Digestive Tract:

Small and Large

Intestines
Small Intestines
- Longest Section of the Digestive Tract
- 3 Parts – Duodenum, Jejunum and Ileum
- Functions – Digestion and Absorption
4 Factors:
1. Length – 5 – 7 m. Long
2. Plicae Circularis
3. Villi
4. Microvilli

Luminal Surface Modifications → Enhance Absorption

1. Plicae Circularis (Valves of Kerckring/valvulae conniventes)

- permanent folds composed of submucosa and mucosa
- Covered with villi
- Present in duodenum, jejunum and prox. Half of ileum
- ↑ surface area by 3 fold
2. Villi
- Permanent Epithelium – covered fingerlike mucosal projections
into the lumen
- Lamina propria core – lacteal, capillaries, smooth muscle fibers
in loose CT ; immune cells
- Rhythmic contractions → help propel nutrients
- Greater in duodenum
- ↑ surface area by 10 fold

3. Microvilli
- Apical surface of epithelial cell of each villus
- Glycocalyx
- Actin filaments
- Seen as brush (striated) border
- ↑ Surface area by 20 – 30 fold
Digestion and Absorption:
a. CHON → Amino Acid
- Absorbed thru active transport
b. CHO → Monosaccharides
- Absorbed by facilitated diffusion
c. Lipids → monoglycerides and free fatty acids
- resynthesized into triglycerides within the enterocytes
- lacteals
LAYERS OF THE SMALL INTESTINES
I. Mucosa – Epithelium, lamina propria, muscularis mucosa
A. Epithelium – simple columnar
- composed of surface absorptive cells, goblet cells
and enteroendocrine cells
1. Surface Absorptive Cells (enterocytes)
- Predominant cells covering the villi
- Tall columnar cells with basal nuclei
- Have densely – packed, glycocalyx – covered microvilli
(aprox. 3,000 microvilli / cell)
- glycocalyx – site for adsorption of pancreatic
digestive enzymes
- Well – developed zonulae occludentes and adherentes
– prevent access of luminal contents into intercellular
spaces and hold epithelium together.

- Functions of surface absorptive cells

a) Digestion – disaccharides → monosaccharides
- dipeptides → amino acids
b) Absorption – monoglycerides and amino acids →
facilitated diffusion
c) Lipid Processing and Chylomicron Assembly – free
fatty acids and monoglycerides → resynthesized into
triglycerides in ser → reconstituted and form a lipochon
complex (chylomicrons) → lacteals → gen. circulation
d) Transport of smaller nutrients
2. Goblet Cells
- Unicellular glands that secrete mucinogen
- Between absorptive cells
- Mucinogen → mucus – lubricates the digestive tracts wall
- protection from pancreatic enzymes
and bacterial invasion
- ↑ in no. toward the ileum

3. Enteroendocrine Cells (Apud Cells)

- Scattered thru/o the epith. And intestinal glands.
- Produce – secretin - ↑ pancreatic and billiary bicarbonate
and water secretion
- Cholecystokinin - ↑ pancreatic enzyme secretion and
gallbladder secretion.
- Gastric – inhibitory peptide - ↓ gastric A. production
- Motilin - ↑ gut motility (stimulates smooth muscles)
 B. Lamina Propria
- In cores of the villi and interstices between crypts of
Lieberkuhn
- Loose CT with lymphoid cells, fibroblasts, mast cells, smooth
muscle cells, nerve endings, lymphoid nodules, lacteals and
capillary loops.
Crypts of Lieberkuhn (intestinal glands)
- Simple tubular glands extending from the intervillous spaces to
the muscularis mucosa below the bases of the villi
- Composed of absorptive cells, goblet cells, paneth cells,
enteroendocrine cells, regenerative cells
1. Paneth Cells
- Pyramidal – shaped cells at the base of the crypts
- Have large, intensely acidophilic apical, membrane – bounded
secretory granules – contain antimicrobial peptides (
defensins) and protective enzymes such as lysozyme and
phospholipase A
 2. Regenerative Cells (stem cells, undifferentiated cells)
- Thin, tall columnar cells in the basal half of the crypts
- Replenish the epithelial cells of the villi

