-ed Functions* mi-ing t/e c/yme ,it/ digestive )uices

secreted in small%intestine lumen and e-#osing t/ec/yme to t/e absorbtive surface of t/e small

t ti



egmentation

Mi ti M tilit : l



Migrating Motility :om#le-

J/en most meal /as been absorbed.segmentation cease and arere#laced bet,een meals by t/e

migrating motility com#le-+ T/is bet,een meal motility consists

of ,ea&. re#etitive #eristaltic ,avest/at move a s/ort distance do,n t/e

intestine before dying out+ ac/ contraction ,ill s,ee# any

remnants of t/e #receding meal #lus

mucosal debris and bacteria for,ard

ti



ecretions

-ocrine gland cells of smallintestine mucosa secrete about 1+5liters of an aCueous salt and mucus

solution called succus entericus+ Functions* #rovides #rotection and

lubrication also #rovides #lenty of

G2( to #artici#ate in t/e digestion offood

No digestive enymes are secreted

inti t/e intestinal )uice+

igestion



igestion

igestion ,it/in t/e small intestinelumen is accom#lis/ed by #ancreaticenymes ,it/ fat digestion being

en/anced by bile secretion+ T/is digestion is com#leted by

s#ecial /airli&e #ro)ections of luminal

surface of small instine e#it/elialcell. microvilli

Absor#tion



Absor#tion

All #roducts of carbo/ydrate. #roteinand fat digestion. as ,ell aselectrolytes. vitamin and ,ater are

absorbed by small intestineindiscriminately+ (nly absor#tioncalcium and iron is ad)usted by body

needs+ Most absor#tion occurs in duodenum

and )e)unum. very little in ileum

normally only B12 and bile salt are



'(4+

Bioc/emistry of gaster and

duodenum+







'(5+

OPP=A



ys#e#sia



OPP=A

T/e descri#tion for a syndrome orcollection of sym#toms com#laints of #ainor discomfort in regio e#igatrica. bloating.nausea. vomiting. belc/ing. Cuic&ly feeling

full. stomac/ feel full+



T=('("O

isorders or diseases in t/e lumen of t/edigestive tract

rugs

iseases of t/e liver. #ancreatic. biliary

systemystemic diseases



ign D ym#tom

T/e c/aracteristic sym#toms of dys#e#siaareu##er abdominal #ain.

bloating.

fullness and tenderness on #al#ation+nausea

i



iagnose

Full blood count and eryt/rocytesedimentation rate

T/e -%ray tests include* T/e u##er gastrointestinal series

T/e small bo,el series T/e barium enema

:T scan

T/e endosco#ic tests include*"

:olonosco#y

i i : i i (



iagnostic :riteria 8(M ===





T t t



Treatment

AntacidsAntic/olinergics

Pro&ineti&

ito#rote&tif

Gistamine G2 Antagonist



Geartburn

G tb



Geartburn

=s a burning feeling in t/e lo,er c/est.along ,it/ a sour or bitter taste in t/et/roat and mout/

J/ t / tb



J/at causes /eartburn

Food #asses from your mout/ to eso#/agust/roug/ 'o,er so#/agus #/incter '!+

Usually. ' closes as soon as food #assest/roug/+ But if it doesnQt close all t/e ,ay

acid from your stomac/ can get t/roug/t/e o#ening and into youreso#/agusre9u-!+

tomac/ acid can irritate t/e eso#/agus

and cause /eartburn+

T/ings t/at can ma&e /eartburn



,orse

:igarette smo&ing:oIee :aIein

Alco/ol

:arbonated drin&s

:itrus fruits

:/ocolate. mints or#e##ermints

(nions'ying do,n too

soon after eating

Being over,eig/t

or obeseAs#irin or ibu#rofen

:ertain medicines

: / tb b i



:an /eartburn be serious

=f you get more t/an occasional /eartburn.it may be a sym#tom of*

acid re9u- disease. gastroeso#/agealre9u- disease "8!.

an in9amed stomac/ lining gastritis!./iatal /ernia

#e#tic ulcer+

Ti ti / tb



Ti#s on #reventing /eartburn

Try to eat at least 2 to 3 /ours before lyingdo,n+ =f you ta&e na#s. try slee#ing in ac/air+

onKt smo&e

'ose ,eig/t if youQre over,eig/t+onQt overeat+

at /ig/%#rotein. lo,%fat meals+

Avoid tig/t clot/esAvoid foods and ot/er t/ings t/at give you

/eartburn



AB(M=NA' B'(AT=N"

Abdominal bloating



Abdominal bloating

a condition in ,/ic/ t/e abdomen belly!feels full and tig/t+ T/e abdomen may bevisibly s,ollen distended!+

:auses



:auses

:ommon causes include*Air s,allo,ing a nervous /abit!

