Esophagus , Stomach, Duodenum and Small Intestine

Esophagus
embryology

Gut Tube formation

folding of embryo. primitive gut formation.

foregut, midgut

&hindgut. foregut gives esophagus. 4&5th wks esophagus to stretch

epithelial lining is endodermal in origin

epithelium stratified columnar at 6-8th wks.
stratified columnar epithelium ciliated at 10-

12th wks.
stratified squamous epit. replaces at 4-5thmnths.

The muscular layers are mesodermal in origin

striated muscle ( upper 1/3)from caudal brachial

arches
smooth muscle ( lower 2/3 ) from splanchnic

mesoderm

Anatomy
Muscular tube pharynx to cardia. Begins at the level of C-6.

Firmly attached at cricoid cartilage &diaphragm;

During swallowing, the proximal points of

fixation move craniad the distance of one cervical vertebral body.

It lies in the midline, with a certain deviation to

left

Esophageal layers
mucosa and muscularis

propria. The mucosa is consists of squamous epithelium for most of its course (Barrett's esophagus). Within the mucosa, there are four distinct layers: Deep to the muscularis mucosa lays the sub mucosa which are good place for successful growth and invasion of cancers!

Three normal narrowing

1.The uppermost narrowing 2.The middle narrowing 3.The lowermost narrowing
These constrictions tend to hold up swallowed foreign objects.

Portion and relations

1.cervical portion of the esophagus
5 cm & b/n trachea & vertebral column. C-6 to T-1&T-2. left recurrent nerve lies closer to the esophagus

Laterally, carotid sheaths & lobes of the thyroid

gland.

cont
2.The thoracic portion of the esophagus
20 cm long & starts at the thoracic inlet.

In upper portion intimate relationship with

trachea & prevertebral fascia.

Above tracheal bifurcation passes to the Rt of the

aorta.
From the bifurcation of the trachea downward,

both the vagal nerves and the esophageal nerve plexus lie on the muscular wall of the esophagus

cont
3.The abdominal portion of the esophagus
2 cm long& includes a portion of the LES .

It starts as the esophagus passes through the

diaphragmatic hiatus.
These fibers blend in with the elastic-containing

adventitia of the abdominal esophagus and the cardia of the stomach.

This portion of the esophagus is subjected to the

positive-pressure environment of the abdomen.

Arterial supply
1.Inferior thyroid a.(cx). 2.Bronchial a.(1 Rt&2 Lt)& esophageal branches from aorta (thoracic). 3.Ascending branch of left gastric artery & inferior phrenic a.(abdominal).

Venous drainage
1.inferior thyroid vein(cervical). 2.bronchial, azygos, or hemiazygos veins.(thoracic). 3.coronary vein.(abdominal).
The sub mucosal venous networks of the

esophagus and stomach are in continuity with each other, (portal venous obstruction).

Lymphatic drainage
1.cervical esophagus -paratracheal & deep cx LNs. 2.upper thoracic esophagus -paratracheal LNs. 3.lower thoracic esophagus -subcarinal nodes and nodes in the inferior pulmonary ligaments.

innervations
The parasympathetic innervations

-mainly by the vagus nerves.

cricopharyngeal sphincter & the cervical

esophagus - both recurrent laryngeal nerves( from vagus n.)

In the thorax, the vagus nerve sends fibers to

the striated muscle as well as parasympathetic preganglionic fibers to the smooth muscle of the esophagus

cont..
These sympathetic and parasympathetic fibers penetrate through the muscular wall forming these networks between the muscle layers to become Auerbach's plexus and within the sub mucosal layer to become Meissonier's plexus They provide an intrinsic autonomic nervous system within the esophageal wall that is responsible for peristalsis..

physiology
Swallowing 3 phases of

swallowing: 1.oral, 2.pharyngeal, and 3.esophageal. These rapid series of events last about 1.5 seconds and, once initiated, are completely reflexive

esophageal sphincter &Peristalsis

The upper esophageal sphincter Peristalsis

The lower esophageal sphincter (LES)

