Menggerakan chyme melalui usus
halus
Falciform ligament :
Membagi liver
kanan dan kiri dan
membentang
hingga umbilical
4th Part
Ascending
short (5 cm)
begins at the left of the L3
vertebra
and rises superiorly as far as
the superior border of the L2
vertebra
runs superiorly and along the
left side of the aorta to reach
the inferior border of the body
of the pancreas.
curves anteriorly to join the
jejunum at the duodenojejunal
flexure
Lacteals mengalir secara bergantian ke
pembuluh limfatik di antara lapisan
mesenterium. Di dalam mesenterium,
getah bening akan mengalir secara
berurutan melalui tiga kelompok kelenjar
getah bening :
- Kelenjar getah bening juxta-​intestinal :
terletak dekat dengan dinding usus.
- Kelenjar getah bening mesenterika :
tersebar di antara arcade arteriae.
- Kelenjar getah bening sentral superior :
terletak di sepanjang bagian proksimal
SMA (Superior Mesenteric Artery)
Arterial Supplies
Veins, Lymph Nodes, Nerve
Paracolic gutters are
peritoneal recesses
(spaces formed by
peritoneum draping
over viscera). These
gutters are clinically
important because
they allow a passage
for infectious fluids
from different
compartments of the
abdomen. For
example; fluid from an
infected appendix can
track up the right
paracolic gutter to the
hepatorenal recess.
Attached to the transverse
colon attaching it to the
posterior abdominal wall
Inervation
Simpatetik
Bagian lumbar dari sympathetic
trunk via lumbar splanchnic
nerves, superior mesenteric
plexus, periarterial plexuses
hypogastric/pelvic plexuses,
Sympathetic and periarterial plexus of
inferior mesenteric and
supply superior rectal arteries.
Parasympathetic
supply
Visceral afferent
fibers
3rd Part
Inferior
6–8 cm long
crosses the L3 vertebra
runs transversely to the left
passing over the IVC, aorta, and
L3 vertebra
crossed by the superior
mesenteric artery and vein and
the root of the mesentery of the
jejunum and ileum
superior : terdapat the head of
the pancreas and its uncinate
process
inferior : anterior surface
covered by peritoneum
except where it is crossed by
the superior mesenteric
vessels and the root of the
mesentery.
posterior : separated from the
vertebral column by the right
psoas major, IVC, aorta, and
the right testicular or ovarian
vessels
Pembuluh limfatik khusus dalam vili
usus yang menyerap lemak disebut
lacteal.
The right colic flexure is located deep to the 9th and 20th ribs
and is overlapped by the inferior part of the liver.
Nerve Supply
plexus
Nerve Supply
Nerves transmit sympathetic,
parasympathetic and visceral
afferent nerve fibers.
parasimpatetik
Pelvic splanchnic nerves via
inferior hypogastric plexus
Innervation
from S2-​S4 spinal cord level
through pelvic splanchnic
nerves and left/right inferior
hypogastric plexuses to the
rectal (pelvic) plexus.
follow the parasympathetic
fibers retrogradely to S2-​S4
spinal sensory ganglia due to
the rectum's position below
the pelvic pain line.
Terdapat peristaltis dari middle stomatch menuju pylorus
Absorbsi chemical compound terjadi di small intestine
duodenum, jejunum, ileum
Large intestine terdiri dari cecum, appendix, colon
(ascending, transverse, descending, sigmoid
Gastrointestinal tract are esophagus, stomatch, small
and large intestines
2nd Part
Descending
longer (7–10 cm)
descends along the right sides
of the L1–L3 vertebrae
runs inferiorly
curving around the head of the
pancreas
bagian awal, terletak di sebelah
kanan dan paralel dengan IVC
saluran bile (empedu) and
saluran main pancreatic
(pankreas utama) memasuki
dinding posteromedial
descending part
entirely retroperitoneal
anterior surface dari bagian
proximal and distal thirds is
covered with peritoneum
The anterior lymphatic vessels
drain into the pancreaticoduodenal
The posterior lymphatic vessels
drain into the superior mesenteric
Efferent lymphatic vessels
drain into the celiac lymph nodes
Superior Mesenteric Artery (SMA) menyuplai jejunum
dan ileum melalui jejunal dan ileal arteries
Superior Mesenteric Vein (SMV) juga menyuplai
jejunum dan ileum.
