HISTOLOGY OF SMALL INTESTINE

PREPARED BY :
Nian Shwan Hawar Ahmad Hawry Shafeeq Heveen Anwar Mozhgan Hdayat

Small Intestine
Portion of digestive tract which is responsible for hydrolysis of chyme into absorbable form: The small intestine (duodenum, jejunum and ileum) is also the principal site for absorption. Four factors confine to provide for an enormous absorptive surface area:

Small Intestine
1. The small intestine is extremely long (4-6 meters in humans)

Small Intestine
2. The mucosa and submucosa are thrown into circularly arranged folds (plicae circulares); these folds are particularly numerous in the jejunum.

Small Intestine
3. The mucosal surface is made up of many finger-like projections (villi) with intervening small openings of simple intestinal glands (crypts of Lieberkuhn).

Small Intestine
4. Extensive microvilli are present at the luminal surface of the enterocytes, the columnar cells covering the villi and crypts * These cells are responsible for the processes of digestion and absorption.

Small Intestine (Villi)

Villi are outgrowths of the mucosa (epithelium plus lamina propria projecting into the lumen of the small intestine.

Small Intestine (Villi)

In the duodenum, they are leaf-shaped, gradually assuming finger-like shapes as they reach the ileum.

Small Intestine: Mucosa

Epithelium: Simple columnar absorptive epithelium (enterocytes) with goblet cells organized into villi.

Small Intestine: Mucosa

Epithelium: Continuous with intestinal glands of Lieberkhn. *

Small Intestine: Mucosa

Lamina Propria: Loose connective tissue underlying villi. Contains blood and lymphatic capillaries.

Small Intestine: Mucosa

Lamina Propria: Loose connective tissue underlying villi. Contains blood and lymphatic capillaries.

Small Intestine: Mucosa

Muscularis Mucosa: Layer of smooth muscle separating mucosa from submucosa.

Small Intestine: Mucosa

Major Functions: Digestion, absorption, lipid processing, transport of small molecules, mucus layer protects mucosal lining from bacterial infection and digestion by enzymes.

Small Intestine: Mucosa

Major Functions: Lymphocytes provide immunological protection from foreign antigens.

Small Intestine: Submucosa

Structure: Layer of loose connective tissue (collagen and elastin), contains small infiltrates of lymphocytes, large blood vessels, submucosal (Meissner's) nerve plexus, lymphatic vessels and mucous glands. *

Major function: supports mucosa.

Small Intestine: Muscularis Externa

Two layers of muscle: outer longitudinal and inner circular. Myenteric (Auerbach's) nerve plexus located between the two muscle layers. *

Small Intestine: Adventitia

Connective tissue containing large blood vessels and nerves.

Small Intestine
Types of epithelial cells: 1. Enterocytes (absorptive cells):

Types of Epithelial Cells

2. Goblet cells (mucus secreting): 3. Undifferentiated cells:

Types of Epithelial Cells

4. M cells:

Types of Epithelial Cells

4. M cells:

Types of Epithelial Cells

5. Paneth cells (exocrine cells with antibacterial activity, lysozyme)

Types of Epithelial Cells

5. Paneth cells (exocrine cells with antibacterial activity):

Types of Epithelial Cells

6. Enteroendocrine cells (secretin):

Small Intestine
Three Regions of the Small Intestine: 1. Duodenum,

2. Jejunum,
3. Ileum.

Small Intestine: Regions

Duodenum: Few goblet cells in mucosa.

Duodenal glands of Brnner located in submucosa.

Bile and pancreatic ducts enter duodenum.

Duodenum: Duodenal glands of Brnner

Small Intestine: Regions

Jejunum:
More goblet cells than found in duodenum.

Does not contain Brunner's glands or Peyer's patches (that are found in the ileum).

Small Intestine: Regions

Ileum: Abundant goblet cells. Peyer's patches located in the lamina propria.

Gartner 14-5; 4

The Mechanisms of Digestion and Absorption in the Small Intestine.

Digestion of food occurs within the lumen or at the mucosal surface; it is the enzymatic degradation of food. Absorption of the resulting nutrients occurs only at the mucosal surface. * The components of chyme (the semi-fluid mass of partly digested food) passed from the stomach into the duodenum through the pyloric valve is digested and absorbed as follows:

The Mechanisms of Digestion and Absorption in the Small Intestine.

Proteins are further digested by pancreatic enzymes (e.g., trypsin) and membrane-bound peptidases (components of the glycocalyx) The resulting amino acids are absorbed via active transport. * Carbohydrates are converted to simple sugars (monosaccharides) by pancreatic amylase and membranesbound disaccharidase (components of the glycocalyx).

The Mechanisms of Digestion and Absorption in the Small Intestine.

