GI Motility III Week 2

Peristaltic reflex (intrinsic) Peristaltic Reflex (intrinsic)

Interneuron

Wednesday, February 09, 2011 Major Functions of the SI & motility requirements o Digest macromolecular nutrients (requires significant agitation & size & solubility) fo o Absorb digestion products (stirring to mix contents w/ digestive enzymes/secretions & maximizes contact b/twn nutrient molecules & epithelial cell membranes) o Absorption of fluid and electrolytes o Retain nutrients in small bowel until maximal digestion & absorption (requires slow distal movement of chyme) o Move chyme from duodenum to point of emptying at ileo-colonic sphincter

myenteric plexus

Interneurons

(Stretch)

Circular muscle contracts Longitudinal muscle relaxes

(Oral)

Circular muscle relaxes Longitudinal muscle contracts

(Aboral)

Intrinsic: Bolus causes distension. Felt by chemoreceptors. Send signals in aboral direction inhibitory neurotransmitters (VIP & NO) released that cause relaxation. Oral direction contraction of smooth muscle Multiple Ganglia of the Submucous & Myenteric Multiple ganglia of the submucous and myenteric plexuses plexuses

Extrinsic from the CNSBolusstimulates receptor Sends signal along vagus to the CNS Signals in front of bolus (aboral) causing relaxationNitric Oxide Those behind cause contraction ACh

Structure & Innervation o Circular (thicker) & longitudinal SM o Duodenum-20 cm o Jejunum- 3 meters o Ileum-4 m long o Functions: Duod. & Jej.- digest & absorb o Innervation: Extrinsic: vagus nerve & sympathetic fibers from celiac & sup. mesenteric ganglia o Intrinsic: distension, mechanoreceptors send signals both aboral and toward anus Oral- contraction to push bous Circular muscle layer Signals sent in the myenteric plexuswhich is between the circular and longitudinal /outter muscle layer o MOTILITY Acetylcholine (parasymp. & myenteric) Serotonin (5-HT) Gastrin CCK (small intestine) Enkephalin Motilin o motility Norepinephrine (sympathetic) Adenosine Somatostatin Nitric oxide (NO) Secretin VIP CCK (stomach) GIP Enteroglucagon

Coordinated Muscle layer Contraction/Relaxation during peristalsis

Small Intestine Motility

Coordinated Muscle layer Contraction/Relaxation during peristalsis o Circular muscle contracts tube diameter lengthens tube decreases volume displaces contents o Longitudinal muscle -RELAXATION relaxes when circular muscle contracts in peristalsis formation of segmentation o Sites: esophagus, stomach, SI, briefly in LI o Functions: propulsive transport or nonpropulsive mixing 3 Main patterns of Small Intestine Motility o Major pre-programmed motility patterns o Digestive patterns (after meal; frequent contractions, net mvt 1 cm/min or total of 3-5 hr from pylorus to ileocecal sphincter o Aboral peristalsis o Mixing pattern o Post-digestive patterns (fasting; strong contractions every ~90 min) o Migrating motility complex o Protective response pattern o Power propulsion Mixing Pattern Motility: SEGMENTATION o Contraction of circular layer(both sides) o Alternating contraction & relaxation o Results in MIXING of food digestive juices Facilitates exposure of luminial contents to mucosal surface breakdown of particle sizexs Contractile patterns of SI o Propagating Contractions o Clustered Contractions Move down intestine; slowly o Segmentation mixing o Multiple are going on at same time Clustered, isolated, propagating

SEGMENTATION

Interdigestive Motility Consists of 3 Phases:

Interdigestive Motility: 3 Phases o Migrating Motor complex generated in stomach Mechanism to clear out stomach of large residual particles o Moves down to duodenum Jejunum Ileum o Contraction in Phase III Phase I Phase II

Migrating Motiltiy Complex

Migrating Motor Complex o Starts 2-3 hr after meal digestion o Triggered by hormone - motilin o Aborally clears undigested debris from SI Three motility phases o Phase III, regular contractions (lengthens as region migrates to ileum) o Starts at 3-6 cm/min slowing to 1-2 cm/min at termination o Phase I, quiescent (shortens as region migrates to ileum) o Phase II, irregular contractions (intermediate)lengthens as region migrates to ileum) o MMC reaches ileum, new begins at antrum o Time between cycles is longer during day o Terminates when food enters SI o I.V. nutrition alone will not terminate MMC o Gastrin & cholecystokinin terminate MMC except in ileum Meal ingestion suppresses interdigestive & initiates digestive motor pattern o Meal stimulates motility in duodenum * antrum o Breaks quiescent period of phase I Sleep fating pattern o Reduced phase II o Lengthened Phase I o Waking up in the morning takes you out of relaxed Phase I Retroperistalsis (Reverse Peristalsis) o protective response to rapidly clear tract of irritants or move obstructions o Large & small intestine o Triggered by: mechanoreceptors in throat mechano & chemoreceptors in stomach & gut labyrinthine receptors in inner ear o Speed of movement may not be tied to slow waves - in such cases, extrinsic neural inputs are involved o Emesis program excellent example Role of Retroperistalsis: o Helps dislodge material that may get stuck o Important in vomiting reflux o Can occur in both small & large intestine