A B C

Lymphoid Nodules
- Small, solitary, in the lamina propria of the duodenum and jejunum
- ↑ in size and no. in the ileum → form large contiguous aggregates
called peyer’s patches
 1. M Cells ( Microfold Cells)
- Highly specialized cells with unusual shape and overlie solitary
nodules and peyer’s patches.
- Belong to the mononuclear phagocyte system of cells – they
initiate immune response by phagocytosing antigens and
passing them to lymphoid cells
- Ass. With protein allergy development
2. Activated Lymphocytes
- Respond to antigenic challenge by forming more B cells
- Differentiate into IgA – producing plasma cells
3. Plasma Cells
- Make IgA – immunogenic defense against bacteria and antigens
in the lumen
C. Muscularis Mucosae
- Composed of inner circular and outer longitudinal layer of
smooth muscle
- Fibers from the inner circular layer enter the villus and extend
thru its core to the tip of the CT and during digestion they
contract rhythmically shortening the villus
II. Submucosa

- Fibroelastic CT with blood and lymphatic vessels, nerve fibers

and meissner’s plexus
- Contains brunner’s glands (duodenal glands) – present only in
the duodenum

Brunner’s Glands (duodenal glands)

- Branched tubuloalveolar glands whose ducts penetrate the
muscularis mucosae and pierce the bases of the crypts and
deliver their secretion into the lumen of the duodenum
- Produce:
1. Alkaline mucin – containing fluid
- Raises luminal PH to optimize pancreatic enzyme act
- Protects the duodenal epith. From acidic chyme
2. Urogastrone (human epidermal growth factor)
- Polypeptide hormone that enhances epithelial cell
division and inhibits gastric HCL prod. By directly
inhibiting parietal cells
III. Muscularis Externa
- 2 layers of smooth muscles – inner circular and outer longitudinal
- inner layer participates in the form of
ileocecal sphincter

- Resp. for peristaltic act. Of the small intestines

- Has auerbrach’s plexus (myenteric) between the 2 layers

IV. External Layer of Small Intestines

1. Serosa – covers all of jejunum

and ileum and part of duodenum
1. Adventitia – covers the
remainder of the duodenum
REGIONAL DIFFERENCES:
Duodenum
- Major distinguishing feature – brunner’s glands
- Retroperitoneal
- Entry PT. for bile and pancreatic ducts
- Has fingerlike villi and relatively few goblet cells
Jejunum
- Intraperitoneal
- Long, leaflike villi
- Many plicae circularis, intermediate number of goblet cells
- No brunner’s glands, no peyer’s patches
Ileum
- Intra peritoneal
- Fewer villi – short and broad – tipped
- Abundant goblet cells
- Many lymphoid nodule clusters (peyer’s patches)
 Ileocecal Junction – abrupt transition in the lining of the valve from the
small intestinal villi form pattern to glandular form in the large intestine.

LARGE INTESTINE

-Composed of – cecum, colon (ascending, transverse, descending,

sigmoid), rectum, anal canal and appendix
-Function – absorption of electrolytes and water ; propulsion of feces to
the rectum

- Contains bacteria that prod. Vit. B12 and vit. K

- Prod. Abundant mucus – lubricates its lining and facilitates passage and
elimination of feces
 LAYER OF THE LARGE INTESTINES

MUCOSA SUB MUCOSA MUSCULARIS SEROSA/ADVENTITIA

EXTERNA
1. Cecum and Colon – no plicae circularis -Fibroelastic CT wt/ -inner circular and -adventitia covers ascending
- no villi blood and lymphatic modified outer long. descending colon
Smooth muscle layer
- epith. Is simple columnar w/ abundant vessels, nerves and -serosa covers cecum and
(teniae coli)
goblet cells, absortive cells, occasional meissner’s plexus rest of colon
-aurbach’s plexus
enteroendocrine cells. - No glands -serosa – appendices epi-
- LP – abundant lymphoid nodules, ploicae – charac. Of trans-
closely packed crypts of lieberkuhn, no verse and sigmoid colon
paneth cells.

2. Rectum – simple columnar -Fibroelastic CT - Inner circular and

- more numerous goblet cells -NO glands outer longitudinal
- fewer and deeper crypts of lieberkuhn

3. Anal Canal – longitudinal folds called -Dense, irreg, - Inner circular forms -adventitia attaches the anus
anal columns or columns of morgagni fibroelastic CT the int. anal sphincter to surrounding structures
containing large
-epith. Simple cuboidal → stratified
veins – ext. and int.
squamous nonkeratinized → stratified hemorrhoidal plexus
squamous keratinized.
- LP – anal glands and circunianal
glands, hair follicles, sebaceous glands

