By: Abduljabbar Hamid Jabbar

University of Baghdad-College Of Medicine

M. B. Ch. B
By: Abduljabbar Hamid Jabbar
University of Baghdad-College Of Medicine
M. B. Ch. B
Small intestine: The small intestine is the major site of digestion and absorption of carbohydrates, proteins, and fats in the
GIT. The small intestine has three parts: the duodenum, the jejunum, and the ileum. Although the small intestine is
approximately 5 m long, it has an absorptive area of over 250 m2 .

Its large surface area is created by numerous folds of the intestinal mucosa (valvulae conniventes or plica circulares), by
densely packed finger-like projections of the mucosa called villi, which line the entire mucosal surface, and by microvilli,
which protrude from the surface of the intestinal epithelial cells (enterocytes). The microvilli give the intestinal mucosa its
characteristics brush border appearance
The life span of a typical epithelial cell varies from two to three days in the esophagus to six days in the large intestine. The
divisions of epithelial stem cells continuously renew the lining of the entire digestive tract. These divisions normally keep
pace with the rates of cell destruction and loss at epithelial surfaces.

This high rate of cell division explains why radiation and anticancer drugs that inhibit mitosis have drastic effects on the
digestive tract. Lost epithelial cells are no longer replaced. The cumulative damage to the epithelial lining quickly leads to
problems in absorbing nutrients. In addition, the exposure of the lamina propria to digestive enzymes can cause internal
bleeding and other serious problems.

Though peristalsis in the small intestine is normally very weak, intense irritation of the intestinal mucosa, as occur in some
sever case of infectious diarrhea, can cause both very powerful and rapid peristalsis called the peristaltic rush. This is
initiated mainly by vagovagal nervous reflexes to the brain stem and back again to the gut. The powerful peristaltic
contractions sweep the contents of the intestine into the colon and thereby relieving the small intestine of either irritative
chyme or excessive distension.
Function of the ileocecal valve: The principal function of the ileocecal valve is to prevent backflow of fecal content from the
colon into the small intestine. The wall of the ileum for several centimeters immediately preceding the ileocecal valve has a
thickened muscular coat called ileocecal sphincter which normally remains mildly constricted.
Following meal, gastroileal reflex intensifies peristalsis, and the hormone, gastrin, which is liberated from the stomach
mucosa in response to food in the stomach, has a relaxant effect on the ileocecal sphincter, both of them cause an increase
emptying.
On the other hand, when the cecum is distended, the degree of contraction of the ileocecal sphincter is intensified while
ileal peristalsis is inhibited, which greatly delays emptying of additional chyme from the ileum. Also, any irritant in the
cecum delays emptying. These reflexes from the cecum to the ileocecal sphincter and ileum are mediated both by way of
the enteric nervous system and through vagovagal reflexes.
Pancreatic secretions: Approximately 1200 to 1500 ml of clear pancreatic juice is produced daily (about pH 8). Pancreatic
juice is secreted mainly in response to the presence of chyme in the upper portions of the small intestine and the
characteristics of the pancreatic juice are determined to some extent by the types of food in the chyme.

Pancreatic juice contains enzymes for digesting all three major types of food proteins, carbohydrates, and fats. It also
contains large quantities of bicarbonate ions which play an important role in neutralizing the acid chyme emptied by the
stomach into the duodenum. Pancreatic juice is isotonic and with the same Na+ and K+ concentrations and much lower Cl
concentration than plasma. The digestive enzymes of the pancreas are:
The digestive enzymes for proteins (proteolytic
enzymes) which are trypsin, chymotrypsin,
carboxypolypeptidase, ribonuclease, and
deoxyribonuclease. By far the most abundant of
these is trypsin .

The digestive enzyme for carbohydrates is

pancreatic amylase which hydrolyzes starches,
glycogen and most other carbohydrates except
cellulose to form disaccharides and a few
trisaccharides.

The digestive enzyme for fat which is pancreatic

lipase that is capable of hydrolyzing neutral fat into
fatty acids and monoglycerides, cholesterol
esterase which cause hydrolysis of cholesterol
esters, and phospholipase which splits fatty acids
from phospholipids.
Pancreas protects itself from autodigestion by proteolytic enzymes by the following
ways:

[1] When synthesized in the pancreatic cells, the proteolytic enzymes are in the
inactive forms (inactive zymogens), trypsinogen, chymotrypsinogen, and
procarboxypolypeptidase, which are all enzymatically inactive.
[2] These become activated only by trypsin.

[3] Trypsin is activated only after it is secreted into the intestinal tract. Trypsinogen is
activated by an enzyme called enteropeptidase (enterokinase) which is secreted by the
intestinal mucosa when chyme comes in contact with the mucosa. Also, trypsinogen
can be autocatalytically activated by trypsin that is already been formed.
Chymotrypsinogen is activated by trypsin to form chymotrypsin, and
procarboxypolypeptidase is activated in a similar manner. It is important that the
proteolytic enzymes of the pancreatic juice not become activated until they have been
secreted into the intestine which otherwise would digest the pancreas itself.