Vena ini terletak di anterior dan di sebelah kanan
Superior Mesenteric Artery (SMA)
Rises superiorly on the right side of the abdominal cavity from
the cecum where it turns to the left at right colic flexure
A secondary retroperitoneal organ on the right side of the
posterior abdominal wall. Covered by peritoneum anteriorly and
on all sides. Separated from anterolateral abdominal wall by
Lymphatic Drainage
Lymphatic Drainage
The transverse colon is the longest, most mobile/movable part
of the large intestine. It varies in position, usually at L3 but in
tall, thin people it may extend to the pelvis.
The left colic flexure is usually more superior, more acute, and
more mobile than the right. It is located anterior to the inferior
part of the left kidney and attaches to the diaphragm through
the phrenicocolic ligament.
Crosses the abdomen from the right colic flexure to the left
colic flexure where it turns inferiorly to become the descending
Transverse Colon
Arterial supply
Left colic dan Sigmoid arteries
Arterial supply
Left colic dan Sigmoid arteries
Proximal part of
Mencampur chyme dengan cairan
pencernaan yang disekresikan ke
dalam lumen small intestine
Pencampuran melalui
Functions of segmentations segmentations memiliki dual
functions
Memaparkan semua chyme ke
permukaan penyerapan mukosa
Segmentation contractions mix and Mencampurkan dan secara small intestine
SEGMENTATION
slowly propel the chyme. perlahan mendorong chyme
Alimentary system
Terdiri dari alimentary system :
Ringlike contractions dari circular
- ​terminal part of esophagus Consists of oscillating smooth muscle sepanjang small
intestine
- ​stomatch
- ​intestines
- ​spleen
- ​pancreas Initiated by BER
Membawa circular smooth muscle
ke threshold
- ​liver
- ​gallbladder
Overview abdominal
- ​kidney viscera
- ​suprarenal glands Segmentation contraction
terinduksi
Dipengaruhi oleh distensi usus,
1. Celiac trunk Derajat respon the circular smooth
hormon gastrin, dan aktivitas saraf
muscle's dan intesitas kontraksi
2. Superior 3 major branch < abdominal aorta Arterial supply ekstrinsik
3. Inferior mesentric arteries
Superior mesentric
Duodenum & ileum memulai
Hepatic portal vein Vein supply Slight/absent between meals Menjadi kuat setelah meal
segment secara serentak saat
makanan pertama masuk ke dalam
usus halus
Splenic vein, inferior
mesenteric vein
Phase I Long period (40- 60 menit)
The migrating motility complex sweeps Intestinal segmentation contraction Digantikan oleh Migrating Motility Phase II 20 - 30 menit Period
Short fasting
the intestine clean between meals. berhenti Complex (MMC)
Phase III Shortest phase
Ileocecal valve is easily pushed open, but forcibly closed when
cecal contents attempt to move backwards
1.
Waktu makan MMC berhenti
Disekresikan selama keadaan
tidak makan
The ileocecal juncture prevents
contamination of the small intestine by
Diatur oleh hormon motilin
colonic bacteria Aktivitas motorik yang
berhubungan dengan makan
mengambil alih
Dihambat dengan pemberian
Pelepasan motilin
makanan
1st Part
Superior
Duodenum is the first, shortest, Duodenum Small-​intestine secretions do not
short (approximately 5 cm) widest, and most fixed part of small
intestine.
contain digestive enzymes
lies anterolateral to the body of
the L1 vertebra Panjangnya sekitar 25 cm / 12 inch 2.
ascends from the pylorus Duodenum membentuk pola
berbentuk C Exocrine gland cells in small-​intestine mucosa secrete succus
overlapped by the liver and - dimulai dari pylorus (right side)
entericus; an aqueous salt and mucus solution. Mucus
- diakhiri di duodenojejunal
gallbladder provides protection and lubrication, aqueous solution provides
junction (left side)
water for enzymatic digestion hydrolysis.
