Anatomy.for.Beginners.3of4.Digestion.DivX60.AC3.www.mvgroup.org.

avi

A transcript.

Timings are approximate

Bold text is unclear/unverified

/bigbreaths August 2005

We know where it goes in, we know where it comes out and we know in between something
useful happens. Tonight, I will show you journey of a mouthful of food along a seven metre
of ingenious tubing. I will actually unravel this woman’s gut, literally. And at the time I have
finished, her tongue will be here, her stomach here, her liver, her pancreas, her small
intestine, large intestine and finally, over here, her anus.

Lesson three: Digestion.

01:45
It is sometimes said ‘you are what you eat’. But, in the case of the humble doughnut, this is
true in quite a surprising way, because the doughnut is actually an elementary model of the
way that we are made. It has a mouth, an anus, some stuff around the outside and a tube
through the middle. In her own case, the stuff around the outside has been elaborated into a
head, a body, arms and legs. And the tube through the middle has got the lot longer and a lot
more convoluted. But our central tube is vital because it is through this tube that we take in
food from the outside world and convert it into our bodies. There is a lot of this tubing. And
it is quite amazing that it all fits into the abdomen in this way.

Our alimentary tract is stuffed in one of our body cavities. To show you that, I have cut the
whole body, frontally, in two parts. And we look at the cut surfaces we see here the upper
cavity for the brain and the large body cavity here, the lung, in front, the heart. But below the
lung on this side, there the alimentary tract starts. These the diaphragm is a liver, the
stomach, the large and small intestine
There is absolutely no space wasted anywhere, and yet there is still room in here for our
intestines to writhe around as they propel our food along. But this very economy of
packaging means that it is actually quite difficult to understand what connects to what. So we
are going to begin our journey at the very beginning, at the mouth.

And we show it at this body to be dissected. The body is fixed. This means we stop
putrefaction by a chemical called formalin. It also has the advantage that the organs become
stiff, they are not so flabby any more. Of course, we had to suspend the body by those
threads. For anonymisation, we put this mask on and we have the mouth open because we
want to follow a piece of food along its journey.

The reason for having the body in the upright position is because we wanted to show you the
gastrointestinal tract in the sort of position that you would normally see it when we eat a
meal, in other words in an upright position.

4:22
Digestion starts in the mouth by saliva and this is produced by the salivary gland. So what I
do now, I open the flap of the skin to expose the salivary glands.

So in this demonstration we are going to use the analogy, the perfectly reasonable analogy, of
the gastrointestinal tract as a food processing plant. And the processing starts with the mouth.
The mouth is our food hopper - this is the place where we take food in, where we crush it up
and break it into smaller pieces, ready for transfer down to the business end of the
gastrointestinal tract, which is in the abdomen.

The mouth is actually a more sophisticated structure than it is often given credit for. We have
muscular lips, by which we can manipulate our food, we have teeth of various different sizes
and shapes to cut it up, we have cutting incisors at the front, we have grinding molar teeth at
the back, we have salivary glands. And I think this might be a good opportunity to use, we
have got a little mini camera here, to give you a
closer-up view of what is happening. So you can get a slightly closer view of the salivary
glands.
The saliva has two main functions. Its main function is to lubricate the food, ready for its
journey down the oesophagus to the intestine. But it also produces an enzyme - this is a
special protein, which digests, in the case of the saliva, starch. So, if you like, this is nature's
own toothpaste, because once you have eaten a mouthful of food and swallowed it, the saliva
then starts to clean your teeth. The other thing we have in the mouth is this strange prehensile
organ, the tongue. And the tongue is very sensitive and very well muscularly controlled. It
exists there to mix up the food and the saliva and get a bolus of food ready to be transferred
to the back of the mouth. In the back of the mouth, there is a group of mussels called the
pharynx, which we use to swallow. And that's what we are going to see next.