Sleep Pattern Click Fasting here to enter Summary

 Vomiting (Emesis) Reflex o Forceful expulsion of intestinal & gastric contents o Stimulation: Pharyngeal (finger down throat) Irritants on gastric mucousa: Noxious substances, over distension or overexcited Motion Vertigo Labryinth Pain, Sights, anticipation o Involve vagal and sympathetic afferents to vomiting center of medulla, also general discharge of ANS: salivation, sweating, rapid breathing, irregular heart beat stretching to overcome normal anti-reflux mechanisms - reverse peristalsis from SI (may occur as low as ileum) to stomach, wave travels 2-3 cm/sec, can push contents to stomach in 35 min), intra-abdominal pressure and intrathoracic pressure (resulting high pressure gradient), movement of stomach through diaphragm hiatus and into thorax, relaxation, repeated several times with LES closed

Retrograde Giant Contraction Followed by Vomiting AS contents get to duodenum STRONG, GIANT contractions in retrograde direction, pylorus is currently in the open state When the contents are in the stomach, GIANT contractions occur in the ANTRUM, these do not immediately lead to vomiting b/c the LES is there. You need severe ANTRAL/GIANT CONTRACTINOS for vomiting to occur. (1) The filled intestine exhibits normal segmenting contractions (2) start of a retrograde giant contraction in proximal jejunum; (3) retropelled digesta reach the duodenum (4) Are forced across the widely opened pylorus into the antrum (5) the giant contraction proceeds to the antrum, the chyme accumulates in the gastric reservoir.

Regulation of Chyme Entry into the Cecum

ILEUM: o As chime moves down ileum o Receptors send signals to the ileocecal sphincter tonically contracted sphinctersrelax Signals also help amplify peristalsis to move chime toward the cecum Regulation of Chyme Entry into the Cecum o Chemoreceptors and mechanoreceptors in cecum feedback to ileum and ileocecal sphincter to regulate chyme entry o Cecum undergoes receptive relaxation similar to proximal stomach o Ileocecal sphincter - prevents back-flow (reflux) to SI; relaxes with jejunum distended, contracts when colon distended) o ~3.5 L of fluid arrives at cecum/day Large Intestine: >90% efficiency at reabsorbing water over 1 m length; absorb electrolytes; store fecal material till expelled (distal); evacuate 200300 ml solid stool/day o Ascending colon Receive chyme from ileum Receptive relaxation Short transit time (~87 min) Reservoir for transverse colon Transverse colon Primary region for absorption of H20 Long transit time (~ 24 hr) Descending colon Completion of absorption Long transit time (~24 hr) Sigmoid colon highly distensible for collection of feces

Large Intestine

Role of Colonic Motility

Motility of Large Intestine o Large contraction move contents from ileum into caecum and ascending colon o Haustral movements: contractions in ascending colon Help with mixing Facilitate absorption of water Fermentation of bacteria o unstimulated areas sac-like (haustra) o haustra - disappear and reappear with contractions and reform at other loci

Fecal continence is aided by a compliant rectum

Reflex responsiveness of the anal region to a distending stimulus in the rectum

Segmented motility o similar to mixing pattern of SI but less dynamic & slower (allow more time for absorption) o circular and longitudinal muscle contractions; net movement is aboral Peristaltic motility o haustral movements (slow, anal movements 815 hr; circular muscle) o mass movement (i.e., power propulsion) 1-3 times per day, segmentation ceases, haustrations disappear and movement along large segment of colon occurs (transverse to sigmoid colon or rectum) o reverse peristalsis can occur if sensory neurons are triggered by obstruction Contractile Pattern of Large Intestine o Shallow peristaltic waves of caecum & colon: Low propulsion o Shallow peristaltic waves at haustrated colon Small aboral flow o Colonic Segmenting Contractions Migrating Aborally Slow aboral propulsion Aboral migration Power Contraction moves material from descending to the Sigmoid Colon SigmoidRectum o Pressure Anal sphincters: o Internal: RELAXATION Positions stool so its ready for elimination o External: CONTRACTION Helps prevent incontinence Power Propulsion in Descending & Sigmoid Colon o Neutrally controlled clearing reflex (defecation) o Moves large volume of feces o Triggered by arrival of large volume of chime into cecum & transverse colon Or in response to gastrocolic reflexRESPONSE TO STRETCH IN STOMACH OR DIGESTION PRODUCTS IN si o Haustra disappear during power propulsion then reappear o Not tied to rate of movement of slow waves