-

Reflux Mechanism
Not all reflux is abnormal. The competence of the LES and its ability to establish a

barrier to reflux depends on several factors. 1.Resting LES pressure >6mmHg(6-26mmHg) 2.Overall sphinctor length >2cm. 3.Intra abdominal length of sphinctor >1cm. Radial asymmetry and abnormal peristalsis prevent proper closure and allow free refluxing of gastric material. Abnormal esophageal motility and poor gastric emptying result in inadequate esophageal clearance that also encourages reflux. Anatomic & physiologic disruptions result to GERD.

stomach
Embryology 5th wk- dilatation of tubular embryonic foregut 7th wk assumes its normal anatomic shape & position by decent ,rotation & dilatation. The rate of growth of the left wall outpaces the right, thus forming the greater and lesser curvatures Its rotation causes left vagus to lie anteriorly and right vagus to lie posteriorly. The ventral and dorsal mesenteries of the foregut become the lesser and greater omentums, respectively, in adult life.

anatomy

relations
Anteriorly left lateral segment of left lobe of liver Posteriorly lesser omental bursa & pancrease Superiorly gastro hepatic ligament Inferiorly attached to transverse colon ( by gastro colic momentum)

relations

Arterial supply

Venous drainage
The left gastric (coronary) and right gastric veins

usually drain into the portal vein.

The right gastroepiploic vein drains into the

superior mesenteric vein, and

The left gastroepiploic vein drains into the splenic

vein.

lymphatic
lymph nodes drain

different areas of the stomach,

gastric cancers may

metastasize to any of the four nodal groups regardless of the cancer location.
extensive sub mucosal

lymphatics plexus frequently microscopic evidence of malignant cells several centimeters from the resection margin of gross disease

innervations
is via parasympathetic and sympathetic fibers. a. The vagus (parasympathetic) nerves stimulate parietal cell secretion, gastrin release, and gastric motility. Acetylcholine is the primary neurotransmitter. b. Sympathetic innervation is via the greater splanchnic nerves( spinal segments T5 -T10). These fibers terminate in the celiac ganglion, and postganglionic fibers follow the gastric arteries to the stomach

Gastric Glandular Organization

CELLS parietal mucus Chief LOCATION body Body,antrum body FUNCTION Secration of acid & intrinsic factor mucus Pepsin

Surface epithelial
entrochromafin-like G D Gastric mucosal internurons Enteric neurons

diffuse
body antrum Body,antrum Body,antrum diffuse

Mucus,bicarbonate,prostaglandins
histamine gastrin Somatostatin Gastrin-releasing peptide Calcitonin gene-related peptide,others

endocrine

body

ghrelin

Physiology
Principal function of stomach is preparing of food for

digestion and absorption Used as storage & participate in digestion of food

Regulation of gastric function.

Both neural and hormonal control

Hormonal mediators are peptides and amines

The mediators act in 3 ways:-endocrine ,paracrine and

neurocrine. Somatostatin act either endocrine or paracrine

Gastric peptides
Gastrin Produced by G-cells from antrum Major hormonal regulator of acid secretion

(gastric) following meal Plays a role in the intrinsic gastric mucosal defense system. Somatostatin Produced by D-cells(body &antrum). Inhibit acid secretion from parietal cell and by inhibiting gastrin release and dawn regulation of histamine release from ECL cells.

cont.
Antral acidification is a principal stimulant of

somatostatin release
Acetylcholine inhibit its release. H. pylori decreases antral D cells and somatostatin levels

increase in gastrin release increase in gastric acid secretion.

Histamine Histamine plays a prominent role in parietal cell

stimulation
histamine is an intermediate of gastrin- and

acetylcholine-stimulated acid secretion.

cont
stimulated by gastrin, acetylcholine, and epinephrine

following. Gastric Acid Secretion Gastric acid secretion by the parietal cell is regulated by three local stimuli: 1. acetylcholine, 2. gastrin, and 3. histamine. These three stimuli account for basal and stimulated gastric acid secretion

Basal Acid Secretion

- Roughly 10% of maximal acid output. - Circadian variation, with night time > day time. - 1 to 5 mmol/h of HCl is secreted( 75% to 90% decrement

after vagotomy).
- ACh plays a significant role in basal acid secretion.