anterior aspect covered by
peritoneum covers Considered partially retroperitoneal
posterior aspects are not
Ileocecal sphincter — always remains mildly constricted.
covered by peritoneum
Pressure on cecal side causes contraction; distention of ileal
side causes relaxation. The sphincter is under neural and
Ampulla
Terbagi menjadi 4 bagian Brush-​border membrane completes hormonal control. Relaxation of sphincter occurs by enhanced
release of gastrin at onset of a meal; allowing preceding meal
- bagian 2 cm pertama dari superior part
- has a mesentery digestion with small-​intestine enzymes to move forward as the new meal enters tract.
- mobile.
- free part
Brush border, contains the following categories of
Veins Arteries membrane-​spanning proteins that function as
Small Intestine In lumen membrane-​bound enzymes:
follow the arteries arise from the celiac trunk and the
drain into the hepatic portal vein through the superior mesenteric artery
superior mesenteric and splenic veins approx range 6 to 7 meters
Fat digestion enhanced by bile secretion; as a result fats are
completely reduced to absorbable units.
✅ Enteropeptidase — activates pancreatic proteolytic enzyme
trypsinogen.
located in the abdominal cavity,
between the stomach and large
intestine.
Proteins are broken down into small peptide fragments and
some amino acids
Aminopeptidases — hydrolyze peptide fragments into amino
acids
✅
absorption of nutrients from
digested food before the remains
Carbohydrates are reduced to disaccharides, α-​limit dextrins
and some monosaccharides
Disaccharidases (maltase, sucrase-​isomaltase, lactase) —
target maltose, α-​limit dextrins and dietary disaccharides.
✅
reach the large intestine.
involves digestive enzymes from
the pancreas and bile which help
break down carbohydrates, All products of carbohydrate, protein, and fat digestion
absorbed indiscriminately non selective
proteins and fats into smaller what is absorbed
molecules. ingested electrolytes, vitamins, and water
except: iron, calcium
mostly in the duodenum and jejunum
Digested nutrients are absorbed most absorption has already been accomplished before the intestinal
adjusted to the body need
through the intestinal walls into where does it contents reach the ileum
Lymphatic Vessels Nerves the bloodstream for distribution occur terminal ileum - has specialized
throughout the body The small intestine is remarkably well very little in the ileum transport mechanism to absorb vit B12
follow the arteries Berasal dari vagus and greater and adapted for its primary role in and bile
lesser (abdominopelvic) splanchnic absorption. sel epitel dengan berbagai mekanisme
Permukaan dalam berbentuk
Penyesuaian mukosa usus halus membentuk lipatan melingkar
nerves melalui the celiac and superior well-​adapted transpor
(mucous lining)
mesenteric plexuses. Luas permukaan besar
vili meningkatkan luas area 10x lipat
microscopic projection
dilapisi mukosa
conveyed to the duodenum via Clinical notes
pathogenesis: environmental, microvili
periarterial plexuses extending to the genetic, and immunologic factors
meningkatkan luas area meningkatkan luas area 3x lipat
/ brush
pancreaticoduodenal arteries celiac disease/ gluten enteropathy immunological disorder 20x lipat
border
lymph nodes kondisi di mana usus halus abnormally sensitive to even smaller projection
gluten usus exposed to gluten
Structure
activate T-​cell
Sel epitel pembungkus permukaan vili
lymph nodes
damage the intestine
Inti jaringan ikat
loss of villi and microvilli mucous flattened
Jaringan kapiler
↓ absorption Pembuluh limfatik terminal
central lacteal
mucus (dari permukaan villi)
+ succus entericus (intestinal juice)
Anatomy "Gastrointestinal System" Physiology Small Intestine mensekresi air dan garam
Source: Moore 8th Edition Source: Sherwood 9th Edition inhibit cell division
sensitif terhadap
kerusakan radiasi
dan obat anti-​kanker
Jejunum & Ileum high rate of turnover
konsentrasi enzim brush-​
seiring bergerak
border cells meningkat
move to surface of the ke atas
has stem cells continuously produced
intestine -> push the old cells kapasitas absorpsi
The mucosal lining experiences rapid duration: 3 days (from crypt to tip)
meningkat