To see the pharynx, we must open it from behind. Therefore it is necessary that I take the
back of the head and also the neck itself off in one piece. This takes a little bit of time. We
have pre-dissected the head a little bit, so we are a little bit faster. So we see, aha, the brain
actually is attached now to the back bone and I have now to go here.. at the back end.. or to
loosen the skin. Marius, my assistant, thank you very much if you help me… so.

So I have to go deep into here

The reason why we are approaching this dissection from behind is because the oesophagus,
which is the next part of the gastrointestinal tract which takes the food down to the abdomen,
is actually located right at the back of the chest and right at the back of the throat, so the view
that we will have in a moment when this block has been removed, is actually a very difficult
view to obtain. This is a view that few anatomists actually attempt to do and it is a view that
few, even medically trained people, have ever seen, because it is only rarely that this type of
dissection is performed. But it will give you the best view that is actually possible of the
location of the oesophagus in the body.

Just lifting that…

And indeed, what I take off here, is the vertebral column, here starting off the rib and here the
brain with the skull - the back of the skull. So we don't need this because right now we want
to look to the front, we want to see the pharynx. So I put this over here, gently

Well we now take the

..skull aside, a little bit of hair to the side. Then what you see here from the back is…

…the back of the mouth called the pharynx. This is actually a muscle layer which I want to
cut open. And this goes down here - the connection down to the stomach, running between
the two lungs here. The right lung and here, the left lung

And the pharynx is actually the last time when you swallow some food that the food is under
your conscious control, because these muscles at the back of the throat are the muscles you
use to swallow.

So when you decide to swallow something, when you make the movement and push the food
towards the back of your mouth and swallow, these are the mussels that contract. And you
know when you swallow, your Adam’s apple moves up and down? That is because that is
actually connected to these muscles. So this is the last time your conscious brain is in control
of food and for the rest of its journey, it is under the control of the intelligence of your
intestines.

10:14
So what we see here, we see the back of the mouth, with over here the uvula. Here is actually
the back of the tongue. So I like now to remove more of this black material. Actually that is
mucus we injected, together with the formalin to prevent putrefaction and make the specimen
stiff. We injected into the arteries that contrasting material. It is also seeped through the
tissue and I have to remove it here, so we have a more clear view. What I also like to do now
is to take a needle and actually when we open this door, this muscle of the back of the mouth
called pharynx, when you open the pharynx to keep it open, I take a dissection needle and I
put the dissection needle in here, so all the time it is kept open, and on the other side, I put in
a dissection needle as well.

So now we have a full passage from the front to the back. And I like to demonstrate this with
a piece of food. This piece of food is marked.

So this is a bit of plasticine that we are using to stand-in for a mouthful of food here. It passes
past the lips, past the incisor teeth, and then as we come round to the back…
Actually in life, you would not go so far, you would swallow.

So I take it here and now what would happen? This piece of food would just travel along the
back of the tongue and over this what I call the epiglottis. The epiglottis which, actually, in
this moment here, closes the windpipe. And it goes around here, down here into the
oesophagus. I will open the oesophagus – the connection between the mouth and the stomach
and we just keep the food here.

This is actually quite a strange arrangement you see at the back of the throat here, because the
food has actually had to cross-over the air stream. So when you swallow, the food has to pass
by your windpipe to get down to the oesophagus, and this is really just an accident of history.
We evolved from a type of fish which had its swim-bladder or air-sack in front of its gut. So
when the fish then developed legs and stood up, it turns out that our lungs are now in front of
our oesophagus. So in order to make sure that the food actually gets into the right tube, we
have this little trapdoor call the epiglottis. And part of the machinery of the pharynx is that
when you swallow, the epiglottis automatically closes. And, of course, sometimes it doesn't
get it quite right, and a particle of food or some fluid actually gets into the top of the
windpipe and that is when we choke. And we have a reflex there, then, to cough that out of
the windpipe and to make sure that the food hasn't gone down and blocked our lungs.