4. Appendix – epith. Simple columnar with -with confluent of - Inner circular and -serosa completely
goblet cells lymphoid nodules outer longitudinal surrounds the a ppendix
- LP – numerous lymphoid nodules, - No glands
shallow crypts, numerous ones cells
GASTROINTESTINAL DISORDERS

I. Gastroenteritis
- Inflammation of the lining of the stomach and intestines,
predominantly manifested by upper gastrointestinal tract symptoms
(anorexia, nausea, vomiting), diarrhea and abdominal discomfort.
1. ESCHERICHIA COLI 0157:H7 INFECTION
- Characterized by acute bloody diarrhea, which may lead to hemolytic
– uremic syndrome
- High levels of shiga toxins are produced in the large intestines after
ingestion of enterohemorrhagic E. coli → direct mucosal damage,
have a toxic effect on endothelial cells in the gut wall blood vessels
and if absorbed, exert toxic effects in the kidney.
- Transmission – ingestion of undercooked beef or unpasteurized milk,
contaminated food or water; fecal – oral route (among infants in
diapers)
- S/S – begins acutely with severe abdominal cramps and watery
diarrhea that may become grossly bloody with 24 hrs.
- Fever – usually absent or low grade, may occasionally reach 39° C
- 5% Cases – hemolytic – uremic syndrome – charac, by hemolytic
anemia, thrombocytopenia and acute renal failure; develop in the 2nd
week of illness with rising temperature and WBC counts; most likely
to occur in children < 5 y.o. or adults > 60 y.o.
- DX – isolation of the organism from stool culture
- Prophylaxis and TX – proper disposal of feces, careful hand
washing, pasteurization of milk, thorough cooking of beef
- supportive care
- antibiotics?
2. STAPHYLOCOCCAL FOOD POISONING
- Acute syndrome of vomiting and diarrhea caused by eating food
contaminated by staph. Enterotoxins
- Common cause of food poisoning; potential for outbreaks is high
when food handlers with skin infections contaminate food left at
room temp.; custards, cream-filled pastry, milk, processed meat and
fish are media where coagulase – positive staph. Grow and produce
enterotoxin.
 - S/S – severe nausea and vomiting – 2-8 hrs after eating food
containing the toxin.
- abdominal cramps, diarrhea (non – bloody), headache, fever
- DX – clinical presentation – several persons are similarly affected
- isolation of organism
- Prophylaxis and TX – careful food preparation
- supportive TX – replacement of electrolytes, fluids