crypts of Lieberkühn
- Jejunum lebih tebal dan lebar (2-4m) dibandingkan ileum (2-3m) turnover sel lama akan dicerna
- Jejunum lebih tervaskularisasi yang membuat jejunum terlihat tubular glands
kembali oleh tubuh
sedikit lebih gelap (A) formed from the mucosa of the
- Ileum lebih tipis, lebih sedikit pembuluh darahnya, sehingga small intestine
bahan pembentukan sel
warnanya lebih terang (B) in between the bases of the villi
baru
- Vasa recta jejunum lebih panjang dibandingkan dengan ileum
lysozyme (bacteria-​lysing
Jejunum : LUQ ( left upper quadrant )
enzyme)
Ileum ​ : RLQ ( right lower quadrant ) secretes antimicrobial
has paneth cells innate immune system
peptides
defensins (proteins with
antimicrobial power)
ers
Lymph Nodes
Passive diffusion occurs by paracellular
Passive
transport through “leaky” tight junctions
Efferent lymphatic vessels Energy-​dependent Na+ absorption Na+ may be absorbed both passively
from the mesenteric lymph
nodes drain to the superior drives passive H2O absorption and actively.
mesenteric lymph nodes. Na+ is actively pumped out of
Active transport involves different carriers at Na+ diffuses from the interstitial
Active the cell by the Na+–K+ pump
the luminal and basolateral membranes fluid into the capillaries
into the interstitial fluid
Na+ channels or secondary active transport
via three different carriers
Lymphatic vessels from the Most H2O absorption depends
terminal ileum follow the ileal Na+–Cl-​symporter on the active carrier that pumps
branch of the ileocolic artery Na+ into the lateral spaces
to the ileocolic lymph nodes.
Na+–H+ antiporter
Na+–glucose
(amino acid) symporter.
The SMA and its branches are
surrounded by a periarterial nerve
plexus through which the nerves are
conducted to the parts of the Carbohydrate
intestine supplied by this artery
Absorption
The sympathetic fibers in the
nerves to the jejunum and ileum
The presynaptic sympathetic fibers Sympathetic stimulation Reducing or stopping
originate in the T8–T10 segments of
synapse on cell bodies of reduces peristaltic and gastrointestinal activity
the spinal cord and reach the
postsynaptic sympathetic neurons in secretory activity of the and making blood (and
superior mesenteric nerve plexus
the celiac and superior mesenteric intestine and causes energy) available for
through the sympathetic trunks and
(prevertebral) ganglia. vasoconstriction “fleeing or fighting.”
thoracic abdominopelvic (greater,
lesser, and least) splanchnic nerves. Digested carbohydrates and proteins
are both absorbed by secondary active
The parasympathetic fibers in the Parasympathetic
transport and enter the blood
Restoring gastrointestinal
nerves to the jejunum and ileum stimulation increases
derive from the posterior vagal peristalsis and secretion
activity following a → Absorption of the digestion end products
sympathetic reaction.
trunks. activity of the intestine
of both carbohydrates and proteins is
accomplished by Na+
The intestine is insensitive to most
pain stimuli, including cutting and → Both categories of end products are
The small intestine also has extrinsic
burning; however, it is sensitive to Protein
and intrinsic sensory (visceral
afferent) fibers.
distension that is perceived as colic absorbed into the blood. Absorption
(spasmodic abdominal pains or
“intestinal cramps”)
the first part of the large intestine Cecum Large Intestine
continuous with the ascending colon
In dissection, the ileal orifice enters prevent reflux from the The large intestine is where water is absorbed from
the cecum between ileocolic lips cecum into the ileum the indigestible residues of the liquid chyme
a blind intestinal pouch
approximately 7.5 cm The valve is unlikely to have any sphincteric action that controls The large intestine can be distinguished from the
passage of the intestinal contents from the ileum into the cecum small intestine by Omental appendices, Teniae coli
Sumber : Moore 8th Ed p.468-471
lies in the iliac fossa of the right and Haustra
lower quadrant The orifice is usually closed by tonic contraction, however,
Sumber : Moore 8th Ed p.468-471
Digested fat is absorbed passively and
of the abdomen, appearing as an ileal papila on the cecal side enters the lymph.