I demonstrate this here. The piece of food comes out of the mouth to the back of the mouth,
and now it approaches the epiglottis. The windpipe closes, it goes here. When a little bit
might go in here, we have the coughing, it would go back, but now this time it closes.
Wonderful, here it goes its way down to the oesophagus, down here into the stomach.

Many of our organs are in very close proximity to each other, so if something goes wrong
with one organ, it can affect the functioning of another. For example, if you develop a cancer
in your oesophagus, you can see that that cancer could make a hole between your oesophagus
and your aorta, and that is a mode of death in people with oesophageal cancer - that the blood
comes out of their oesophagus.

Conversely, you can see that if you have a cancer of the lung, that can actually sometimes
involve the oesophagus and close-up the oesophagus and stop it working.
So these anatomical details, although they sometimes seem quite mysterious and why would
anybody want to learn about them in that detail, actually are used by doctors everyday to
understand the symptoms that they see in their patients.

14:47
Now I am about to take the tongue and the back of the mouth out, and, for that reason, I
actually cut here along what is called the soft palette on both sides and I loosen here, just
right of the big arteries in the vein who up go to the head. I loosen that and, indeed, here, we
have the tongue.

The oesophagus, although it seems to be just a conduit running down from the back of the
mouth to the stomach, is actually also quite a sophisticated organ. There is nothing in the
body that is there not for a reason. The oesophagus has mucus glands in its wall, which also
help to further lubricate the food on its journey down to the stomach. And it also has to have
a muscular wave, which travels from the top of the oesophagus down to the bottom to get the
food down to the stomach.

So what I do now in front, here, is the windpipe - the trachea. And I have to cut his windpipe
through.

And what I see here is the opening of the trachea and the opening of the trachea where I take
this mucus out again. And now, I take all the nerves away. The oesophagus moves through
the diaphragm into the stomach. And the stomach, now, I have to approach from the front.
Therefore, I take the knife and I will do a cut below the costal margin, just along the
diaphragm. So I am going now through all the muscles of the abdomen.

Tense abdominal muscles when you are not trying to, is actually a medical warning sign.
There is a reflex that causes the abdominal muscles to tense if there is infection or
inflammation or sometimes other bad things happening inside the abdomen. So a tense
abdomen is referred to as guarding and that is a medical warning sign and is something that
doctors look for if somebody is complaining of tummy pain, for example.
I actually cut here through three plates of muscle, which protect the internal organs.

If you are able to admire your own abdominal muscles when you get home if you can still see
them anymore, the front one is the one that runs up and down that people like to showed off
in pictures, sometimes. And that is called the rectus abdominus which is a straight up and
down muscle. But that behind that there are two oblique muscles - one making a fan in one
direction - an external oblique and one making a fan in another direction; and then behind
that there is a transverse muscle. So there is actually several muscle layers there that protect
your abdominal contents.

And now, we are about to take all this abdominal flap down, and I like a little bit more to
open the belly, take this flap down.

For any medical student, when you open the abdomen, it is a little bit difficult to understand,
so let me explain. This is here, the liver. To the right side, here, this is the stomach. The
stomach, actually, the stomach is connected - a kind of connective tissue which looks like a
kind of fur,

this is called the greater omentum. This has two functions - it is a flap of tissue that hangs
down. And one function is to store fat - it is a kind of internal winter blanket that we have at
the front of our abdomen, here. Now, men tend to store fat more in this greater omentum
than women do, which is why you tend to see more pot-bellied men than you do women.
And another feature of the greater omentum is that if there is infection inside the greater
abdomen, this actually sticks to the area where the infection is, and so can help limit the
spread of infection inside the abdomen

So, we don't need it now, it obscures the view of the organs, therefore I take this connective
tissue away. It is attached here, to the large intestines, and not to open the large intestine by
accident, I cut it, just from just below and just at the border.

20:02
So, John, that is your winter blanket okay. And we take it over here. And this is the large
intestine. And below here, is the small intestine.

