Last edited: 9/9/2021

1. GI MOTILITY OF THE ESOPHAGUS & STOMACH

Gastrointestinal | GI Motility of the Esophagus & Stomach Medical Editor: Ilia-Presiyan Georgiev

o The cell becomes negatively charged

OUTLINE o Starts to repolarize

I) MOTILE FUNCTIONS OF THE GIT (4) Factors can that cause

II) SMOOTH MUSCLE CELLS
the cell to reach the threshold
III) ESOPHAGUS
o Acetylcholine
IV) STOMACH
V) REVIEW QUESTIONS  Released by the parasympathetic nervous system
VI) REFRENCES (PSNS)
• Vagus nerve
• Sacral (S2-S4) nerves
o GI Hormones
 Gastrin
I) MOTILE FUNCTIONS OF THE GIT  Cholecystokinin
 Secretin
(1) Segmentation  Motilin
o Stretching of the GI organ
Large areas of the intestines contract their smooth
muscle creating rings at multiple different points of the These factors stimulate cations to float into the cell
intestine o Makes the cell very positive
o This keeps mixing the chyme contents which helps  Just enough to break the threshold
the digestive process
(5) The sarcoplasmic reticulum of the SMC
Helps the intestinal mucosa to come into contact with the
is stimulated trough certain signaling processes
substances
o There are a lot of Ca++ sequestered there by
o Increases the absorption of nutrients
 Calsequestrin
Mostly in the small and large intestine  Calreticulin
(2) Propulsion (peristalsis) When stimulated the sarcoplasmic reticulum
o Pushes Ca++ into the sarcoplasm
The alternating waves of contraction and relaxation
o There it helps to initiate the cross bridge formation
moving the GI content along the GIT
 By activating calmodulin
(3) Reservoir function (storage) o Calmodulin activates different myosin light-chain
kinases
Holds GI content for long periods of time
o They phosphorylate the myosin head and
o The large intestine holds a lot of the feces for large
generates contraction
amounts of time
o The stomach can hold food for 4 to 6 hours (6) When the charge of the cell
The function is carried out by sphincters passes the threshold it produces spike potentials
o Many cation stimuli, bring the depolarizing wave high
above the threshold
II) SMOOTH MUSCLE CELLS  More spike potential is produced
 The force of the contraction is high
(1) There are two types of contractions
Rhythmic (alternating contraction and relaxation) (7) The interstitial cells of Cajal are
o Segmentation connected to the other smooth muscle cells by gap
o Propulsion junctions
Tonic (sustained contraction) When the cell depolarizes
o Sphincters o Ca++ is released
o It can be pushed into the connected cells
(2) Smooth muscle cells have to ability to depolarize
and to contract
o Resting potential of -80 mV
o Threshold potential of -55mV
Interstitial cells of Cajal - pacemaker cells
o Spontaneously depolarize
o Generate action potentials
 Cause the smooth muscle of the GIT to contract
They generate slow (subthreshold) waves
(3) Smooth muscle cells have ‘leaky’ Ca++ channels
Always open
o Allows small amounts of Ca++ to enter the cell
o Slightly depolarize the cell
When the threshold is approached
o Special K+ channels open
Figure 1 Smooth muscle cell properties.
o K+ leaves the cell

GI Motility of the Esophagus & Stomach GASTROINTESTINAL PHYSIOLOGY: Note #1. 1 of 5

 III) ESOPHAGUS The condition is diagnosed with a barium esophagram
o The patient swallows dye
(A) PHYSIOLOGY AND FUNCTIONS  Part of it collects in the diverticulum

(1) The esophagus is designed to transport Treatment is surgical

o The diverticulum is removed
GI contents form the pharynx down to the stomach o The layer is fused together
Primary function is peristalsis
o The alternating waves of contraction and then (2) Achalasia
relaxation Usually located around the lower esophageal sphincter
Doesn’t do any segmentation and reservoir function (LES)
o Although there are a couple of sphincters Caused by loss of the distal part of the myenteric plexus
 Upper esophageal sphincter (UES) o The portion of the esophagus can’t relax
• Primarily made up of the cricopharyngeal  Can’t receive and pass the bolus
muscle o The bolus accumulates proximally to the the portion
• Innervated by the vagus nerve  Starts dilating the esophagus.
 Lower esophageal sphincter (LES) Symptoms
• A.k.a. cardiac sphincter or gastroesophageal o Megaesophagus
sphincter o Dysphagia
o Regurgitation
(2) The bolus stretches
o Coughing
the esophageal walls o Weight loss
o Activates stretch receptors that have the ability to o Malnourishment
stimulate and inhibit the myenteric plexus
The condition is diagnosed via esophageal manometry
 Ascending (stimulatory) neurons
o A small pressure gauge is placed inside the
 Descending (inhibiting) neurons
esophagus
o The plexus is located between the two muscle layers
 The pressure is measured
the esophagus
o Pressure above 40mmHg is indicative of achalasia
 Outer longitudinal
 Inner circular Treatment
o Surgical
(3) Stimulating the ascending neurons o Conservative
to a certain point causes them to release specific  Botulinum toxin
chemicals  Nitrates
o To the circular muscle layer causing it to contract  Ca++ channel blockers
 Acetylcholine
 Substance P
o To the longitudinal muscle layer causing it to relax
 Vasoactive intestinal peptide (VIP)
 Nitric oxide (NO)
This closes up the lumen
(4) Stimulating the descending neurons
to a certain point causes them to release specific
chemicals
o To the circular muscle layer causing it to relax
 Vasoactive intestinal peptide (VIP)
 Nitric oxide (NO)
o To the longitudinal muscle layer causing it to contract
 Acetylcholine
 Substance P
This opens up the lumen