inferior to the junction of the Sumber : Moore 8th Ed p.468-471
terminal ileum and cecum of the
abdomen
Sumber : Moore 8th Ed p.468-471
Sumber : Moore 8th Ed p.468-471
Sumber : Moore 8th Ed p.468-471
6 - 10 cm in length Appendix vitamin absorption in the body
is passive.
Contains masses of lymphoid
passively absorbed along with
water.
Vitamin Absorption is largely passive Fat Soluble Vitamins: Vitamins
that dissolve in fat
Arises from the posteromedial
aspect of the cecum inferior to the
ileocecal junction
Fat-​soluble vitamins are
transported in micelles
Meso-​appendix Has short triangular mesentry
absorbed passively with the end
products of fat digestion.
Variable position, but it is retrocecal
Vitamin B12: Vitamin B12
must be in combination with
gastric intrinsic factor
can be absorbed via receptor-​
mediated endocytosis in the
terminal ileum.
Iron Absorption Required: Storage of Unneeded Iron :
for the production of red blood Stored as ferritin in small
cells absorbed into the blood. intestinal epithelial cells.
Iron Absorption
Ferritin is not absorbed into the
Ascending Colon hepcidin hormone from the
blood and is considered a
liver.
storage iron.
Anatomical Relation
Ferritin is lost in the feces
binds ferroportin and controls
during mucosal regeneration
the export of iron into the blood.
within a few days.
Iron and calcium absorption is absorbed and transported by
greater omentum.
transferrin
regulated.
used for hemoglobin synthesis.
Colon
Venous Drainage Arterial Supply
From branches of the Calcium enters the luminal membrane exits the basolateral membrane by two
SMA, ileocolic and of the small-​intestine epithelial cells down energy-​dependent mechanisms: a primary
right colic arteries. Calcium Absorption its electrochemical gradient through a active transport Ca2+ ATPase pump and a
specialized Ca2+ channel; is ferried within secondary active transport Na+–Ca2+
These arteries the cell by a Ca2+ binding protein, calbindin antiporter.
anastomose with
each other and other
arteries to form the Normally, of the average 1000 mg of Ca2+
marginal artery. taken in daily, only about two thirds is Vitamin D greatly enhances all of these steps
absorbed in the small intestine, with the in Ca2+ absorption.
rest passing out in the feces.
Vitamin D can exert this effect only after it
secretion of parathyroid hormone increases
has been activated in the liver and kidneys, a
in response to a fall in Ca2+ concentration in
Venous Drainage process that is enhanced by parathyroid
the blood.
Arterial Supply hormone.
energy-​rich products are subjected to After passing through the portal circulation,
The venules that leave the small-​intestine Consequently, anything absorbed into the immediate metabolic processing. the venous blood from the digestive system
Most absorbed nutrients immediately villi, along with those from the rest of the digestive capillaries first must pass empties into the vena cava and returns to
pass through the liver for processing. digestive tract, empty into the hepatic portal
vein, which carries the blood to the liver.
through the hepatic biochemical factory
before entering the general circulation.
harmful substances are detoxified by
the heart to be distributed throughout the
body, carrying glucose and amino acids for
the liver before gaining access to the
use by the tissues.
general circulation.
colon.
Fat, which cannot penetrate the intestinal Contractions of the villi, accomplished by the The smaller lymph vessels converge and
Anatomical Relation The absorbed fat is carried by the systemic
capillaries, is picked up by the central lacteal muscularis mucosa, periodically compress eventually form the thoracic duct, a large
circulation to the liver and to other tissues of
and enters the lymphatic system instead, the central lacteal and “milk” the lymph out lymph vessel that empties into the venous
the body.
bypassing the hepatic portal system. of this vessel. system within the chest.