So the viscera are actually arranged in the body cavities in a series of layers. The gut is in
front, the liver is above, the pancreas and kidneys are to the back of the abdominal cavity.
And the way it is all joined together is such that it is easiest to take out both the whole of the
intestines and its helper glands in one block, which is what we are going to be doing next, and
then we will be able to demonstrate those various glands to you when the block is on the table
in due course.

Now I move with my hand between the peritoneum and the side of the muscles and the back
of the abdominal cavity to take all the organs out just here, below the diaphragm.

So while it is possible to dissect the human body and take the organs apart, we are not
actually made in a way that is supposed to be taken apart, so it can be quite tricky on
occasions to achieve it.

Okay, so I take the liver down now, and here and I feel the oesophagus and there it is and
there is also the tongue from the front and now it should be more easy to loosen the liver.
Marius, take your finger away, careful.

Large knife, large knife, yes.

And now I can take the whole abdominal specimen down.

We should be able to take out the last part of the large intestines, the rectum with the anus
that is here.

Knife.

So, absolutely gorgeous, now.

It is about 15 kg.
The last cut over here.

Yes, and I will place over here. The liver, the oesophagus, the larynx, the stomach, small and
large intestines.

So, to date, if we refer back to our mouthful of food, it has travelled past the pharynx and the
epiglottis, down the oesophagus and the next port of call is going to be the stomach.

So let's identify now, clearly the stomach. And here, we see the oesophagus entering a large
receptacle. And this, actually, this here, is the stomach.

So let's have a look at where that is on a live person. Over here we have Juliet, our resident
anatomical artist, and our fine specimen, Dennis.

Here is the oesophagus, running down behind his lungs and here we have the stomach. So
the stomach is where the food lands about 4 or 5 seconds after you have swallowed it. And
the stomach has a variety of functions. First of all, obviously, it acts as a storage receptacle
for the food. Secondly, it doesn't matter how much you wash or cook food - there are always
germs, or bacteria and other things like fungi still on it, and we don't want these coming into
us from the outside world. Already, even though this is the first port of call in the intestine is
deep within our bodies. So one of the important functions of the stomach is as a steriliser.
The stomach actually secretes very concentrated hydrochloric acid. This acts to sterilise the
food, to help sterilise it. The acid is sufficiently concentrated that if you got it on your skin, it
would cause a burn. But the stomach protects itself from this acid by secreting a specialised
mucus, which protects its lining from the hydrochloric acid, and stops that being a problem
for the stomach.

Now as the food drops into this strong acid, it starts to fizz away. And as we all know food,
when you have eaten it, sometimes gives off gas. It is an anatomical peculiarity that where
the oesophagus comes into the stomach is about a third of the way down this border of the
stomach, here. With a little dome of stomach above there called the fundus. And the gas that
is fizzing away inside of the stomach tends to build up in this fundus here, and make a little
dome of gas and then every so often you make a diaphragmatic movement, push the gas
down and it comes up the oesophagus as a burp. So that is the anatomy, if you like, of a burp.
Another thing that the stomach does is that it secretes a special protein, which begins the
primary processing of the food in the stomach. The protein is called pepsin and it begins to
break up the food, break up the protein of the food into smaller units.

There is, of course, a slight problem with this acid being present in the stomach - which is
that the air in the fundus here can actually pull apart the opening of the oesophagus into the
stomach, which is normally kept closed by a fairly lose sphincter. And if that does get
slightly pulled apart, the acid from the stomach can get into the lower end of the oesophagus.
Now, the oesophagus is not protected in the same way as the stomach is from acid, and so
that happens, it starts to inflame and irritate the bottom end of the oesophagus, and that is
what we know as heartburn.

So, let's have a look at the stomach in the dissection specimen.

The stomach is a little bit crumpled here on the left side. We have to clean it from the inside.
Therefore I just fill it up now with water. And there, the stomach comes out in full. Thank
you. Would you keep it here? And now I will open it.