3. Viral Gastroenteritis (intestinal flu)

- Characterized by vomiting, watery diarrhea and abdominal cramps
- Most common cause of infections diarrhea
- Cause by – rotavirus, calicivirus, enteric adenovirus, astrovirus
- rotavirus – most common cause of severe, dehydrating
diarrhea in children; highly contagious and most occur by
fecal – oral route
- Norwalk virus (calicivirus) – principal cause of epidemic viral
gastroenteritis
 - S/S – watery diarrhea – most common symptom
- dehydration; vomiting, fever, abdominal cramps, myalgias
- DX – clinical presentation; assays that detect viral antigen in stool
- Prevention and tx – breastfeeding afford some protection
- hand washing
- appropriate fluid resuscitation – oral rehydration, IV
rehydration; sports drinks and carbonated beverage are not
appropriate for < 5 y.o. children
II. MALABSORPTION SYNDROMES
- Due to impaired absorption of nutrients from the small instestines
1. Celiac Disease (nontropical sprue/gluten enteropathy/celiac sprue
- Chronic Intestinal Malabsorption Disorder caused by
intolerance to gluten
- Hereditary disorder due to sensitivity to the gliadin fraction of
gluten; gliadin acts as antigen forming an immune complex in
the intestinal mucosa promoting aggregation of killer
lymphocytes → mucosal damage with loss of villi and
proliferation of crypt cells
 - S/S – steatorrhea, iron – diffeciency anemia, edema
(hypoproteinema), weight loss, short stature, infertility, aphthous
stomatitis, diarrhea, abdominal discomfort.
- DX – biopsy – flat mucosa -
- clinical and laboratory response to gluten – free diet-
- TX – exclusion of gluten from the diet
- supplementary vitamins, minerals and hematinics
2. Whipple’s Disease (Intestinal Lipodystrophy)
- Rare Disease, predominating in men aged 30 – 60, caused by the
bacterium tropheryma whippelii and charac. By anemia, skin
pigmentation, joint symptoms (arthritis, polyarthralgia), weight loss,
diarrhea and severe malabsorption
- DX – biopsy – foamy macrophages containing glycoprotein
- clubbing of villi, dilated lymphatics, partial villus
atrophy
- TX – Antibiotics – chloramphenicol, tetracycline, penicillin, co -
trimoxazole
III. Inflammatory Bowel Diseases
1. Crohn’s Disease (Regional Enteritis/Granulomatous Ileitis/Ileocolitis)
- Nonspecific chronic transmural inflammatory disease that
commonly
affects the distal ileum and colon but may occur in any part of the git
- Cause – unknown
- Factors – genetic; cigarette smoking
- Pathology – earliest mucosal lesion – crypt injury in the form of
inflammation (cryptitis) and crypt abscesses which progress to
tiny focal aphthoid ulcers usually located over nodules of
lymphoid tissue.
- Pathcy mucosal ulcers and longitudinal and transverse ulcers
with intervening mucosal edema frequently creates a
characteristic cobblestoned appearance.
- Transmural inflammation, deep ulceration, edema, muscular
proliferation and fibrosis → sinus tracts and fistulas, mesenteric
abscesses and obstruction.
- Segments of disease bowel are charasteristically sharply
demarcated from adjacent normal bowel (skip areas) – regional
enteritis
- S/S – most common patterns: 1) inflammation charac. By right lower
quadrant abdominal pain and tenderess; 2) recurrent partial
obstruction due to intestinal stenosis → severe colic, abdominal
distention, constipation, vomiting; 3) diffuse jejunoileitis →
malnutrition and chronic debility; 4) abdominal fistulas and
abscesses
- DX – clinical presentation
- barium enema x – ray – reflux of barium into the terminal ileum
with irregularity, nodularity, stiffness, wall thickening,narrowed
lumen.
- colonoscopy; biopsy
- Prognosis – GI cancer (cancer of colon and small bowel) is the
leading cause of crohn’s dis- related death
- TX – no known cure
- drugs – symptomatic relief
- surgery – 70%
 2. Ulcerative Colitis
- chronic, inflammatory, and ulcerative disease arising in the
colonic mucosa, charac. Most often by bloody diarrhea
- Cause – unknown
- genetic predisposition
- Pathology – degeneration of reticulin fibers beneath the mucosal
epith., occlusion of subepith. Capillaries and progressive
infiltration of the lamina propria with plasma cells, eosinophils,
lymphocytes, mast cells – crypt abscesses, epithelial necrosis,
mucosal ulceration – usually begin in the rectosigmoid and may
extend proximally, eventually involving the entire colon.
- S/S – bloody Diarrhea – some may have > 10 bowel move’ts /day
with sever cramps and rectal tensesmus
- some may have mild lower abdominal cramps and blood and
mucus in the stools.
- CX – bleeding; toxic colitis; toxic megacolon
- ↑ incidence of colon cancer
- DX – history and stool exam; sigmoidoscopy (confirmatory)
- Biopsy – distorted crypt architecture, crypt atrophy, chronic
inflammatory infiltrate.
- Total colonoscopy – most sensitive and widely used
- Barium enema – loss of haustration, mucosal edema, minute
serration, grass ulceration.
- Prognosis – localized ulcerative proctitis – best prognosis
- total proctocolectomy – curative
- CX – massive hemorrhage, perforation, sepsis
- TX – avoidance of raw fruits and vegetables.
- drugs
- surgery – emergency colectomy
- elective
IV. Tumors
1. Colorectal Cancer
- Cancer of the colon is more common in women
- Cancer of the rectum is more common in men
 - Predisposing factors – genetic; chronic ulcerative colitis,
granulomatous colitis, familial polyposis
- low – fiber diets, high in animal protein, fat and refine carbohydrates
- S/S – right colon – obstruction is a late event
- left colon – cancer tends to encircle the bowel → alternating
constipation and diarrhea.
- stool may be streaked or mixed with blood
- cancer of rectum – bleeding with defecation
- DX – screening – testing stool for occult blood
- colonoscopy
- CEA
APPENDICITIS
- Acute inflammation of the appendix
- Most common cause of an attack of severe, acute abdominal pain that
requires operation.
- S/S – sudden – onset epigastric or periumbilical pain followed by brief
nausea and vomiting then shifting of pain to the right lower quadrant;
direct tenderness and rebound tenderness in right lower quardrant,
 localized pain on cough, fever, leukocytosis
- Rovsing sign
- Psoas sign
- DX – clinical examination
- ultrasound, CT scan
- TX – appendectomy
- Antibiotics