Gastrointestinal

Physiology I
Part 1 cont..

Dr Lwiindi
(Medical Physiologist)
GASTRIC MOTILITY,
EMPTYING AND
VOMITING
 Outline/Objectives
At the end, learner must be able to………
 Gastric motility and emptying

 Regulation of Gastric motility and emptying

 Vomiting and its’ control

 Associated clinical conditions

 Stomach
 Specialized for accumulation of food
 Capable of considerable expansion (can hold 2-3L)
 Gastric juice converts food into semiliquid
called chyme
 4 Parts
 Cardia
 Fundus
 Body
 Pylorus
Stomach
 Stomach
 Gastric mucosa has numerous openings called
gastric pits
 Gastric glands empty into bottom of pits
 4 functionally different cell types compose
glands
 Mucous cells
 Chief cells
 Parietal cells
 Enteroendocrine cells
Stomach
 Introduction
 Food from the esophagus is stored in the
stomach; thus its’ a reservoir.
 Then mixed with acid, mucus, and pepsin; and
released at a controlled, steady rate into the
duodenum.
 Both peristaltic and segmental contractions occur
in the stomach.
 Regulation is achieved through intergration of
neural reflexes and hormonal influences mediated
via enteric and autonomic nervous systems.
 Gastric motility and emptying
 The stomach has three anatomic divisions—the
fundus, body, and antrum.
 The orad region of the stomach includes LES, the
fundus and the proximal body; contains oxyntic
glands and is responsible for receiving the
ingested meal.
 The caudad region of the stomach includes the
antrum, distal body and pyloric spincter;
responsible for the contractions that mix food and
propel it into the duodenum.
 1. Receptive relaxation
• A vagovagal reflex that is initiated by distention
of the stomach and is abolished by vagotomy.
 The orad region of the stomach relaxes to
accommodate the ingested meal.
 Mediated by vagal afferents stimulation and
movement of the pharynx and esophagus.
 CCK participates in "receptive relaxation" by
increasing the distensibility of the orad
stomach...ie inhibits gastric motility.
 2. Mixing and digestion
• The caudad region of the stomach contracts to mix the
food with gastric secretions and begins the process of
digestion and the size of food particles is reduced.
 Slow waves (BER), initiated by Interstitial cells of
Cajal in the caudad stomach occur at a frequency of 3-
4 waves/min. They depolarize the smooth muscle cells.
 If threshold is reached during the slow waves, action
potentials are fired, followed by contraction.
 The frequency of slow waves sets the maximal
frequency of contraction.
 Contd…..
 A wave of contraction closes the distal antrum.
Thus, as the caudad stomach contracts, food is
propelled back into the stomach to be mixed
(retropulsion).
 Gastric contractions are increased by vagal
stimulation and decreased by sympathetic
stimulation.
 Even during fasting, contractions (the "migrating
myoelectric complex") occur at 90-minute
intervals and clear the stomach of residual food.
Motilin is the mediator of these contractions
 3. Gastric emptying and regulation
 The caudad region of the stomach contracts to propel food into the
duodenum.
 The rate of gastric emptying depends on

1. Isotonicity or osmolality of the stomach contents.

 If the stomach contents are hypertonic or hypotonic, gastric emptying is
slowed via a negative feedback ie enterogastric feedback mechanism.
2. Type of food ingested (figure 2)
• Food rich in carbohydrate leaves the stomach in a few hours. Protein-rich
food leaves more slowly, and emptying is slowest after a meal containing fat
 Fat inhibits gastric emptying (i.e., increases gastric emptying time) by
stimulating the release of CCK. (Enterogastrone feedback)
3. H+ in the duodenum; inhibits gastric emptying via direct neural reflexes.
H+ receptors in the duodenum relay information to the gastric smooth
muscle via interneurons in the GI plexuses.
 Regulation of Gastric motility and
emptying..fig 3
 2 mechanisms inhibit gastric motility,
secretion and duodenal filling:
 1. Neural enterogastric reflex
2. Hormonal (enterogastrone) mechanisms.
Figure1. Gastric contractions and emptying
Figure 2. Effect of CHO, protein and fat on the rate of emptying
of the human stomach. From Ganong, 24th ed
Figure 3. Control of gastric motility and emptying.
 Gastric motility on fasting
“Migrating Motor Complex, MMC”
Occurs on fasting
To clear undigested food particles
Peristaltic contractions sweep down stomach and
duodenum – pylorus relaxes
Pattern of contraction approx every 90 min
Slow peristaltic waves sweeping whole of GI tract
Thought to be controlled by motilin
18
Importance of MMC
1. Sweep the contents of the small intestine
towards the colon

