physio 7

Date @May 8, 2024

status 1 Summrize

URL 1 https://t.me/sa3ed123443/7339

FROM Ali .S

small intestine
small intestine consists of three parts

1. duodenum

2. jejunum

3. ileum

small intestine has 250 M2 as surface area due to mucosal folding

also 20-40 villi/m2 share to increase the absorptive surface of small

intestine

Absorption is a major function of small intestine so movement in small

intestine will be slow and depends on

its myogenic contraction

enteric nervous system

vegus has low effect on movement on small intestine

manipulation of small intestine during surgery can initiate inflammatory

response which will lead to

relaxation and filled with water and liquids from blood

secretion of small intestine { succus entericus }

composition of succus entericus

physio 7 1
 it is secreted by intestinal glands {crypt of lieberkuhn}

it is alkaline fluid { PH 8} with volume about 2L / day

this high volume reabsorped by intestine because slow movement

so any drug increase motility of intestine will lead to watery diarrhea

consists of NA and K and HCO3 and CL

lets take about CL secretion

it is the major ion secreted in succus entericus

first in basolateral border NA- K-CL co-transport which drives

the active transport of CL from blood into cell

then CL diffuse into lumen through apical border through 2 CL

channels

1. CL channel activated by CAMP

a. these channels can be activated by cholera toxin result

in marked secretion of CL and NA followed by water
causing watery diarrhea

2. CL channels activated by increase CA +2

a. activated by cholinergic stimulation, secretine, glucagon

and VIP

b. VIP abnormally increase in some pancreatic tumors

result in marked secretion of CL and NA followed by
water causing watery diarrhea called pancreatic cholera

also consists of mucous

mucous help in protection of duodenal mucosa against acidic juice

lubrication and facilitation of passage of food along intestine

also consists of enzymes which is two types

1. intracellular enzymes or cellular enzymes

a. not because it called intracellular enzyme that mean it is inside

the cells NO

i. these enzymes has active site outside toward lumen { brush

border }the cell and the reset part inside the cell

physio 7 2
 b. like disaccharidases and proteolytic enz and enteric lipase

2. extracellular enzymes

a. like enterokinase and amylase

so function of succus entericus

1. alkaline fluids act as solvent for products of digestion

2. mucous lubrication and protects the mucosa from chemical and mechanical
damage

3. digestion of CARB

a. amylase split starch into dextrin and maltose

b. maltase splits maltose into 2 glucose

c. lactase splits lactose into glucose and fructose

4. digestion of Fats

a. lipase for splitting fat into glycerol and fatty acids

5. digestion of proteins

a. into amino acid by trypsin which activated from trypsinogen by

enterokinase

movement of small intestine

slow movement happen by basal electric rhythm BER

12/ minute in duodenum

9/ in ileum

types of small intestine movement

1-mixing or segmentation contraction movement

physio 7 3
 1. it is several contraction & relaxation movement

Function

1. Help digestion by mixing food with digestive enzymes

2. Help absorption by bringing food in contact with the absorbing surface

Frequency

in Duodenum : 12 per min

in Ileum : 9 per min

Origin or Control or Cause

mainly myogenic {MCQ} depend on basal electric rhythm

2-Normal Peristaltic Movement of small intestine

Mechanism

Stretch of a part of intestine leads to

1. Contraction behind the stretched part (Cholinergic/ACh).

2. Relaxation in front of stretched part (Purigenic/ATP).

3. The peristaltic wave travels at a rate about 1 cm/ second for about 5
cm then dies

Function

1. Propagation of food along the intestine.

2. help digestion& absorption

Control

Myenteric nerve plexus

Cause

physio 7 4
 Neurogenic due to local axon reflex

Factors increase peristaltic activity of the small intestine

1. Beginning of entry of chyme into the duodenum.

2. Gastroenteric reflex

3-peristaltic rush {Mas peristalsis}

1. doesn’t occur normally {mcq}

2. it occur due to strong irritation or sever distension of small intestine

3. this will lead to strong rapid peristalsis which evacuates rapidly intestine
contents leads to diarrhea

movement of villi
it is alternative contraction and relaxation of villi leads to milking of villi

milking of villi help in drainage of lymph flow from central lacteal into the
lymphatic system