Lipids (triglycerides) are converted to monoglycerides by pancreatic lipases. *

The Mechanisms of Digestion and Absorption in the Small Intestine.

The resynthesized triglycerides are absorbed by intestinal lymphatics (lacteals).

The Mechanisms of Digestion and Absorption in the Small Intestine.

Amino acids & monosaccharides are absorbed by intestinal capillaries & pass via the portal vein to liver.

CONGENITAL ANOMALIES
Heterotopia

Usually pancreas, but can be gastric mucosa appearing as small nodules in the mucosa or intestinal wall

Atresia

and Stenosis

Duodenal atresia is most common, followed by jejunum and ileum Stenosis can also be acquired e.g. intussusceptions Meckel diverticulum Failure of vitteline duct

ENTEROCOLITIS

DIARRHEA & DYSENTERY

Diarrhea

An increase in stool mass, frequency or fluidity in most patients Characterized by pain, urgency, perianal discomfort and incontinence
Low-volume, painful, bloody diarrhea

Dysentery

INFECTIOUS ENTEROCOLITIS
Intestinal diseases of microbial origin Characterized by diarrhea and in some instances ulceration of the bowel Causes >12,000 deaths per day among children in developing countries and equals of all deaths before age 5 worldwide

MALABSORPTION SYNDROMES

MALABSORPTION SYNDROMES

Malabsorption - Definition

Characterized by suboptimal absorption of fats, fatsoluble and other vitamins, proteins, carbohydrates, electrolytes and minerals, and water

CELIAC DISEASE

Morphology

Grossly, mucosa appears flat or scalloped, or even normal Microscopically, diffuse enteritis with marked atrophy or total loss of villi Epithelial cells degenerated with loss of microvilli and increased intraepithelial lymphocytes Crypts exhibit increased mitotic activity. Morphology mimics other diseases, like tropical sprue Mucosa will revert back to normal when stimulus taken away.

Celiac Disease Morphology

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Diffuse atrophy and blunting of

Celiac Disease Morphology

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WHIPPLE DISEASE

A rare systemic disease of primarily the intestines, joints, and CNS, caused by gram-positive actinomycete, Tropheryma whippelii

Pathogenesis unknown

Patients are usually white, M:F = 10:1, 40-50 years of age Lamina propria is laden with distended macrophages, containing tiny, rod-shaped bacilli that are PAS positive

Whipple Disease - Morphology

Normal Whipple

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GRIPE

DISACCHARIDASE (LACTASE) DEFICIENCY

Disaccharidase is an apical membrane enzyme that cleaves lactose.

Disaccharidase deficiency

Lactose in gut lumen

Leadin g to

Diarrhea & Malabsorption

causinOsmotic purgative g Effect

CIRCULATORY DISORDERS

ISCHEMIC BOWEL DISEASE

General

Can be restricted to either the small or large intestine, or both Infarctions seen with acute occlusion of celiac, superior and inferior mesenteric arteries Insidious loss of one vessel may go unnoticed due to rich anastomoses

Etiology

Arterial thrombosis Arterial embolism Venous thrombosis Nonocclusive ischemia; e.g. cardiac failure, shock, etc. Miscellaneous
Radiation injury Volvulus Stricture

Ischemic Bowel Disease Morphology

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Ischemic Bowel Disease Morphology

Web Path

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OBSTRUCTIONS/ DILATATIONS

Most obstructions in small intestine because of small diameter. Hernias, adhesions, intussusceptions and volvulus make up about 80%

HERNIAS

Etiology

Usually weakness in wall of peritoneal cavity may permit protrusion of a pouch-like, serosa-lined sac of peritoneum Most common sites
inguinal and femoral canals umbilicus surgical scars

Clinical Significance
Segments of viscera protrude and become trapped e.g. small bowel Ischemia Incarceration = permanent trapping of bowel loop due to edema from impaired venous drainage Strangulation = compromised arterial supply & venous drainage infarction

ADHESIONS

Etiology

Inflammation (peritonitis) e.g. surgery, infection, radiation and endometriosis As healing occurs, get adhesions between bowel loops, bowel wall, & surgical site
Twisting of bowel loops around peritoneal fibrous bands, strangulating & obstructing the bowel

Complications

Adhesions
Robbins 6th Edition

Adhesions - Morphology

Web Path

ADENOCARCINOMA

Epidemiology
Age - 40-70 years Majority in duodenum Major risk factor is inflammation from CD

Clinical Features
Weight loss, cramping, nausea, vomiting Obstructive jaundice if located in Ampulla Fatigue if blood loss

Clinical Complications

Most neoplasms penetrates wall invade mesentery

metastasized to regional nodes diagnosis is made 70% survival at 5 years with surgery

liver by time

Adenocarcinoma Morphology

GRIPE

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