Housekeeper of the small intestine

2. Inhibit the migration of colonic bacteria into

the terminal ileum

19
Ingestion of a meal suppresses the interdigestive
motility and induces a fed motor pattern
Phase III Fed motor pattern
Meal
Antrum

closed
Pylorus
open

Duodenum

Postprandial motility is characterised by 5 min

 a lower amplitude of the antral waves occurring at

maximal frequency,
 rhythmic pyloric opening and closure
 co-ordinated duodenal contractions occurring in sequence
with the antral waves 20
 Vomiting
 Vomiting (known medically as emesis and
informally as throwing up) is the forceful
expulsion of the contents of the stomach and
often upper SI through the mouth and
sometimes the nose.
 Vomiting is different from regurgitation;
Regurgitation is the return of undigested food
back up the esophagus to the mouth, without the
force and displeasure associated with vomiting.
 Process
 The vomiting act has two phases; the retching
phase and expulsion phase.
 In the retching phase the abdominal muscles
undergo a few rounds of coordinated
contractions together with the diaphragm and
other inspiratory muscles.
 In this phase nothing is expelled except there is
excessive salivation and the sensation of
nausea.
 Contd….
 In the next phase, the expulsive or vomiting phase,
intense pressure builds up in the stomach due to vigorous
contractions in both the diaphragm and the abdomen.
 These contractions last for extended periods of time -
much longer than a normal period of muscular
contraction.
 Reverse peristalsis empties material from the upper part
of the small intestine into the stomach.
 The glottis closes, preventing aspiration of vomitus into
the trachea. This stops breathing in mid inspiration.
 Contd…..
 The abdominal wall muscles contract against a
fixed chest wall which increases intra-abdominal
pressure and squeezes the stomach further ( fig 5).
 The lower esophageal sphincter and the
esophagus relax, and the gastric/intestinal
contents are ejected.
 The relief of pressure and the release of
endorphins into the bloodstream after the
expulsion causes the vomiter to feel better.
 Regulation of vomiting .figures 4
and 5
 The vomiting center lies in the reticular formation of the
medulla in brainstem and consists of various scattered
groups of neurons in this region that control the different
components of the vomiting act.
 A chemoreceptor trigger zone, known as the area
postrema lies on the lateral walls of the fourth ventricle
of the brain which when stimulated can lead to vomiting.
 The area postrema is a circumventricular organ and as
such lies outside the blood–brain barrier; it can therefore
be stimulated by blood-borne drugs/substances that can
stimulate vomiting or inhibit it….opiates, tumor
chemotherapy, hormones during pregnancy, etc.
 Input to the Vomiting centre
 The chemoreceptor trigger zone in the area postrema
has numerous dopamine D2 receptors, serotonin 5-HT3
receptors, opioid receptors, acetylcholine receptors, and
receptors for substance P which when stimulated lead to
emesis.
 The vestibular system, which sends information to the
cerebellum via cranial nerve VIII (vestibulocochlear
nerve) due to overstimulation of labyrinths in ears; plays a
major role in motion sickness, and is rich in muscarinic
receptors and histamine H1 receptors.
 The vagus and glossopharyngeal nerves are activated
when the pharynx is irritated which send information to
NTS and area postrema (vagus only).
 Contd…..
 The Vagal afferents and enteric nervous
system inputs transmit information regarding the
state of the gastrointestinal mucosa: Irritation of
the GI mucosa by chemotherapy, radiation,
distention, or acute infectious gastroenteritis
activates the Serotonin 5-HT3 receptors of these
inputs.
 The CNS mediates vomiting that arises from
psychiatric disorders and stress from higher brain
centres i.e. from limbic
system/hypothalamus….pain, sights,
anticipation, emotions
 Outputs of the Vomiting centre
 The vomiting act encompasses three types of outputs
initiated by the chemoreceptor trigger zone: Motor,
parasympathetic nervous system (PNS), and sympathetic
nervous system (SNS). They are as follows:
 PNS output; Increased salivation to protect tooth
enamel from stomach acids. (Excessive vomiting leads
to dental erosion).
 The body takes a deep breath to avoid aspirating vomit.
 PNS output: Retroperistalsis, starts from the middle of
the small intestine and sweeps up digestive tract contents
into the stomach, through the relaxed pyloric sphincter.
 Contd……
 Intrathoracic pressure decreases (by inspiration
against a closed glottis), coupled with an increase
in abdominal pressure as the abdominal muscles
contract, propels stomach contents into the
esophagus as the lower esophageal sphincter
relaxes. The stomach itself does not contract in the
process of vomiting except for at the angular
notch, nor is there any retroperistalsis in the
esophagus.
 Vomiting also initiates an SNS response causing
both sweating and increased heart rate.
Figure 4. Neural pathways that lead to vomiting
Figure 5. Control of vomiting