- H2-blockers diminishes acid secretion by 90%,so

histamine also plays an important intermediary role in this process.

- Thus, it appears likely that basal acid secretion is due to

a combination of cholinergic and histaminergic input.

Stimulated Acid Secretion

food is a physiologic stimulus for acid secretion. Three

phases of the acid Secretory response t

1.The cephalic phase

Sensory perception of food stimulates neural centers &

in the cortex &hypothalamus. Higher centers transmit signals to the stomach by the vagus nerves release acetylcholine activates muscarinic receptors located on target cells. Acetylcholine directly increases acid secretion by the parietal cell and can both inhibit and stimulate gastrin release, the net effect being a slight increase in gastrin levels.

2.Gastric Phase
The gastric phase of acid secretion begins when food

enters the gastric lumen. Digestion products of ingested food interact with microvilli of antral G cells to stimulate gastrin release. Food also stimulates acid secretion by causing mechanical distention of the stomach. Gastric distention activates stretch receptors in the stomach to elicit the long vagovagal reflex arc. It is abolished by proximal gastric vagotomy. However, antral distention also causes gastrin release in humans, and this reflex has been called the pylorooxyntic reflex.

In humans, mechanical distention of the

stomach accounts for about 30% to 40% of the maximal acid Secretory response to a peptone meal, with the remainder due to gastrin release.
The entire gastric phase accounts for

most (60%-70%) of meal-stimulated acid output because it lasts until the stomach is empty

3.Intestinal Phase
initiated by entry of chyme into the small intestine.
It occurs after gastric emptying and lasts as long as

partially digested food components remain within the proximal small bowel. It accounts for only 10% of the acid Secretory response to a meal and does not appear to be mediated by serum gastrin levels. It is hypothesized that a distinct acid stimulatory peptide hormone (entero-oxyntin) that is released from small bowel mucosa may mediate the intestinal phase of acid secretion

Pharmacologic Regulation of Gastric Acid Secretion

Site-specific receptor antagonists for histamine,

gastrin, and acetylcholine inhibit gastric acid secretion by competitive inhibition of the receptor. The best known site-specific antagonists are the group collectively known as 1. H2-receptor antagonists( ranitidine, cemtedin). 2. The proton pump inhibitors( omeprazol ).

ATP = adenosine triphosphate; cAMP = cyclic adenosine monophosphate; CCK = cholecystokinin; H2 = histamine 2; IP3 = inositol trisphosphate; PIP2 = phosphatidylinositol 4,5-bisphosphate; PLC = phospholipase C.

Gastric Emptying
Gastric emptying is slowed by increasing caloric content Liquid emptying is faster than solid emptying. Osmolarity, acidity, caloric content, and nutrient

composition are important modulators.

Stimulation of duodenal osmoreceptors, glucoreceptors, and

pH receptors clearly inhibits gastric emptying by a variety of neurohumoral mechanisms.

CCK has been consistently shown to inhibit gastric emptying

at physiologic doses .
The orexigenic hormone ghrelin has the opposite effect.

Liquid Emptying
The gastric emptying of water or isotonic saline follows first

order kinetics, with a half emptying time around 12 minutes. Thus, if one drinks 200 mL of water, about 100 mL enters the duodenum by 12 minutes, Up to an osmolarity of about 1 M, liquid emptying occurs at a rate of about 200 kcal per hour. Duodenal osmoreceptors and hormones (e.g., secretin and VIP) are important modulators of liquid gastric emptying. Generally, liquid emptying is delayed in the supine position. Nutrient composition and caloric density affect liquid gastric emptying. Glucose solution (the least calorically dense), emptied the fastest. Other more calorically dense solutions, such as milk protein and peptide hydrolysates , emptied slower