This filling of the stomach that we have just seen here is what actually happens when you
have a large meal - the stomach does dramatically change in size.

26:40
This is a little food, which, actually we placed here and the water pushed it down into the
stomach.

We discovered our food.

The stomach actually has quite an impressive array of hormone secreting cells. And these
hormones circulate in the blood to the distal parts of the gut and tee-it-up to receive the food
when the stomach is ready to release it. The stomach also has a complicated array of sensory
receptors. And these identify the state that the food is in within the stomach. Sometimes if
you take a bad mouth full of food, say with toxins in it, or with something in it that isn't good
for the body, the stomach may decide that the food is not good to be passed on to the rest of
the intestine. And when that happens, these senses are responsible for inducing a wave of
contraction to go in the reverse direction, and push the food back out of the stomach up the
oesophagus and out. Which is obviously what happens when we vomit. But let's assume that
our food was a good mouthful of food and when the pre-digestion process has reached its
conclusion, the stomach then begins to contract and pass it towards the far end of the
stomach, where there is a valve called the pylorus, which regulates its passage into the small
intestine.

So let's see where the small intestine is on our live model.

We have reached the pylorus, which is this thickened area here which lets the food through
into the small intestine. Which starts with a specialised C-shaped bit called the duodenum and
then the folds of small intestines are disposed like this.

The small intestine is the real engine-room of the bowel. This is where the food is finally
broken down into its elementary constituents and absorbed into the bloodstream. Food that
we eat is essentially alien material. It comes from other animals, it comes from plants. Their
constituents are not our constituents. But most foodstuffs are composed of elementary
constituents. Starches, for example, are composed of sugars. Proteins are composed of
building blocks called amino acids. Fats are composed of elementary building blocks of fatty
acids as well. And in the small bowel is where these are broken down and then absorbed into
the bloodstream. So let's have a look inside the small intestine on our dissection specimen.

When you look inside the small intestine, we see the folds and we see some food. Now after
some water, we see more clearly, the folds
One of the points about the folds in the small intestine, it that these greatly increase its
surface area. And on the folds, in fact if we used a microscope, there are smaller folds, and
on the cells that make up those folds, there are even smaller folds called microvilli. So the
area of the small intestines is greatly increased to allow food to be absorbed. The bowel also
has a fairly constant structure throughout. It has an inner, circular layer of muscle. And the
function of this is to squeeze the food along the gut, and an outer longitudinal layer of muscle
which sloshes the food back and forth, and ensures that the enzymes, the digestive enzymes,
and food is well mixed.

Also present in our gut is quite a lot of bacteria - there is probably about one or two kilos of
bacteria within our gut, and these actually enter our gut during foetal life. But these are the
right sort of bacteria, because they not only help us digest our food, they also help us make,
well they also make vitamins that we can't make for ourselves, which are then absorbed
through our gut.

It is said, and I don't know who worked this out, the gut has a nervous system that weighs
about the same as our brains. But obviously, this isn't a nervous system that we are conscious
of.

All along the gut there are two nerve plexuses, which control the muscular movements of our
gut, and the movement of food along it. And obviously, this is very important for the
coordinated passage of a meal along the gastrointestinal track.

And when you think now that I can cut the small intestine open, it is wrong, because as you
see, it is really takes a very thick sack away around, because it is nourished from the back by
first larger and always more smaller arteries and veins. So, this nourishment from behind
which you see all along this conduit of the large and small intestines, especially here, we have
to cut off, in order to have the small intestine in along in its full length. So listen, and have a
look for only a little bit of cutting here, of this piece, I get a long, long piece of small bowel,
and I continue this now.

I should just say that we have used the word intestine and we have used the word bowel, but
these are essentially interchangeable words, small bowel, small intestines, and sometimes the
whole tract is referred to as the gut.
Looking at the small intestine, you see here, in the opening, a very important opening, where
actually, the juice from the liver through bile duct comes. And this big liver actually is an
accessory organ for digestion.

