THE STOMACH

Gross Anatomy of the Stomach

Stomach is a temporary storage tank that starts chemical breakdown of protein digestion
- Converts bolus of food to paste-like chyme
- Empty stomach has ~50 ml volume but can expand to 4 L
- When empty, stomach mucosa forms many folds called rugae
Major regions of the stomach
- Cardial part (cardia): surrounds cardial orifice
- Fundus: dome-shaped region beneath diaphragm

- Body: midportion
- Pyloric part: wider and more superior portion of
pyloric region, antrum, narrows into pyloric
canal that terminates in pylorus
o Pylorus is continuous with duodenum
through pyloric valve (sphincter controlling
stomach emptying)
- Greater curvature: convex lateral surface of
stomach
- Lesser curvature: concave medial surface of
stomach
- Mesenteries extend from curvatures and tether stomach to other digestive organs
- Lesser omentum: Runs from lesser curvature to liver
- Greater omentum: drapes inferiorly from greater curvature over intestine, spleen,
and transverse colon
o Blends with mesocolon, mesentery that anchors large intestine to abdominal
wall
o Contains fat deposits and lymph nodes
- Autonomic nervous system supplies stomach
o Sympathetic fibers from thoracic splanchnic nerves are relayed through celiac
plexus
o Parasympathetic fibers are supplied by vagus nerve
- Blood supply
o Celiac trunk (gastric and splenic branches)
o Veins of hepatic portal system

Microscopic Anatomy of the Stomach

Types of gland cells
- Glands in fundus and body produce most gastric juice
- Glands include secretory cells
1. Mucous neck cells
- Secrete thin, acidic mucus of unknown function
 2. Parietal cells
- Secretions include:
- Hydrochloric acid (HCl)
- pH 1.5–3.5; denatures protein, activates pepsin,
breaks down plant cell walls, and kills many
bacteria
- Intrinsic factor
- Glycoprotein required for absorption of vitamin
B12 in small intestine
3. Chief cells
- Secretions include:
o Pepsinogen: inactive enzyme that is
activated to pepsin by HCl and by pepsin
itself (a positive feedback mechanism)
o Lipases - Digests ~15% of lipids
4. Enteroendocrine cells
- Secrete chemical messengers into lamina propria
o Act as paracrines - Serotonin and histamine
- Hormones
o Somatostatin (also acts as paracrine) and gastrin
Mucosal barrier
- Harsh digestive conditions require stomach to be protected
- Mucosal barrier protects stomach and is created by three factors
o Thick layer of bicarbonate-rich mucus
o Tight junctions between epithelial cells
 Prevent juice seeping underneath tissue
o Damaged epithelial cells are quickly replaced by division of stem cells
 Surface cells replaced every 3–6 days

Clinical
• Gastritis
– Inflammation caused by anything that breaches stomach’s mucosal barrier
• Peptic or gastric ulcers
– Can cause erosions in stomach wall
§ If erosions perforate wall, can lead to peritonitis and hemorrhage
– Most ulcers caused by bacterium Helicobacter pylori
– Can also be caused by non-steroidal anti-inflammatory drugs (NSAIDs), such
as aspirin
Digestive Process in the Stomach
Process carried out by stomach
- Carries out breakdown of food
- Serves as holding area for food
- Delivers chyme to small intestine
- Denatures proteins by HCl
- Pepsin carries out enzymatic digestion of proteins
o Milk protein (casein) is broken down by rennin in infants
 Results in curdy substance
- Lipid-soluble alcohol and aspirin are absorbed into blood
- Only stomach function essential to life is secretion of intrinsic factor for vitamin B12
absorption
o B12 needed for red blood cells to mature
o Lack of intrinsic factor causes pernicious anemia
o Treated with B12 injections