Lacteal: Specialized lymphatic vessels in
the intestinal villi (tiny projections of the
mucous membrane) that absorb fat
Anatomical position
terletak diantara left colic flexure They empty their milk-​like fuid into the
dan the left iliac fossa Descending Colon lymphatic plexuses in the walls of the
jejunum and ileum.
memiliki karakteristik lengkung
berbentuk S
Most common cause of diarrhea is
Excessive intestinal motility yang
Anatomical position
disebabkan dari iritasigut wall karena
Sigmoid Colon Diarrhea results in loss of fluid and infeksi dari bakteri/virus ataupun
The sigmoid colon memanjang dari
cause of diarrhea karena emotional stress.
the iliac fossa to the third sacral (S3)
vertebra
electrolytes
Diarrhea characterized by feses Diare juga terjadi saat
yang cair dan frequensi yang
Anatomical terdapat partikel aktif yang
sering. Tetapi selain itu, zat yang
Vascularization Rectum and Anal canal
disekresi yang normalnya di berlebih seperti defisiensi
Position reabsorbsi tetapi juga hilang
bersama cairan. Selain itu
laktase yang menyebabkan
kehilangan HCO3- akan cairan tertahan di lumen
menyebabkan metabolic asidosis
·Bagian rectum dimulai pada Toxin dari bacterium vibrio cholerae
Superior Middle Inferior rectum merupakan bagian paling
Sacrum 3 dan secara
Makroskopis berbeda dengan
distal dari Large Instestine yang dan beberapa microorganisme yang
memiliki fungsi utama untuk membuat sekresi berlebihan dari
colon dengan tidak adanya
menyimpan feses sebelum
taenia coli, Haustra dan
akhirnya di defekasi. Bagian
jumlah cairan dari mucosa small
Middle and appendiks omentum
panjangnya sekitar 12 – 15 cm proximal terhubung dengan intestine diare diproduksi sebagai
inferior parts of sigmoid colon ( rectosigmoid respon terhadap toxin dari infeksi
Anorectal junction and yang tersusun dari longitudinal
fibers dan circular fibers. junction ) dan terminalnya patogen.
rectum the rectum anal canala terhubung dengan anal canal (
Anorectal Junction ) Sumber : Sherwood 9th Ed p.610
·Alur dari rectum terdiri dari 2
major flexures/lekukan
Most digestion and absorption have been
The large intestine is primarily a drying The colon normally receives about accomplished in the small intestine, the
500 mL of chyme from the
contents delivered to the colon consist of
Sacral Flexures – anteroposterior and storage organ small intestine each day indigestible food residues, unabsorbed
biliary components, and the remaining fluid
curve dengan bentuk cekung di
bagian anterior yang disebabkan
oleh adanya sacrum dan coccyx
The colon extracts more H2O and salt, The primary function of the large
Anorectal flexure –
drying and compacting the contents to intestine is to store feces
anteroposterior curve dengan
form a firm mass known as feces before defecation
bagian cembung di anterior yang
terbentuk karena puborecatlis
muscle Sumber : Sherwood 9th Ed p.610
Sumber : Sherwood 9th Ed p.610
ada tambahan 3 lateral flexures
yang terdapat di dalam rectum
wall ( Superior, intermediate,
inferior
ampulla rektum adalah bagian
akhir dari rektum dan terletak di
dalam pelvic cavity, di antara
abdomen and pelvic floor
muscle. Ini adalah bagian rektum
yang melebar yang bertumpu
pada diafragma panggul dan
bersentuhan dengan prostat
pada pria dan dinding vagina
posterior pada wanita. ampulla
terletak di depan ujung tulang
ekor
Internal anal spinchter ( involuntary
·Anal Canal terdapat 2 ) yang melingkupi 2/3 bagian dari
spinchter : anal canal akan terelaksasi saat
rectum full dan saraf mentrigger
bowel movement,
2,5 - 4 cm long and 2 -3 mm thick
External Spinchter ( voluntary ) hanya
akan terelaksasi pada waktu tertentu
saat akan defekasi. Jika tidak
spinchter akan tetap berkontraksi
dibantu juga oleh otot puborectalis
untuk mencegah adanya
leakage/kebocoran.