Okay let's see where the liver is on our live model and here we have a liver that we have
prepared earlier.

This is a plastinated liver and it is about the right size to be Dennis’s own liver. The liver is
the largest solid organ in the body and it is tucked up on the right side of your abdominal
cavity, but high up under the rib cage.

Well, let's take a large knife and make some thinner slices to look inside.

32:42
All pathologists do it, while they do autopsies, in order to see some metastases of carcinoma
for example.

So the cut surface of the liver looks quite normal. Do you see here? These are the veins and
the arteries where the blood and our red polymer fixation material is inside.

When you look at the cut surface of the liver, it doesn't look like much. The liver is a very
homogeneous organ - it all looks the same. But that belies its importance as the main
metabolic factory of the body. This is where all the nutrients, the broken down nutrients from
the small bowel, come first, and the liver begins to rebuild those into our own constituents, so
all the good stuff digested from our mouthful of food comes here from the gut, before it is
distributed around the body in the bloodstream.

The liver also amazingly has four complete sets of tubing that go in and out of it. It has an
arterial and a venous supply. It has a portal blood supply, bringing these nutrients from the
gut and it also has a series of excretory tubes, the bile ducts, which take the liver’s main
secretion, the bile, out from the liver and into the small intestine.

Perhaps I should remind us where that is on our live model over here.

The bile enters here, and the bile is an important part of the digestive process because not
only does it help us dissolve and absorb fatty substances, but it is also quite alkaline, and that
helps to neutralise the acid that has come through from the stomach, and protect the rest of
the small intestine from the effects of stomach acid.

There is also another thing that comes in at the same papilla, and that is the juices from the
other main assistant organ of the gut, the pancreas. The pancreas is a hidden organ. Here is a
pancreas that we have prepared earlier. Again, it is probably about the right size for Dennis.
It is actually described as having a head, a body and a tail - this one looks a bit like a sea-
horse, but in fact in the body, it is horizontal with its head nestled against the curve of the
duodenum, there, and the rest of the organ running across the back of the abdominal cavity,
behind the stomach.

Now, the pancreas is really a turbo-charged salivary gland. This is the gland that makes all
those special protein enzymes that digest our foodstuffs. And this is the most dangerous
gland in the body because if these enzymes are let loose on our tissues, they can digest us, as
well. And there is a reason why that can sometimes happen, and we will show you that back
over on the dissection specimen.

The pancreas shows its typical glandular tissue and I want to take a cut.

This is a very typical glandular view and all those tiny little globules give off their juice into a
duct, which actually opens here in the first part of the small intestine, just here the opening

And this has an interesting consequence, because the opening into the duodenum of the
pancreatic duct is usually a joint opening with the bile ducts. Now, bile can sometimes give
rise to stones, most people will have heard of gallstones, and these can originate in the
gallbladder, because one of the main jobs of the gallbladder is to concentrate the bile.
Gallstones can sometimes move down the bile ducts and get stuck in this little papilla. And if
they do, they can stop the pancreatic juices coming out of the pancreas. And that can cause
the pancreas to begin to digest itself. This is a major medical emergency - it is called acute
pancreatitis, and even with modern medical methods, probably about half of people who get
acute pancreatitis die of that condition.

Now we have been talking about so far the so-called exocrine functions of the pancreas. This
is the pancreatic juice that is excreted into the outside world via the gut. But the pancreas also
has another hidden function, which we can show you on monitor here.