[4] The same cells that secrete the proteolytic enzymes into the acini of the pancreas
secrete simultaneously another substance called trypsin inhibitor. This substance is
stored in the cytoplasm of the glandular cells surrounding the enzyme granules and it
prevents activation of trypsin both inside the secretory cells and in the acini and ducts
of the pancreas.

However, when the pancreas becomes severely damaged or when a duct becomes
blocked, large quantities of pancreatic secretion become pooled in the damaged areas
of the pancreas. Under these conditions, the effect of trypsin inhibitor is sometimes
overwhelmed, in which case the pancreatic secretions rapidly become activated and
digest the pancreas giving rise to the condition called acute pancreatitis.
The enzymes of the pancreatic juice are secreted entirely by the acini
of the pancreatic glands. On the other hand, two other important
components of the pancreatic juice, bicarbonate ions and water, are
secreted in large amounts mainly by the epithelial cells of the
ductules leading from the acini .

The alkaline ions or the pancreatic juice serves to neutralize acid

emptied into the duodenum from the stomach. The secretion of
bicarbonate ions by the pancreas is an active process. The
mechanism of bicarbonate secretion is similar to the process of HCI
secretion by the stomach, except that the events on the two sides of
the cells are reversed.

Because the amount of bicarbonate secreted by the pancreas is

reflexly regulated by the amount of acid entering the duodenum from
the stomach, the amount of bicarbonate secreted by the pancreas is
normally about equal to the amount of acid secreted by the stomach.
This also means that the bicarbonate released into the blood by the
stomach is normally equal to the amount of acid released into the
blood by the pancreas.

When the alkaline blood leaving the stomach mixes with the acidified
blood from the pancreas, the overall result is no change in the acidity
of the blood returning to the heart. However, a loss of large
quantities of bicarbonate ions from the intestinal tract during periods
of prolonged diarrhea leads to a net accumulation of acid in the
blood, just as, loss of acid from the stomach by vomiting leads to a
net alkalinization of the blood.
Regulation of pancreatic secretion: Pancreatic secretion is regulated by both nervous and hormonal mechanisms. However,
hormonal regulation is by far the more important. Like gastric secretion, pancreatic secretion is divided into the following
three phases:

[1] Cephalic phase: The thought, sight, smell, or taste of food produces the cephalic phase of pancreatic secretion via vagal
stimulation. It is scanty and rich in enzymes.

[2] Gastric phase: Pancreatic secretion is slightly enhanced during the gastric phase by:
[A] Distention of the antrum and the body of the stomach, which initiates a vagovagal reflex resulting in a low volume of
pancreatic secretion containing both bicarbonate ions and enzymes.

[B] Food breakdown digestion products (primarily amino acids and peptides) can stimulate pancreatic secretions because
of their ability to cause the G cells of the antrum to release gastrin. Gastrin produces a low-volume, high-enzyme
pancreatic secretion.
[3] Intestinal phase: The major stimulants
for pancreatic secretion are the hormone
CCK and secretin. They are released from
endocrine cells in the duodenum and
jejunum during the intestinal phase of
pancreatic secretion in response to the
entrance of chyme into the small intestine.

CCK, in addition to its effect on the

gallbladder, is a potent stimulant of
pancreatic enzyme secretion. Protein and
fat are the major stimuli for CCK secretion.
CCK induces secretion of enzyme-rich
pancreatic juice.

Secretin stimulates the HCO3 - secretion.

Low pH (< 4.5), caused by the presence of
gastric acid (HCl) in the intestine, is a
potent stimulus for the release of secretin.
Secretin causes secretion of HCO3 − -rich
pancreatic juice.
Secretin is very important for two reasons:
[A] Neutralization of the acidic chyme: Secretin is released from the mucosa of small intestine when the pH of
the duodenal contents falls below 4.5 and its release increases very greatly as the pH falls to 3.0.

This immediately causes large quantities of pancreatic juice containing abundant amounts of sodium
bicarbonate to be secreted. In this way, the acid contents emptied into the duodenum from the stomach
become neutralized, and peptic activity of the gastric juice is immediately blocked. Since the mucosa of the
small intestine cannot withstand the digestive action of acid gastric juice. This is a highly important and even
essential protective mechanism against the development of duodenal ulcers.

[B] Provides a proper alkaline medium for the action of pancreatic enzymes

Because CCK and secretin are potentiators of each other’s action, small concentrations of CCK and secretin
together can produce significant amounts of pancreatic bicarbonate ions and enzymes secretions, while
either one alone would have little or no effect.
Pancreatitis and Pancreatic Cancer: Pancreatitis is an inflammation of the pancreas that occurs quite
commonly. Pancreatitis involves the release of pancreatic enzymes within the pancreas itself, which digest
pancreatic tissue. It can result from alcoholism, the use of certain drugs, pancreatic duct blockage, cystic
fibrosis, viral infection, or pancreatic cancer. Symptoms can range from mild abdominal pain to systemic
shock and coma.

Cancer of the pancreas can obstruct the pancreatic and common hepatic ducts, resulting in jaundice.
Pancreatic cancer may not be detected until the tumor has become fairly large, and it can become so large as
to block off the pyloric region of the stomach.
Thank You
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