es

Ana-Rectal Responses The rectum has more segmented contractions than sigmoid colon so kept nearly empty Feces moves to rectum by mass movement via power propulsion, retrograde movement to sigmoid colon can occur When fecal matter is pushed into rectum, it distends the rectum resulting in a relaxation of the internal anal sphincter relaxes (rectoanal reflex). The internal sphincter is smooth muscle that is tonically contracted Stool enters the anal canal Signals to CNSAwareness Do Something Decide (voluntary) contract the sphincter & postpone or relax the external sphincter (striated muscle) and defecate

Neuronal Pathways, Defecation Reflex & Fecal Continence

Neuronal Pathways: Defecation Reflex & Fecal Continence o Distension of rectum neural pathways from chemo- and mechanoreceptors send inhibitory motor signal to internal anal sphincter o Mechano- and chemo-receptors in anal canal discriminate gas, liquid or solid o Conscious cortex makes appropriate decision to control external anal and puborectalis muscles o If appropriate, defecation reflex is triggered

Muscular actions for Defecation o Puborectalis Muscle-relaxes o External anal sphincter relaxes o Rectus muscle contracts o Diaphragm pushed down o Power propulsion in sigmoid colon & rectum o Force feces past anal sphincter o Voluntary Control of external anal sphincter * puborectalis muscle can temporarily inhibit reflex Defecation Muscles

Classifiying:Reversible or Chronic Chronic: you can have myogenic or neurogenic Pseudo-Obstructino/Subclassification o Reversible: self-limiting Peritonial insult Paralytic ileus Retroperitoneal hemorrhage MI Uremia Porphyria o Chronic: (CIP)-recurrent Myogenic or NEUROGENIC Idiopathic (CIP) or SECONDARY (CISP) IdiopathicFamilial or sporadic Chronic Intestinal Pseudo Obstruction o Neuropathic: Extrinsic Diabetes Dysautonomia CNS disease: spinal cord, MS, parkinsons Enteric: Familial Autosomal recessive or dominant Sporadic Degenerative non inflammatory Degenerative Inflammatory Paraneoplastic Chagas disease CMV Idiopathic Developmental Aganglionosis o Myopathic: Familial Visceral: Type I: autosomal dominant Type II autosomal recessive Sporadic: Scleroderma Amyloid Polymyositis Myotonic dsytrophy

MOTILITY DISORDERS OF THE SMALL INTESTINE o Intestinal Obstruction: partial or complete blockage of bowel resulting in failure of contents to move through intestine o Causes: Mechanical (bowel obstruction) Bowel does not work correctly but no structural problem (ileus; pseudoobstruction) Mechanical Obstruction o abnormal tissue growth o adhesions or scar tissue that form after surgery o foreign bodies (ingested materials that obstruct the intestines) o gallstones o hernias o impacted feces (stool) o intussusception (part of the intestine invaginates into another section) o tumors blocking the intestines o volvulus (twisted intestine) Pseudo-obstruction= Paralytic Ileus o Impairment of intestinal propulsion absence of any lesion occluding the lumen of the gut o Symptoms: Nausea, vomiting, abdominal distension Fullness, abdominal pain Constipation/diarrhea Severe malabsorption o Causes: Chemical, electrolyte, or mineral disturbances (such as decreased potassium levels) Complications of intra-abdominal surgery Decreased blood supply to the abdominal area (mesenteric artery ischemia) Injury to the abdominal blood supply Intra-abdominal infection Kidney or lung disease Use of certain medications, especially narcotics Gastroenteritis (bacterial, viral, food poisoning) Bloat o More in women o Most often due to abdominal distension (not gas) o Associated w/ diminished propulsion of SI & LI & heightened sensitivity to distension

MOTILITY DISORDERS OF THE LARGE INTESTINE Diarrhea o Definition: increased stool fluidity and frequency (e.g., loose, watery stools usually >3 times/day) o Associated symptoms: cramping, abdominal pain, bloating, nausea, urgency o Duration: Acute (1-2 days), chronic (>2 days; possible dehydration and/or more serious condition), chronic (e.g., chronic disease) o Excessive number of propagating contractions reduce time for water reabsorption Common Causes of diarrhea o Bacterial infections. Several types of bacteria consumed through contaminated food or water can cause diarrhea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli (E. coli). o Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, and viral hepatitis. o Food intolerances. Some people are unable to digest food components such as artificial sweeteners and lactosethe sugar found in milk. o Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. o Reaction to medicines. Antibiotics, blood pressure medications, cancer drugs, and antacids containing magnesium can all cause diarrhea. o Intestinal diseases. Inflammatory bowel disease, colitis, Crohns disease, and celiac disease often lead to diarrhea. o Functional bowel disorders. Diarrhea can be a symptom of irritable bowel syndrome.