Regulation of Gastric Secretion

Gastric mucosa secretes >3 L of gastric juice/day and are regulated by:
- Neural mechanisms
o Vagus nerve stimulation increases secretion
o Sympathetic stimulation decreases secretion
- Hormonal mechanisms
o Gastrin stimulates HCl secretion by stomach and gastrin antagonist hormones
by small intestine
Gastric secretions are broken down into three phases
1. Cephalic (reflex) phase
- Conditioned reflex triggered by aroma, taste, sight, thought
2. Gastric phase
- Lasts 3–4 hours and provides two-thirds of gastric juice released
- Stimulation of gastric phase
o Distension activates stretch receptors, initiating both long and short reflexes
o Chemical stimuli, such as partially digested proteins, caffeine, and low acidity,
activate enteroendocrine G cells to secrete gastrin
o Release of gastrin then initiates HCl release from parietal cells and activates
enzyme secretion
 Prods parietal cells to secrete HCl by:
 Binding to receptors on parietal cells
 Stimulating enteroendocrine cells to release histamine
 Buffering action of ingested proteins causes pH to rise, which activates
more gastrin secretion
- Inhibition of gastric phase
 o Low pH inhibits gastrin secretion
 Occurs between meals
 Occurs during digestion as negative feedback mechanism
 The more protein, the more HCl acid is secreted, causing decline
in pH, which inhibits gastrin secretion
3. Intestinal Phase
- Begins with a brief stimulatory component followed by inhibition
- Stimulation of intestinal phase
o Partially digested food enters small intestine, causing a brief release of
intestinal (enteric) gastrin
 Encourages gastric glands of stomach to continue secretory activities
 Stimulatory effect is brief and overridden by inhibitory stimuli as
intestine fills
- Inhibition of intestinal phase
o Four main factors in duodenum cause inhibition of gastric secretions:
 Distension of duodenum due to entry of chyme
 Presence of acidic chyme
 Presence of fatty chyme
 Presence of hypertonic chyme
o Inhibitory effects protect intestine from being overwhelmed by too much
chyme or acidity
o Inhibition is achieved in two ways: enterogastric reflex and
enterogastrones
o Enterogastric reflex
 Duodenum inhibits acid secretion in stomach by:
 Enteric nervous system short reflexes
 Sympathetic nervous system and vagus nerve long reflexes
o Enterogastrones
 Duodenal enteroendocrine cells release two important hormones that
inhibit gastric secretion
 Secretin
 Cholecystokinin (CCK)
Clinical
- Vomiting (emesis) is caused by:
o Extreme stretching
o Intestinal irritants, such as bacterial toxins, excessive alcohol, spicy food,
certain drugs
- Chemicals and sensory impulses stimulate emetic center of medulla
- Excessive vomiting can lead to dehydration and electrolyte and acid-base
imbalances (alkalosis)

THE LIVER
- Liver, gallbladder, and pancreas are accessory organs associated with small
intestine
- Liver: digestive function is production of bile
o Bile: fat emulsifier
Gross Anatomy of Liver
- Largest gland in body; weighs ~3 lbs
- Consists of four primary lobes: right, left,
caudate, and quadrate
- Falciform ligament
o Separates larger right and smaller
left lobes
o Suspends liver from diaphragm and
anterior abdominal wall
- Round ligament (ligamentum teres)
o Remnant of fetal umbilical vein along
free edge of falciform ligament
- Lesser omentum anchors liver to stomach
- Hepatic artery and vein enter liver at porta hepatis

- Bile ducts
o Common hepatic duct leaves liver
o Cystic duct connects to gallbladder
o Bile duct formed by union of common hepatic and cystic ducts
Microscopic Anatomy of the Liver
- Liver lobules
o Hexagonal structural and functional units
o Composed of plates of hepatocytes (liver cells) that filter and process
nutrient-rich blood
o Central vein located in longitudinal axis
 - Portal triad in each corner of lobule contains:
o Branch of hepatic artery, which supplies oxygen
o Branch of hepatic portal vein, which brings nutrient-rich blood from intestine
o Bile duct, which receives bile from bile canaliculi
Bile Composition
- Yellow-green, alkaline solution containing:
o Bile salts: cholesterol derivatives that function in fat emulsification and
absorption
o Bilirubin: pigment formed from heme
 Bacteria break down in intestine to stercobilin that gives brown color of
feces
o Cholesterol, triglycerides, phospholipids, and electrolytes
Clinical
- Hepatitis
o Usually viral infection, drug toxicity, wild mushroom poisoning
- Cirrhosis
o Progressive, chronic inflammation from chronic hepatitis or alcoholism
o Liver  fatty, fibrous  portal hypertension
- Liver transplants successful, but livers are scarce
o Liver can regenerate to its full size in 6–12 months after 80% removal