(B) PATHOLOGY
(1) Zenker’s diverticulum
Usually located right above the UES
Sometimes the walls of this part of the esophagus
become weak
o Form a small pouch (a diverticulum) right above the
sphincter.
o More common with older people.
Symptoms
o Dysphagia
 Trouble or difficulty swallowing
o Cough
o Regurgitation
o Halitosis (foul smell)
 Caused by food is percolating in the pouch

Figure 2 Esophagus physiology, functions and pathology.

2 of 5 GASTROINTESTINAL PHYSIOLOGY: Note #1. GI Motility of the Esophagus & Stomach

 IV) STOMACH
(A) PHYSIOLOGY AND FUNCTIONS
(1) The stomach
has three main functions
o Storage (reservoir)
o Mixing (churning)
o Emptying
and can act as two individual organs
o The fundus and the upper part of the body
 Reservoir function
o The lower part of the body and the pylorus
 Mixing and emptying
(2) Reservoir function
(i) Stomach secretion phases
(a) Cephalic phase
Thought, sight, smell and taste of food have the ability to
activate the efferent fibers of the vagus nerve
o Before the food reaches the stomach
The efferent fibers of the vagus nerve go to the fundus of
the stomach
There they stimulate nerves to trigger the release of VIP
and NO
o These substances cause the smooth muscle cells to
relax
The relaxation of the fundus and the upper part of the
body of the stomach in response to the cephalic phase is
called receptive relaxation
o The stomach starts relaxing and dilating prior to the
food being in the stomach
o It is getting ready to receive the bolus
(b) Gastric phase
The bolus enters the stomach
o The volume starts increasing
o Causes distension and stretching within the walls
o Triggers reflex arks that release VIP and NO and
promote even more relaxation of the smooth muscle
 Short reflex ark - a local reflex
• Triggers the release of VIP and NO
 Long reflex ark – activation of the afferent fibers
of the vagus nerve which subsequently activate
the efferent fibers
• Trigger the release of VIP and NO
This relaxation is called adaptive relaxation
The stomach can continue to occupy a large volume of
content without increasing the intragastric pressure
Both receptive and adaptive relaxation play a role in
gastric accommodation
o The intragastric volume may increase but the
intragastric pressure will remain constant to a limit
o Above 1.5 liters the pressure stats rising
The bolus is high in partially digested proteins
o Increases the pH
o Activates particular cells – enteroendocrine G cells
 Located within the lower part of the stomach (body
and antrum)
These cells release specific chemicals:
o Gastrin
 Stimulates the SMCs to relax even more.
• Part of the adaptive relaxation
 Causes the antrum of the stomach to contract
• Helps emptying the stomach
GI Motility of the Esophagus & Stomach
(c) Intestinal phase
When the stomach empties the contents that goes into
the small intestine is rich in H+, fat, peptides,
carbohydrates, etc.
o These factors stimulate certain enteroendocrine cells
to secrete
 Cholecystokinin
• In response to fat and partially digested
proteins
 Secretin
• In response to acidic chyme
 Gastric inhibitory peptide/ glucose-dependent
insulinotropic peptide (GIP)
• In response to carbohydrates
o All these play a crucial role in the relaxation of the
stomach
 Mainly the fundus and the upper body
o Allow the stomach to store the food a little bit longer
o The duodenum prepares for the chyme contents
(3) Mixing and emptying functions
go hand-in-hand
In the mid part of the body there is high concentrations of
pacemaker cells of Cajal
o Between the middle circular and the outer longitudinal
muscle layer
o Have a basic electrical rhythm of about 3 to 5 action
potentials per minute
They generate and send out action potentials
o Cause the stomach smooth muscles to contract
o The contractions start off within the body of the
stomach
 Increase in intensity and force as they go down to
the pylorus
An action potential generates and spreads to the upper
part of the body
o Causes a contraction
 Yanks some of the chyme stored in the fundus into
the body to be mixed with gastric juices
In the mid part of the body
o Pushes the chyme towards the pylorus
At the level of pylorus, the contractions are almost
occluding the lumen.
The pylorus can be divided into three portions – distal,
middle and proximal.
(a) Proximal portion
When the chyme goes in the proximal aspect of the
pyloric antrum this part of the pyloric antrum squeezes
down and occludes the lumen behind
o Prevents the chyme from flowing back to the stomach
Meanwhile, the parts distal to the proximal aspect of the
antrum relax so the chyme from the proximal aspect can
be pushed in
o This is propulsion
In order for substances to pass through the pyloric canal
they need to be less than 2mm in size
(b) Middle portion
The middle aspect contracts and pushes its contents
onwards through the still relaxed distal aspect
o About 3-4ml is pushed into the duodenum
o The rest is pushed back into the stomach to continue
mixing with the gastric juice and reduce the size of
the particles
 This is both propulsion and mixing
GASTROINTESTINAL PHYSIOLOGY: Note #1. 3 of 5
 (c) Distal portion The diagnosis is confirmed via an ultrasound
Treatment is pyloromyotomy
The distal/terminal aspect of the antrum contracts and o Cutting the sphincter
closes off
o Because its right next to the pyloric sphincter which
also contracts and closes off the lumen
o Any substances left in the terminal aspect can’t go
into the duodenum and are pushed back into the
stomach
 This is retropulsion