Solid Emptying
Normally, the half-time of solid gastric emptying is <2 hours.
solids have initial lag phase with little emptying of solids occurs. During this phase much of the grinding and mixing occurs. A linear emptying phase follows, during which the smaller

particles are metered out to the duodenum. When liquids & solids are ingested together, liquids empty first. Solids stored in fundus & delivered to the distal stomach at constant rates for grinding. Liquids also are sequestered in the fundus, but they appear to be readily delivered to the distal stomach for early emptying. The larger the solidity of meal, the slower the liquid emptying. Patients bothered by dumping syndrome are advised to limit the amount of liquid consumed with the solid meal, taking advantage of this effect.

Small intestine

EMBRYOLOGY Duodneum from forgut Jejunum and ileum from midgut. Epithelial lining from endoderm Muscular connective tissue from splanchnic mesoderm. 5th wk of devt intestinal length increases rapidly hernation of midgut occurs through umbilicus. This midgut loop has cranial & caudal ends with the cranial limb developing into the distal duodenum, jejunum, and proximal ileum and the caudal limb becoming the distal ileum and proximal two thirds of the transverse colon.

Anatomy
The length of bowel that extends from the pylorus to the cecum. a. The duodenum, which is retroperitoneal, extends from the pylorus to the ligament of Treitz. b. The jejunum (proximal 40%) and ileum (distal 60%), which are intraperitoneal, make up the remainder of the small intestine. c. The total length of small bowel is approximately 3 m (the duodenum measures 30 cm; the jejunum is 110 cm; andthe ileum is 160 cm).

Duodenum

Arterial supply
superior mesenteric

artery(except proximal duodenum) There is an abundant collateral blood supply to the small bowel provided by vascular arcades coursing in the mesentery. Venous drainage of the small bowel parallels the arterial supply, superior mesenteric vein splenic vein portal vein.

jejunum and the ileum

JEJUNUM
THE ILEUM

proximal Larger

2/5th

Distal 3/5th

Smaller

circumference
Thicker than ileum
one or two arcades

circumference
Thinner
4 or 5 separate

Long, straight vasa

arcades
Shorter vasa recta

recta

The innervations
parasympathetic and sympathetic Parasympathetic fibers are derived from the vagus, and

affect secretion, motility, and probably all phases of bowel activity. The sympathetic fibers come from three sets of splanchnic nerves and have their ganglion cells usually in a plexus around the base of the superior mesenteric artery. Motor impulses affect blood vessel motility and probably gut secretion and motility.. Lymphatic drainage from the mucosa adjacent nodes cisterna chyli thoracic duct.

Layers of the wall of the small intestine

a. The mucosa consists mostly of - absorptive columnar epithelium and - mucous-producing goblet cells. Theabsorption of nutrients takes place through the epithelial cells that cover the intestinal villi and have a total surface area of approximately 500 m2. Mucosal cells proliferate rapidly and have a life span of 5 days. b. The sub mucosa is the strongest layer and provides strength to an intestinal anastomosis. It contains nerves,Meissner's plexus, blood vessels, lymphoid tissue (Payer patches), and fibrous and elastic tissue. c. The muscularisthe muscle layerconsists of an outer longitudinal layer and an inner circular layer with Auerbach's myenteric plexus of ganglion cells in between. d. The serosa is the outermost layer and derives embryologically from the peritoneum.

 The primary functions of the small intestine are digestion and

Physiology

absorption. All ingested food and fluid, plus secretions from the stomach, liver, and pancreas, reach the small intestine. The total volume may reach 9 L/day, and all except 12 L will be absorbed. Motility a. after a meal two types of contractions occur. 1. To-and-fro motion mixes chyme with digestive juices and provides prolonged exposure to the absorptive mucosa. 2. Peristaltic contractions move food distally. b. In the fasting state, a strong contraction begins in the duodenum and occurs every 2 hours (migrating motor complex). This completes the emptying of residual food from previous meals. c. Parasympathetic stimulation promotes contractions, whereas sympathetic stimulation inhibits them