THE GALLBLADDER
- Gallbladder: chief function is storage of bile
- Gallbladder is a thin-walled muscular sac on ventral surface of liver
- Functions to store and concentrate bile by absorbing water and ions
- Contains many honeycomb folds that allow it to expand as it fills
- Muscular contractions release bile via cystic duct, which flows into bile duct
Clinical
- Gallstones (biliary calculi): caused by too much cholesterol or too few bile salts
o Can obstruct flow of bile from gallbladder
o Painful when gallbladder contracts against sharp crystals
o Obstructive jaundice: blockage can cause bile salts and pigments to build up in
blood, resulting in jaundiced (yellow) skin
 Jaundice can also be caused by liver failure
o Gallstone treatment: crystal-dissolving drugs, ultrasound vibrations
(lithotripsy), laser vaporization, or surgery
THE PANCREAS
- Pancreas: supplies most of enzymes needed to digest chyme, as well as bicarbonate
to neutralize stomach acid
- Location: mostly retroperitoneal, deep to greater curvature of stomach
- Head is encircled by duodenum; tail abuts spleen
- Exocrine function: produce pancreatic juice
- Acini: clusters of secretory cells that produce zymogen granules containing
proenzymes
- Ducts: secrete to duodenum via main pancreatic duct; smaller duct cells produce
water and bicarbonate
- Endocrine function: secretion of insulin and glucagon by pancreatic islet cells

Composition of Pancreatic Juice

- 1200–1500 ml/day is produced containing:
o Watery, alkaline solution (pH 8) to neutralize acidic chyme coming from
stomach
o Electrolytes, primarily HCO3− Digestive enzymes
 Proteases (for proteins): secreted in inactive form to prevent self-
digestion
 Amylase (for carbohydrates)
 Lipases (for lipids)
 Nucleases (for nucleic acids)
- Proteases are secreted in an inactive form; they are activated after they reach
duodenum
o Enteropeptidase, enzyme bound to plasma membrane of duodenal epithelial
cells, activates pancreatic protease trypsinogen to trypsin
o Once trypsin is activated, it can then activate:
 More trypsinogen
 Procarboxypeptidase to active carboxypeptidase
 Chymotrypsinogen to active chymotrypsin

Bile and Pancreatic Secretion into the Small Intestine

- Bile duct and pancreatic duct unite in wall of duodenum
o Fuse together in bulblike structure called hepatopancreatic ampulla
- Ampulla opens into duodenum via volcano-shaped major duodenal papilla
- Hepatopancreatic sphincter controls entry of bile and pancreatic juice into
duodenum
- Accessory pancreatic duct: smaller duct that empties directly into duodenum
- Regulation of bile and pancreatic secretions
 - Bile and pancreatic juice secretions are both stimulated by neural and hormonal
controls
- Hormonal controls include:
o Cholecystokinin (CCK)
o Secretin
- Bile secretion is increased when:
o Enterohepatic circulation returns large amounts of bile salts
o Secretin, from intestinal cells exposed to HCl and fatty chyme, stimulates
gallbladder to release bile
o Hepatopancreatic sphincter is closed, unless digestion is active
o Bile is stored in gallbladder and released to small intestine only with
contraction