:onsti#ation

"astroeso#/ageal re9u-

=rritable bo,el syndrome'actose intolerance and ot/er food

intolerances

(vereating

mall bo,el bacterial overgro,t/Jeig/t gain



More serious disorders t/at may causebloating are*

Ascites and tumors

:eliac disease

um#ing syndrome(varian cancer

J/en t/e #ancreas is not able to #roduceenymes to /el# digestion #ancreatic

insuciency!

Gome :are



Gome :are

Avoid c/e,ing gum or carbonated drin&s.es#ecially t/ose ,it/ /ig/ levels of fructoseor sorbitol

Avoid foods suc/ as Brussels s#routs. turni#s.cabbage. beans. and lentils

o not eat too Cuic&ly

to# smo&ing

Treat your consti#ation. ,it/ >bersu##lements suc/ as #syllium can ma&e yoursym#toms ,orse+

J/en to contact a medicalf i l



#rofessional

:all your /ealt/ care #rovider if you /ave*Abdominal #ain

Blood in t/e stools or dar&. tarry loo&ingstools

iarr/eaGeartburn t/at is getting ,orse

omiting

Jeig/t loss



NAUA D (M=T=N"

Mec/anism of Nausea andi i



omiting

omit-#ulsion ,it/ #ersistent of stomac/ contents outfrom mout/.commonly itKs consider cause byabnormal gastric motility+

omit doesnKt a##ear by reverse #eristaltic+

T/e most im#ortant force t/at #ress gastriccontents suc/ as dia#/ragm contraction#rioryins#iration muscle! and abdominal muscle activee-trinsic muscle!

Nausea is t/e sensation of /aving an urge tovomit+



omit is start ,it/*=n/ale and glottis closingcontraction of

dia#/ragm descend to #ress gastric andabdominal muscleKs contraction #ressabdomen cavityintraabdomen #ressure R!and abdomen contents #us/ed to t/e to# gastric #us/ed from to# and under gastriccontents #us/ to in oeso#/agus and out frommout/+





"lottis closing

vomit didnKt enter tores#oratory tract+

Uvula ,as liftedclose a nasal cavity+

omit a yello, a##earancet/ereKs a gall

t/at enter to duodenum from /e#ar andgall bladder+



Usually.vomit ,as started by manycommon sign*-#ulsion of saliva LLL

,eating

Geartbeats velocity R!Nausea

tiology of vomit



tiology of vomit

Tactil stimulation on laryn-Ks bac&side+=ritation on stomac/ or duodenum

=ntracranial #ressure R!e- intercerebrumbleeding

8otation or /ead accelerationdiy e-carsic&seasic&airsic&

=ntensive #ain from anot/er organ

:/emicale- emetic drugs

Ps/ycis vomit by emotion factor!



Management



g

=denti>cation and elimination of t/eunderlying cause if #ossible

:ontrol of t/e sym#toms if it is not #ossibleto eliminate t/e underlying cause

:orrection of electrolyte. 9uid or nutritionalde>ciencies

$iagnostic



g

Blood tests%rinalysis

5#rays of the abdomen







Treatment



"ive intravenous 9uids+=f de/ydration is severe

Antivomiting drugs anti%emetics!

may be /el#ful but t/ey s/ould be used

only ,/en t/e #otential bene>ts out,eig/t/e ris&s+





"8

&6$



&6$• "astroeso#/ageal re9u- disease "8! is a

condition in ,/ic/ food or liCuid travelsbac&,ards from t/e stomac/ to t/e eso#/agust/e tube from t/e mout/ to t/e stomac/!+

• (ccurs ,/en t/e amount of gastric )uice t/at

re9u-es into t/e eso#/agus e-ceeds t/e normallimit. causing sym#toms ,it/ or ,it/outassociated eso#/ageal mucosal in)ury

• T/is action can irritate t/e eso#/agus. causing

/eartburn and ot/er sym#toms+• "astroeso#/ageal re9u- is a common condition

t/at often occurs ,it/out sym#toms after meals+

:lassi>cation



"astroeso#/ageal8e9u-

P/ysiological

"astroeso#/ageal 8e9u- %"8

"astroeso#/ageal 8e9u-

isease "8ym#tomatic!

