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:

Stores, mixes,
and grinds
food to form
an emulsion

Gastroesophageal
Junction
Incisura
Pylorus
Duodenal
Bulb

Cardia
Body
Antrum

F
u
n
d
u
s

Anatomy and Physiology of

Digestive System - Stomach
Hydrochloric acid
from parietal cells
denatures protein
Pepsinogen
(Pepsin) from
zymogen (chief)
cells begins
proteolysis

Surface Epithelial Cell

Mucous Cell

Parietal Cell

Zymogen Cell
Lymph Nodule
Argentaffine Cell
Muscularis Mucosae

Pyloric Glands

Submucosa

Gastric or Fundic Glands

Anatomy and Physiology of

Digestive System - Stomach
Pepsin

Acid

pH 1-3

Mucous gel
layer

Bicarbonate / Mucus

pH 7

Gastric lumen

Gastric mucosa

Zymogen
Cell

Mucous
Cell

Parietal
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.
Magnesium

D.
Calcium

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 B12

B.
Magnesium

D.
Calcium

Sites of Nutrient
Absorption
Much harder
question

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

C. Vit B12

B.
Magnesium

D. Fat

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:

A. Zinc Sulfate

C. Magnesium
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:

A. Zinc Sulfate

C. Magnesium
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, watersoluble 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
membraneassociated
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 potentialdependent

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
Polysaccharides
Starch
Glycogen
Disaccharides
Sucrose
Lactose
Monosaccharide
Fructose

Intake (gm) % Total

200
1

64
0.5

80
20

26
6.5

10

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

GLUT2

GLUT5

GLUT2
SGLT1

Galactos
e
Fructose

Glucose

Fiber Digestion and

Absorption

Non-starch carbohydrate of plant origin

that escapes enzymatic digestion in the
small intestine

Two types
Cellulosic: high molecular weight, nonsoluble (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 longchain 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?

A. Arachidonic acids

C. Chenodeoxycholic
acids

B. Medium-chain fatty
acids

D. Picric acids

Digestion and Absorption - ???

Good question
12.

Which of the following fatty acid(s) is

absorbed directly into the enterocyte without
micelle formation?

A. Arachidonic acids

C. Chenodeoxycholic
acids

B. Medium-chain fatty
acids

D. Picric 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 !!