Here you can see a histological section of pancreas and this shows in this area these are the
pancreatic cells that secrete those special enzymes that digest the food, but in the middle here,
or at least in this area here, there is a paler area. And this is, this subsumes the so-called
endocrine functions of the pancreas. Endocrine functions are where a gland secretes
something into the bloodstream. And these little islands here are called the islets of
Langerhans, they were discovered by Paul Langerhans when he was a medical student in the
19th century. I think they were the days to be doing research, when you could make a lasting
discovery as a medical student. Part of the reason was because that he was actually using the
dyes that had recently been developed by the chemical industry at that time to stain fabrics,
and it turns out that they stain people's tissues pretty well, as well and allow you to see these
things. These islets of Langerhans are important because one of their functions is to secret
the hormone insulin, and insulin is a key metabolic regulator in the body, but especially of
blood sugar. And it is the function of these little islets here, of which there are many
distributed throughout the pancreas - if that fails then the condition of diabetes results, in
which blood sugar, which is the main energy currency of the body, becomes unregulated and
becomes very high.

So, so far we have absorbed the main nutrients from the gut. But after every good banquet,
there needs to be a good cleanup. And the organs that are mainly responsible for that are the
kidneys.
And the kidneys are at the back and therefore we have to turn the whole organ parcel over.
And the kidneys are protected, in fat, and I have to open this fat capsule to reveal, here, the
kidney.

So let's see where the kidneys are on our live model

Again, we have here some plastinated kidneys.

The kidneys are often a bit higher up than people expect. The blood vessel that supplies them
comes off at the bottom of your breastbone, so the kidneys are at about this level, but at the
back of the abdominal cavity, hidden around the back of the abdominal cavity. There are also
somewhat larger than people often imagine them to be, but again, this kidney is probably
about the right size to be one of Dennis’s.

Let’s now see how the kidney looks inside. So I bisect the kidney in two halves.

39:21
And there on the cut surface, you see small, red, tiny dots

And this is what they look like.

This little guy is called a glomerulus. There are about 1 1/2 million of these in each of your
kidneys - so you have about 3 million of these. And their job is to filter the blood plasma,
which comes in at the edge of the tuft, here across, a sort of special type of filter-paper that is
present within these tufts, to produce a plasma filtrate in that space, and that means that all
the small molecules stay with the fluid and comes out, but the larger molecules get retained
behind. The point of the kidney is that, whenever we eat something, we take in excess water,
we take in excess salts, and there are toxic breakdown products and waste products from our
own chemical process in the body. And all the water-soluble substances like that, come out in
the kidney are refined in these tubules and exit the kidney as urine.

The small intestine enters the large intestine, which runs around the small intestine like the
frame of a picture.

Let's see where this is on our live model.

Juliet has here has drawn on the large intestine. The large intestine starts with a blind ended
diverticulum called the cecum, off which comes the appendix. It then goes up, across, down,
does a final little wiggle before making its final exit to the outside world. So let's have a look
inside the large intestine on our dissection specimen.

Let's open now, the large intestine, starting here from the last part of the small intestine. I go
inside, crossing the border between small and large intestines and crossing a valve which
actually prevents that faeces goes back from the large to the small intestine. So the large
intestine starts up here, but this part is called the cecum -the blind part. And attached to this
is an appendix, and you will see whether this lady had an appendix or it was removed by an
operation. And indeed, nothing to be seen, the appendix is not there anymore.

Let's open now, and I go this way, up

So the large bowel receives the residue of a meal that the small bowel wasn't able to absorb.
It has two main functions. First of all it acts as a storage compartment for faeces, and you
can see some faeces here. These are the indigestible remains of the final meal.