Primary "8*Motility #roblemAIecting lo,erso#/ageal s#/incter

econdary "8*-ternal factor causingtransient rela-ations oflo,er so#/ageal s#/inctereg+ Food allergy!

:lassi>cation

#idemiology



#idemiology



"astroeso#/ageal 8e9u-i "8!



isease "8!

tiology



tiology• 'ifestyle % Use of alco/ol or cigarettes. obesity.

#oor #osture slouc/ing!

• Medications % :alcium c/annel bloc&ers.t/eo#/ylline. nitrates. anti/istamines

• iet % Fatty and fried foods. c/ocolate. garlic and

onions. drin&s ,it/ caIeine. acid foods suc/ ascitrus fruits and tomatoes. s#icy foods. mint9avorings

• ating /abits % ating large meals. eating soon

before bedtime• (t/er medical conditions % Giatal /ernia.

#regnancy. diabetes. ra#id ,eig/t gain

astroesophageal 6e*u+



p g

Pathophysiology,allo,

T/e lo,er eso#/ageal s#/incter rela-es or

ecrease t/e #ressure of t/e ' or=ncreased intra%abdominal #ressure

tomac/ contents and corrosive acid ,ell u#

8egurgitation

amage t/e lining of t/e eso#/agus



"8 Treatment



"8 Treatment

'ifestyle c/angesdietary modi>cations avoid acidic re9u-%inducing foods tomatoes. c/ocolate. mint!. Dbeverages )uices. carbonated. caIeinateddrin&s. alco/ol!. altered slee# #osition. ,eig/

reduction. smo&ing cessation

P/armacot/era#y

urgical t/era#ies

Treatment P/armacot/era#y



P/armacot/era#y

-amination



-amination

Bernstein testBarium meal test

ndosco#y

P/

P#i test



"AT8=T=



"astritis is an in9ammation. irritation. orerosion of t/e lining of t/e stomac/ gastric mucosa+ =t can occur suddenlyacute! or gradually c/ronic!+

8=S FA:T(8 (F "AT8=T= G+ #ylori infection

8egular use of as#irin or ot/erNA=s

(lder age

T=('("O (F "AT8=T=



Bacterial infection

8egular use of #ain relievers

-cessive alco/ol use

tress

Bile re9u- disease Oour o,n body attac&ing cells in your

stomac/ autoimmune gastritis!

(t/er diseases and conditions

:'A=F=:AT=(N (F"AT8=T=



"AT8=T=Acute gastritisAcute G+ #ylori infection(t/er acute infectious gastritis

:/ronic atro#/ic gastritis Ty#e A Ty#e B=ndeterminant

Uncommon forms of gastritis'ym#/ocyticosino#/ilic

:ro/nKs diseasearcoidosis=solated granulomatous gastritis

OMPT(M (F "AT8=T=



Nausea or recurrent u#set stomac/

Abdominal bloating

Abdominal #ain

omiting

=ndigestionBurning or gna,ing feeling in t/e stomac/

bet,een meals or at nig/t

omiting blood or coIee ground%li&ematerial

Blac&. tarry stools

=nfection of G+ P='(8O



G+Pyloryinfectsgaster urease

motility

Ureaammonia :(2

ac A

Provides a survival needs for bacteria:auses e#it/elial in)ury

TG 1

TG2

gastritis

#rotective

Pat/ogenesis of Gelicobacter #yloriinfection



An ability to colonize and adhere to gastric epithelial

cells.

The possesion of flagella that allows movement

through the luminal mucous layer to site of higher Ph.

An ability of adherent strains to supress acid secretion

to improve their survival.

Secretion of urease that produces ammonia results in

a more alkaline environment.

Release of vacuolating cytotoin !"acA# that promotes

bacterial survival and causes epithelial in$ury.



T/e #resence of cytoto-in%assosiated gene :agA!

strains t/at can esca#e normal immune res#onses andcause in9ammation ,it/ release of in9ammatorycyto&ines and reactive o-ygen metabolites t/atdamages mucosal e#itelial cells and loss of t/e#rotective mucosal barrier+

8ecruitment and activation ofneutro#/ils.macro#/ages.and mast cells ,it/ release ofin9ammatory cyto&ines t/at #romote celllar in)ury+

o,n%regulation of antral somatostatin leading toincreased gastrin.acid.im#aired mucosal bicarbonat

#roduction and increased mucosal e-#osure to acid and#e#sin+



Activationin/ibition of T%and B% cellimmune res#onses t/at may contribute tomucosal in)ury+

8elease of cyto&ines and c/emo&ines t/at

#romote gastric e#it/elial cell deat/ andcell #roliferation t/at can result inatro#/y.ulcers.or malignant gro,t/+

-amination



Urea breat/ test

erologi

Bio#sy urea test



Manifestacion*Burn feeling in e#igastrium!