THE SMALL INTESTINE

Gross Anatomy of Small Intestine
- Small intestine is the major organ of
digestion and absorption
- 2–4 m long (7–13 ft) from pyloric
sphincter to ileocecal valve, point at
which it joins large intestine
- Small diameter of 2.5–4 cm (1.0–1.6
inches)
- Subdivisions
 o Duodenum: mostly retroperitoneal; ~25.0 cm (10.0 in) long; curves around
head of pancreas
 Has most features
o Jejunum: ~2.5 m (8 ft) long; attached posteriorly by mesentery
o Ileum: ~3.6 m (12 ft) long; attached posteriorly by mesentery; joins large
intestine at ileocecal valve
- Blood supply:
o Superior mesenteric artery brings blood supply
o Veins (carrying nutrient-rich blood) drain into superior mesenteric veins,
then into hepatic portal vein, and finally into liver
- Nerve supply
o Parasympathetic innervation via vagus nerve, and sympathetic innervation
from thoracic splanchnic nerves
-
Microscopic Anatomy of Small Intestine
Modifications of small intestine for absorption
- Small intestine’s length and other structural
modifications provide huge surface area for
nutrient absorption
o Surface area is increased 600 to
~200 m2 (size of a tennis court)
- Modifications include:
o Circular folds
 Permanent folds (~1 cm deep)
that force chyme to slowly spiral
through lumen, allowing more
time for nutrient absorption
o Villi
 Fingerlike projections of mucosa
(~1 mm high) with a core that contains dense capillary bed and
lymphatic capillary called a lacteal for absorption
o Microvilli
o Cytoplasmic extensions of mucosal cell that give fuzzy appearance called the
brush border that contains membrane-bound enzymes brush border
enzymes, used for final carbohydrate and protein digestion
Histology of the small intestine wall
- Modifications of mucosa and submucosa of small intestine reflect its function in
digestion
- Intestinal crypts: tubular glands scattered between villi
- Five main types of cells found in villi and crypts
o Enterocytes: make up bulk of epithelium
  Simple columnar absorptive cells bound by tight junctions and contain
many microvilli
 Function
 Villi: absorb nutrients and electrolytes
 Crypts: produce intestinal juice, watery mixture of mucus that
acts as carrier fluid for chyme
o Goblet cells: mucus-secreting cells found in epithelia of villi and crypts
o Enteroendocrine cells: source of enterogastrones (examples: CCK and
secretin)
 Found scattered in villi but some in crypts
o Paneth cells: found deep in crypts, specialized secretory cells that fortify small
intestine’s defenses
 Secrete antimicrobial agents (defensins and lysozyme) that can destroy
bacteria
o Stem cells that continuously divide to produce other cell types
 Villus epithelium renewed every 2–4 days
- Mucosa-associated lymphoid tissue protects intestine against microorganisms and
includes:
o Individual lymphoid follicles
o Peyer’s patches (aggregated lymphoid nodules), located in lamina propria
 Found in great numbers in distal part of small intestine, where bacterial
numbers increase
o Lamina propria also contains large numbers of plasma cells that secrete IgA
- Submucosa consists of areolar tissue
o Duodenal glands of duodenum secrete alkaline mucus to neutralize acidic
chyme

Intestinal Juice
- 1–2 L secreted daily in response to distension or irritation of mucosa
- Major stimulus for production is hypertonic or acidic chyme
- Slightly alkaline and isotonic with blood plasma
- Consists largely of water but also contains mucus
o Mucus is secreted by duodenal glands and goblet cells of mucosa

Digestive Process in the Small Intestine

- Chyme from stomach contains partially digested carbohydrates and proteins and
undigested fats
- Takes 3–6 hours in small intestine to absorb all nutrients and most water
- Sources of enzymes for digestion
o Substances such as bile, bicarbonate, digestive enzymes (not brush border
enzymes) are imported from liver and pancreas
 o Brush border enzymes bound to plasma membrane perform final digestion of
chyme
Motility of the small intestine
- After a meal
o Segmentation is most common motion of small intestine
o Initiated by intrinsic pacemaker cells
o Mixes/moves contents toward ileocecal valve
o Intensity is altered by long and short reflexes and hormones
 Parasympathetic increases motility; sympathetic decreases it
- Between meals
o Peristalsis increases, initiated by rise in hormone motilin in late intestinal
phase (every 90–120 minutes)
o Each wave starts distal to previous wave; referred to as migrating motor
complex (MMC)
o Meal remnants, bacteria, and debris are moved toward large intestine
o Complete trip from duodenum to ileum takes ~2 hours