Constipation o Definition: fewer than 3 bowel movements/week o Constipation is a symptom. Features also include: o stools are usually hard, dry, small in sized and difficult to eliminate o bowel movement many be painful, involve straining o feeling of bloat or full bowel o Occurs when: o the colon absorbs too much water o colon contractions are slow or sluggish (faulty colonic propulsion) o disordered anorectal function o Other: o almost everyone experiences constipation at some point o common after surgery, pregnancy and child birth Causes of Constipation o not enough fiber in the diet o lack of physical activity (especially in the elderly) o medications o milk o irritable bowel syndrome o changes in life/ routine pregnancy, aging,, travel o abuse of laxatives o ignoring the urge to have a bowel movement o dehydration o specific diseases or conditions, such as stroke (most common) o problems with the colon and rectum o inability to relax external anal sphincter o problems with intestinal function (chronic idiopathic constipation)

 Conditions that Cause Constipation o Neurological disorders multiple sclerosis Parkinson's disease chronic idiopathic intestinal pseudo obstruction stroke spinal cord injuries o Metabolic and endocrine conditions diabetes uremia hypercalcemia poor glycemic control hypothyroidism o Systemic disorders amyloidosis lupus scleroderma

MOTILITY DISORDERS OF THE RECTUM & PELVIC FLOOR Fecal Incontinence o Definition: involuntary passage of fecal material (inability to control your bowels) o Causes: Weakness of anal sphincter muscles that allow voluntary hold back of a bowel movement Causes: injuries to pelvic floor muscles or nerves (e.g., injury resulting from delivering a baby, hemorrhoid surgery, diabetes, myasthenia gravis) Loss of sensation for rectal fullness Constipation (rectum fills up and overflows, watery stool can leak around hard stools; stretching of rectal muscles so they cant hold a stool) Stiff (less elastic) rectum due to scarring (some causes: radiation treatment, rectal surgery, inflammatory bowel disease) Diarrhea (loose stool is difficult to control) Hirschsprungs Disease o Loss of intrinsic nerves (congenital aganglionosis) to part (short-segment HD) or all (long-segment HD) of the colon and rectum. Anus is always involved. o HD may also have a myogenic component and abnormalities in interstitial cells of Cajal o Nerve cells stop growing (migrating, differentiating, proliferating, surviving) along the intestine towards the anus o Newborns fail to have their first bowel movement within 48 hours of birth (incidence: 1 : 5,400-7,200 newborns) o Failure of normal peristalsis and relaxation of internal anal sphincter o Constipation or intestinal obstruction

Emotional Response to Stress alters colonic motility

Stress can Affect GI motility o IBS patients have an exaggerated colonic myoelectrical and contractile response to emotional stress when compared with controls o Rapid contractile acitivy accompanied by blood flow IRRITABLE BOWEL SYNDROME (IBS) o Characterized by cramping, abdominal pain, bloat, constipation, diarrhea o 20% of adults in USA have symptoms of IBS o Cause unclear o Colon is sensitive to certain foods and stress o Immune system may also have a contributory role Rome II IBS Diagnostic Criteria o At least 12 wks (not consecutive) in preceeding 12 months of abdominal discomfort or pain w/ 2 of 3: Relieved with defecation and/or Onset associated with a change in frequency of stool and/or Onset associated with a change in the form of stool Supportive Symptoms of IBS & Subtypes o Fewer than 3 BM / wk o 3 bm per day o Hard or lumpy stools o Loose (mushy) or watery stools o Straining during a BM o Urgency (having to rush to have one) o Feeling of incomplete BM o Passing mucus during a BM o Abdominal fullness, bloating or swelling Diarrhea-predominant o 1 or more of 2, 4 or 6 & non of 1, 3 or 5 Constipation Predominant o 1 or more of 1, 3, or 5 and no of 2, 4, or 6 IBS PATHOGENESIS-Altered motility

IBS Pathogenesis: Altered Motility