this movement of villi controlled by

local reflexes in submucosal plexus in response to chyme in small

intestine, leading to secretion of vilikinin so stimulation of movement

regulation of small intestine movement

nervous control
1. intrinsic {high effect}

a. stimulation : distension by food

b. receptors : mechano-receptors

c. reflex :local reflex

d. effect : increase motility

e. chemical transmitter : ACH

2. extrinsic {low effect}

physio 7 5
 a. parasympathetic : increase motility

b. sympathetic : decrease motility

hormonal control
1. CCK and gastrin increase motility

2. secretin and GIP decrease motility

3. villikinin increase motility of villi

other factors
1. serotonin and substance P increase motility

defecation

paralytic ileus

A condition in which there is relaxation of intestinal muscles leading to

decreased or absent of intestinal motility

occur in postoperative due to trauma which lead to direct inhibition of

smooth muscle

or peritoneal irritation which lead to sympathetic discharge to intestine

→ relaxation

characterized by vomiting and abdominal distension with gases and fluid

and no peristalsis movement

TTT by

physio 7 6
 aspiration of gases and fluid by special tubes to stoop over distension
of intestine

-IV fluids to prevent dehydration

prostigmine to increase contraction of intestine and start peristalsis

again

ileocecal valve and sphincter

function of ileocecal valve and sphincter

1. the valve prevent backflow of fecal content from the colon into small
intestine

2. the sphincter remains mildly contracted to delay emptying of ileal

contents to caecum which allow enough time for absorption

control of opening and closure of ileocecal sphincter

1. Nervous regulation

a. mainly by local nerve plexus { local reflex}

i. distention of stomach lead to stimulation of long reflex which

stimulate gastro ileal reflex so relaxation of sphincter

ii. distention of terminal ileum stimulate local reflex lead to

relaxation of sphincter

iii. distention of cecum stimulate local reflex lead to contraction of

sphincter

b. Extrinsic nerves

i. parasympathetic lead to relaxation of sphincter

ii. sympathetic lead to contraction of sphincter

2. hormonal regulation

a. gastrin lead to relaxation of sphincter

Large intestine

physio 7 7
 the colon functionally divides into three parts

1. Proximal colon or absorbing colon

a. it includes cecum and ascending colon and proximal half of

transverse colon

b. its main function is absorption of water and electrolytes from chyme

2. Distal colon or storage colon

a. it includes distal half of transverse colon and descending colon and

sigmoid colon

b. its main function is storage the faces

3. rectum and anal canal

a. its function is defecation

b. normally rectum and anal canal don’t have any stool

i. because any small amount of stool in this part will lead to

defecation reflex and this is called soiling defecation

movement of large intestine

1-mixing or segmentation contraction movement

2-propulsive {Peristaltic} Movement

3-Normal peristalsis

4-peristaltic rush {Mas peristalsis}

here in large intestine it occur normally unlike small intestine

happen due to gastro-colic or duodeno-colic reflexes

this explained by defecation after morning meal

so it happen once or twice per day often after meals

this mass peristalsis delivers stool to sigmoid colon and rectum then
defecation reflex start

physio 7 8
 function of large intestine
1. the primary function of large intestine is absorption of water and
electrolytes

a. and digest and absorb components of meal that can not absorb more
proximally

2. store of waste products of the meal until they can excrete from body

3. large intestine contain many trillions of commensal bacteria

a. these colonies of bacteria metabolized other endogenous substance

such bile acids and bilirubin

b. also these bacteria detoxify xenobiotic such as drugs

c. also protect the colic epithelium from infection by invasive pathogens

d. also synthesis some vitamins like K- B complex

4. large intestine excrete certain heavy metals such mercury

5. mucous secretion protect mucosa from chemical and mechanical irritation

regulation of colonic motility

1. nervous regulation

a. Intrinsic as

i. myenteric plexus which is inhibitory

b. Extrinsic as

i. sympathetic inhibitory

ii. parasympathetic stimulatory

2. hormonal regulation

a. gastrin and prostaglandins are stimulatory

b. adrenaline is inhibitory

Hirschsprung's disease

physio 7 9
 Normally, the large intestine
continuously squeezes and
relaxes to push stool along, and
this process controlled by your
nervous system
Congenital megacolon due to
congenital absence of ganglion
cells in the wall of bowl leading to
the Aganglionic segment remains
contracted , no peristalsis so
blocking faces