(i) Stomach secretion phases

Cephalic phase causes a lot of contractility in the
pylorus and a little bit of the body
o The chyme can leave
During the gastric phase the pyloric contractility is
inhibited
o The chyme going in the duodenum would have
negative effects
During the intestinal phase receptors pick up significant
distension and activate the SNS
o The pyloric sphincter is stimulated, contracts and Figure 3 Stomach physiology, functions and pathology.
closes off the pyloric canal
 Helps prevent particles entering the duodenum
 Called the enterogastric reflex (a sympathetic
reflex)
(4) Migrating motor complex (MMC)
During the ‘fasting’ state (the interdigestive period)
Stimulated by the hormone called motilin
A peristaltic wave that starts in the body of the stomach
and moves its way down the pylorus
o Tries to empty the contents of the stomach into the
duodenum.
o Relaxes the pyloric sphincter
 Particles larger than 2mm can pass through it
The surface epithelium of the body is undergoing much
damage from the gastric juices and hydrochloric acid
o The cells regenerate every 3 to 6 days
 Produces a lot cellular debris (desquamated
cells)
o MMC helps clear the debris

(B) PATHOLOGY
(1) Hypertrophic pyloric stenosis
Caused my hyperplasia (more cells) or hypertrophy
(bigger cells) of pyloric sphincter
o Its common a couple weeks after birth
o Males are genetically more probable to suffer from it
o There are environmental aspects
 Macrolide antibiotics
Symptoms
o Projectile vomiting (main)
 The hypertrophic pyloric sphincter narrows and
eventually occludes the pyloric canal
 Stops the emptying of the stomach
 The stomach stretches
 Eventually the afferent fibers of the vagus nerve
are activated and send the information to the
emetic center
• Located in the medulla oblongata
 Trigger projectile vomiting
o Visible peristalsis
 The muscles of the stomach get thicker overtime
o Palpable olive shaped mass in the epigastrium
 During physical examination
o Signs of metabolic alkalosis in the bloodwork
 The pH of the blood is high because they are
losing hydrochloric acid and chloride
o Dehydration
 Patients lose a lot of fluids
o Electrolyte imbalances

4 of 5 GASTROINTESTINAL PHYSIOLOGY: Note #1. GI Motility of the Esophagus & Stomach

 V) REVIEW QUESTIONS

Which is not one of the three main motile functions

of the GIT?
a. Segmentation
b. Propulsion
c. Emptying
d. Storage

Which factor doesn’t cause a smooth muscle cell to

reach the threshold potential?
a. Acetylcholine
b. Norepinephrine
c. Cholecystokinin
d. Stretching of the GI organ

What is the main motile function of the esophagus?

a. Segmentation
b. Propulsion
c. Emptying
d. Storage

Which substance causes the muscles of the

esophagus to relax?
a. Vasoactive intestinal peptide
b. Substance P
c. Motilin
d. Acetylcholine

Which is not a symptom of Zenker’s diverticulum?

a. Dysphagia
b. Cough
c. Regurgitation
d. Weight loss

Treatment of achalasia does not include:

a. Surgery
b. Botulinum toxin
c. Chlorides
d. Ca++ channel blockers

Which is not one of the stomach secretion phases?

a. Cephalic
b. Esophageal
c. Gastric
d. Intestinal

Which part of the stomach is mainly related to the

reservoir function?
a. Fundus
b. Lower Body
c. Cardia
d. Pylorus

Where do the contractions responsible for mixing

and emptying the content of the stomach originate?
a. Fundus
b. Cardia
c. Pylorus
d. Body

What is the main symptom of hypertrophic pyloric

stenosis?
a. Projectile vomiting
b. Visible peristalsis
c. Metabolic alkalosis
d. Dehydration

CHECK YOUR ANSWERS

GI Motility of the Esophagus & Stomach GASTROINTESTINAL PHYSIOLOGY: Note #1. 5 of 5