Absorption
Vitamins, fat, protein, carbohydrates, water, and electrolytes

are all absorbed in the small intestine. a. Water is absorbed mostly at jejunum passively. b. Electrolytes 1. Potassium is absorbed by intercellular pores in the jejunum(passive). 2. Sodium is actively transported, and once a gradient is established, chloride follows passively. 3. Calcium is actively transported in the jejunum (enhanced by vitamin D and parathyroid hormone). 4. Iron is absorbed as the ferrous (reduced) ion Fe2+. active transport in the duodenum and jejunum. c. Fat absorption occurs mainly in the jejunum.

cont
d. Carbohydrates -digested in to monosaccharides ,galactose and glucose( active transport), and fructose(diffusion). e. Protein digested by pepsin(stomach) & pancreatic proteases(SI) in to tripeptides, dipeptides,& amino acids(active absorption). f. The fat-soluble vitamins A, D, E, and K are absorbed from micelles by the mucosa. Vitamin B12 is complexed with intrinsic factor and absorbed in the distal ileum. Vitamin C, thiamine, and folic acid are actively transported. The remaining water-soluble vitamins are absorbed by passive diffusion

Endocrine Function
Hormone Somatostatin Secretin Cholecystokinin Sourcea D cell S cell I cell Actions Inhibits GI secretion, motility, and splanchnic perfusion Stimulates exocrine pancreatic secretion Stimulates intestinal secretion Stimulates pancreatic exocrine secretion Stimulates gallbladder emptying Inhibits sphincter of Oddi contraction Simulates intestinal motility Inhibits intestinal motility and secretion Stimulates intestinal epithelial proliferation Stimulates pancreatic and biliary secretion Inhibits small bowel motility Stimulates intestinal mucosal growth

Motilin Peptide YY Glucagon-like peptide 2 Neurotensin

M cell L cell L cells N cell

Gastrointestinal Hormones
The gastrointestinal hormones are distributed along

the length of the small bowel in a spatial-specific pattern. The small bowel is the largest endocrine organ in the body.

Diagnostic and Therapeutic Uses of Gastrointestinal Hormones

HORMON gastrin chollecystokinin secreting glucagon DIAGNOSTIC/THERAPUTIC USES Pentagastrin (gastrin analogs)used to measure maximal gastric acid secretion. Biliary imaging of gallbladder contraction Provocative test for gastrinoma Measurement of maximal pancreatic secretion Suppresses bowel motility for endocrine spasm Relieves sphincter of oddi spasm Provocative test for insulin , catecholamine ,and growth hormone release Treatment of carcinoid diarrhea and flushing Decrease secretion from pancreatic and intestinal fistulas Ameliorate symptoms associated with hormone overproducing endocrine tumors Treatment of esophageal variceal bleeding

Somatostatin analogues

IMMUNE FUNCTION
During the course of a normal day, we ingest a number

of bacteria, parasites, and viruses. Small intestine serves as a major immunologic barrier in addition to its digestive & endocrine function. To deal with pathogens the gut has evolved into a highly organized and efficient mechanism for antigen processing, humoral immunity, and cellular immunity. The gut-associated lymphoid tissue is localized in three areas: -Payer patches, - lamina propria lymphoid cells, and -intraepithelial lymphocytes.

 one of the major protective immune mechanisms for

the intestinal tract is the synthesis and secretion of IgA.

The intestine contains more than 70% of the IgA-

producing cells in the body.

IgA is produced by plasma cells in the lamina propria

and is secreted into the intestine, where it can bind antigens at the mucosal surface.
Secretory IgA inhibits the adherence of bacteria to

epithelial cells and prevents their colonization and multiplication.

In addition, Secretory IgA neutralizes bacterial toxins

and viral activity and blocks the absorption of antigens from the gut.

references
Schwartz principles of surgery 9th ed.
Grays-anatomy Sabiston surgery 18th ed

Pharmacology-Lange
internet

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