In Hirschsprung's disease, the nerves that control this movement are

missing from a section at the end of the bowel, which means stool can
accumulate and form a blockage or very very hard mass

Manifestation

cause severe constipation

serious bowel infection called enterocolitis

gas distention

Diagnosis

abdominal X ray with radiocontrast

rectal biopsy mucosa , submucosa

TTT

surgical resection

innervation of rectum and anal canal

1. sympathetic innervation

a. they are the lesser splanchic nerves

i. arise from LHCs of upper 4 lumbar

b. it inhibit defecation reflex by

physio 7 10
 i. relaxation of rectal wall

ii. contraction of internal anal sphincter

2. parasympathetic innervation

a. Afferent

i. fibers from pelvic nerve carry sense of rectal distention

b. Efferent

i. fibers of pelvic nerve from LHCs of sacral 2-3-4

c. it stimulate defecation reflex by

i. contraction of rectal wall

ii. relaxation of internal anal sphincter

3. somatic innervation

a. Afferent

i. fibers of pudendal nerve carry sensation of anal canal distention

b. Efferent

i. fibers of pudendal nerve from LHCs of sacral 2-3-4

c. they are motor to external urethral sphincter

defecation reflex two types

1. intrinsic defecation reflex

a. happen by local reflex when rectal distention initiates

b. this will lead to peristaltic wave in descending and sigmoid colons

c. and rectum forcing faces towards the anus and relaxation of internal
anal sphincter

2. Spinal defecation reflex includes

physio 7 11
 Parasympathetic reflex {Rectal
Anal reflex
reflex}

occurs When the faces in the rectum When the faces in the Anal canal

Distension of the rectum Distension of the anal canal

stimulation

Mechano-receptors in the wall of Mechano-receptors in the anal

receptor the canal
rectum

2,3,4 sacral segments 2,3,4 sacral segments

center

1-contraction of the wall of the 1-Potentiate the previous effect

rectum mentioned in
2-Descending & sigmoid colon parasympathetic reflexes
response 3-Relaxation of anal sphincters 2-Causes contraction of levetor
(internal ani helping the outward
& external) expulsion of faces

Pelvic nerve
Afferent

Pelvic nerve & pudendal nerve for

Efferent
external sphincter

voluntary control of defecation

1. if the condition are suitable 1. if the condition are not suitable

a. cerebral impulses help in a. cerebral impulses help in

initiate of defecation inhibition defecation
voluntary through voluntary through

i. activation of defecation i. inhibition of defecation

center center

ii. relaxation of anal ii. contraction of external

sphincter anal sphincter

iii. straining which lead to

increase intra abdominal
pressure and squeezing
of rectum

physio 7 12
 fecal continence
it is the ability to control elimination of rectal contents during rest and
during sudden increase intra abdominal pressure like in cough or sneezing

mechanism of fecal continence {short note }

1. tone of sphincter

a. the resting pressure of external and internal sphincter is 60mmhg

higher than rectal pressure 6mmgh

b. 80% due to tone of internal sphincter

c. 20% due to tone of external sphincter

2. tone of puborectalis muscle

a. puborectalis muscle keep the ano-rectal angle which form a barrier

against passage of stool from rectum to anal canal

3. Anal sensation

a. anal mucosa is sensitive to pain and touch and temperature

i. this allow anal canal to differentiate between solod and liquid

stool from gases

4. rectal sensation

a. rectum is sensitive only to stretch which help in giving desire to

defecation and triggers reflex and voluntary contraction of external
sphincter and puborectalis and

b. this will maintain continence in stress condition caused by increase

in rectal pressure

5. rectal compliance

a. rectum can accommodates different fecal volumes without marked

increase in intra rectal pressure

b. which will maintain continence till time of defecation

6. rectal motility

physio 7 13
 a. BER in rectum is more than sigmoidal colon

i. this act as barrier to fecal flow and make rectum empty between
defecatory periods

b. which will maintain continence till time of defecation

7. intact innervation of anorectal region

8. consistency of stool

physio 7 14