THE LARGE INTESTINE

Gross Anatomy of Large Intestine
- Large intestine has three unique features
not seen elsewhere:
o Teniae coli: three bands of
longitudinal smooth muscle in
muscularis
o Haustra: pocketlike sacs caused by
tone of teniae coli
o Epiploic appendages: fat-filled
pouches of visceral peritoneum
Subdivision of Large Intestine
- Cecum: first part of large intestine
- Appendix: masses of lymphoid tissue
o Part of MALT of immune system
o Bacterial storehouse capable of recolonizing gut when necessary
o Twisted shape of appendix makes it susceptible to blockages
- Colon: has several regions, most which are retroperitoneal (except for transverse
and sigmoid regions)
o Ascending colon: travels up right side of abdominal cavity to level of right
kidney
 Ends in right-angle turn called right colic (hepatic) flexure
- Transverse colon: travels across abdominal cavity
o Ends in another right-angle turn, left colic (splenic) flexure
- Descending colon: travels down left side of abdominal cavity
 - Sigmoid colon: S-shaped portion that travels through pelvis
- Rectum: three rectal valves stop feces from being passed with gas (flatus)
- Anal canal: last segment of large intestine that opens to body exterior at anus
o Has two sphincters
o Internal anal sphincter: smooth muscle
o External anal sphincter: skeletal muscle
-
Clinical
- Appendicitis: acute inflammation of appendix; usually results from a blockage by
feces that traps infectious bacteria
o Most common in adolescence when entrance to appendix is at widest
- Venous drainage can be impaired, leading to ischemia and necrosis (tissue death)
- Ruptured appendix can cause peritonitis
- Symptoms: pain in umbilical region, moving to lower right abdominal quadrant
o loss of appetite, nausea, and vomiting are also seen
- Treatment: surgical removal (appendectomy), or in some cases, with antibiotics.

Microscopic Anatomy of Large Intestine

- Large intestine contains thicker mucosa made up of simple columnar epithelium
- Except in anal canal, where it becomes stratified squamous epithelium to withstand
abrasion
- Does not contain circular folds, villi, or digestive secretions
- Contains abundant deep crypts with many mucus-producing goblet cells
- Mucosa of anal canal hangs in long ridges or folds referred to as anal columns
- Anal recesses: located between anal columns; secrete mucus to aid in emptying
- Pectinate line: horizontal line that parallels anal sinuses
- Superficial venous plexuses of anal canal form hemorrhoids if inflamed

Bacterial Flora
- Bacterial flora: consist of 1000+ different types of bacteria
- Outnumber our own cells 10 to 1
- Enter from small intestine or anus to colonize colon
- Metabolic functions
o Fermentation
 Ferment indigestible carbohydrates and mucin
 Release irritating acids and gases (~500 ml/day)
o Vitamin synthesis
 Synthesize B complex and some vitamin K needed by liver to produce
clotting factors
o Keeping pathogenic bacteria in check
 Beneficial bacteria outnumber and suppress pathogenic bacteria
  Immune system destroys any bacteria that try to breach mucosal
barrier

Digestive Process in the Large Intestine

- Residue remains in large intestine 12–24 hours
- No food breakdown occurs except what enteric bacteria digest
- Vitamins (made by bacterial flora), water, and electrolytes (especially Na+ and Cl−)
are reclaimed
- Major functions of large intestine is propulsion of feces to anus and defecation
- Motility of the large intestine
o Haustral contractions: most contractions of colon, where haustra
sequentially contract in response to distension
 Slow segmenting movements, mostly in ascending and transverse colon
o Gastrocolic reflex: initiated by presence of food in stomach
 Results in mass movements: slow, powerful peristaltic waves that are
activated three to four times per day
o Descending colon and sigmoid colon act as storage reservoir
- Defecation
o Mass movements force feces toward rectum
o Distension initiates spinal defecation reflex
o Parasympathetic signals
 Stimulate contraction of sigmoid colon and rectum
 Relax internal anal sphincter
o Conscious control allows relaxation of external anal sphincter
o Muscles of rectum contract to expel feces

Mechanism of Digestion and Absorption

- Digestion breaks down ingested foods into their chemical building blocks
- Digestion: catabolic process that breaks macromolecules down into monomers
small enough for absorption
o Intrinsic and accessory gland enzymes are involved in digestion
o Enzymes carry out hydrolysis, whereby water is added to break chemical
bonds
- Only these molecules are small enough to be absorbed across wall of small intestine
- Absorption is process of moving substances from lumen of gut into body
- Tight junctions ensure molecules must pass through epithelial cell rather than
between them
o Materials enter cell through apical membrane (lumen side) and exit through
basolateral membrane (blood side)
- Lipid molecules can be absorbed passively through membrane, but other polar
molecules are absorbed by active transport
- Most nutrients are absorbed before chyme reaches ileum