It is useful that this large bowel does act as a storage compartment for faeces, because this
means that we don't have to go to the toilet as often as we eat, which is helpful. The other
main function of the large bowel - it's a sort of compressor and waste facility. It absorbs
water from the semisolid material that comes in, or from the rather liquid material, in fact,
that comes in from the small bowel, and changes it into the rather harder material that finally
comes out at the far end.
When the food moves round the large intestine, the final part of the gastrointestinal tract, is
known as the anus. And I'm not going over to Dennis to demonstrate that, but the anus is
normally a fairly constricted ring, and obviously, this has to dilate up and close down, dilate
up and close down as the food makes its final exit from our body. And this actually causes
certain problems in the anus. The anus as it dilates up and can actually develop a fissure in it
and the anal fissure can be very painful, and they can be quite difficult to heal up, because the
anus isn't something you can stop using while they get better. And sometimes they can close
up leaving a little communication between the outside body and inside the anus. And this is
known as the fistula in-ano. This is a condition that has caused a lot of misery during human
history, and one of the people who suffered from it was Louis XIV. And this had, actually,
quite a happy consequence for one of his doctors, because one of his doctors was able to
incise the fistula with a small operation, which is what is still done today, without which it
wouldn’t cure, but with which they are actually are cured quite quickly. And Louis XIV was
so grateful to this doctor that he made him a life baron. Now, fortunately that doesn't happen
so often these days, because doctors tend to get taken to court in a different way. But anyway,
times move on and so finally to the remains of the meal that we have been discussing.

The end of the large intestine is the anus. The anus from the outside. And here, a kind of
circular muscle opens at best only once a day, leaving the faeces out. And in this way, we
arrive at the end of our journey through the whole intestinal tract. The anus is the end, as the
tongue was the mouth at the beginning.

44:36
And this is the right time to invite you for questions. Please.

If someone were to have an ulcer, how would that look, and what exactly is an ulcer?

An ulcer, actually, would either appear in the lining of the stomach or in the beginning of the
small intestine.

That's right, the definition of an ulcer is that the epithelial lining - the lining layer of the area
is actually destroyed. And that give access of the, for example in the stomach, of the stomach
acid to the underlying tissues. And that means that the acid and the digestive hormones can
actually erode a hole through the stomach and if it goes the whole way, it can actually make a
hole from the stomach into the peritoneal cavity which is a cause of peritonitis - inflammation
of the peritoneal cavity.

You mentioned that the large appendum of the stomach can accumulate fat. How many
grams or kilos of fat can it amass?

It is very different in different people actually. Some people have quite a small greater
omentum, as in fact this lady did. In some people it can actually measure many kilos, 5,6,7,8
kilos in large..

In America: 20 kilos is possible!

We hear today of people having their stomachs stapled. What exactly is done when
somebody has their stomach stapled?

Well, the idea of a stomach stabling operation, or fundoplasty, is to pinch off part of the
stomach, so the feeling of being full is induced sooner than it is if your stomach is allowed to
expand to the full thing. And this is something that in many cases helps very obese people not
to eat too much, because they feel full sooner, and it helps them to lose weight.

Last question now please.

Yea, I have a question about acid reflux. There are so many medications on the market now
for acid reflux because of the food you eat, the medicines you take or due to sinus infections.
Can you talk a little bit about that?
This is a very complicated issue. Actually, my doctoral thesis dealt with that. First of all we
have an angulation of the oesophagus in the upper part of the stomach. And, depending on
this angulation, it influences the sphincter the circle muscle here, the opening at the end of the
oesophagus. Moreover, the pressure, the inter-abdominal pressure is very important. So
whether you sleep flat, or you sleep a little upright, whether you have a large obesity is a big
inter-abdominal pressure or not, it is very important.

To cure the feeling once the acid goes up, it's already too late, but it only eases the symptoms,
but doesn't cure.

There are three foods that are particularly associated with reflux because they tend to delay
emptying of the stomach. And they are wine, or alcohol, coffee and chocolate. So it is
normally quite a bad idea to do what we all do after a dinner party. Which have a glass of
wine with the party, have a coffee afterwards, and some chocolate and then go to bed.

Good to know.

As I promised you in the beginning, now I will unravel this woman's gut from the tongue to
the anus. Therefore I need assistance.

And here, there is the pharynx.

And here is the stomach, OK, would you come over here. Some small intestine, please go
ahead here. And here starts the large intestine.

And would you come over here? And over here, and actually, this is what I promised you: 1,
2, 3, 4, 5, 6, 7 metres of intestinal tract.