Nausea

Bitter in t/e tounge

isfagia

:om#lication*

so#/agitis is classi>ed into t/e follo,ing 4

grades

=.==.===.=+



PPT=: U':8

Pe#tic ulcer



#(#en sores t/at develo# on t/e inside

lining of your stomac/. u##er smallintestine or eso#/agus+

T/e most common sym#tom of a #e#tic

ulcer is abdominal #ain T/e t,o most common ty#es of #e#tic ulcer

are called 6gastric ulcers7 and 6duodenalulcers7



J/at causes #e#tic ulcers



A bacterium called 'elicobacter pyloriNonsteroidal anti%in9ammatory drugs+8arely. cancerous or noncancerous tumors

in t/e stomac/. duodenum. or #ancreascause ulcers+

rin&ing too muc/ alco/olmo&ing cigarettes or c/e,ing tobacco8adiation treatments

Pe#tic ulcers are not caused by stress or eating s#icy food. butbot/ can ma&e ulcer sym#toms ,orse+ mo&ing and drin&ing

alco/ol also can ,orsen ulcers and #revent /ealing+

#ato>siologi



G+ Pylori UreaseMucin B#/os#oli#ase

Netralisir asam lambungPeradangan sel mu&osa lambung

Antibodi tubu/ R

G+Pylori &olonisa

Nembus cairan lambNem#el sel e#itel

"U

re9u-UPU

G+ SolonisasiNem#el di e#itel duodenal

J/at are t/e sym#toms of a#e#tic ulcer



# #

J/at are t/e sym#toms of a#e#tic ulcer



# #&mergency ,ymptomss/ar#. sudden. #ersistent. and severe stomac/ #ainbloody or blac& stoolsbloody vomit or vomit t/at loo&s li&e coIee grounds

7alarm8 symptoms could be signs of aserious problembleeding,/en acid or t/e #e#tic ulcer brea&s a

blood vessel#erforation,/en t/e #e#tic ulcer burro,s

com#letely t/roug/ t/e stomac/ or duodenal ,allobstruction,/en t/e #e#tic ulcer bloc&s t/e #at/

of food trying to leave t/e stomac/

Go, are ulcers diagnosed



u##er "= series

"

Treatment



=f you /ave a #e#tic ulcer ,it/ an '( pylori infection. t/e standard treatmentuses diIerent combinations of t/e follo,ing medications for 5 % 14 days* T,o diIerent antibiotics to &ill '( pylori. suc/ as

clarit/romycin Bia-in!. amo-icillin. tetracycline. ormetronidaole Flagyl!

Proton #um# in/ibitors suc/ as ome#raole Prilosec!.lanso#raole Prevacid!. or esome#raole Ne-ium!

Bismut/ t/e main ingredient in Pe#to%Bismol! may be

added to /el# &ill t/e bacteria

=f you /ave an ulcer ,it/out an '( pylori infection. or one t/at is caused byta&ing as#irin or NA=s. your doctor ,ill li&ely #rescribe a #roton #um#in/ibitor for H ,ee&s+

(t/er medications t/at may be used for ulcer sym#toms or disease are*

Miso#rostol. a drug t/at may /el# #revent ulcers in #eo#le,/o ta&e NA=s on a regular basisMedications t/at #rotect t/e tissue lining suc/ as

sucralfate!

Possible :om#lications



Bleeding inside t/e body internal bleeding!

"astric outlet obstruction

=n9ammation of t/e tissue t/at lines t/e,all of t/e abdomen #eritonitis!

Perforation of t/e stomac/ and intestines

8eferences



alley. Art/ur F+ Seit/ ' Moore+ :linically(riented Anatomy+ 5t/ edition+ 'i##incottJilliams D Jilcins? 200$

Fauci. Braun,ald. Sas#er. d&&+ GarrisonKsPrinci#les of =nternal Medicine vol ==+ d

1E+United tated * mc"ra,%Gills. 200H+

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