360 SEC TION III Endocrine   

endocrine—Pharmacology

Thionamides Propylthiouracil, methimazole.

MECHANISM Block thyroid peroxidase, inhibiting the oxidation of iodide as well as the organification and
coupling of iodine Ž inhibition of thyroid hormone synthesis. PTU also blocks 5′-deiodinase
Ž  Peripheral conversion of T4 to T3.
CLINICAL USE Hyperthyroidism. PTU used in Primary (first) trimester of pregnancy (due to methimazole
teratogenicity); methimazole used in second and third trimesters of pregnancy (due to risk
of PTU-induced hepatotoxicity). Not used to treat Graves ophthalmopathy (treated with
glucocorticoids).
ADVERSE EFFECTS Skin rash, agranulocytosis (rare), aplastic anemia, hepatotoxicity.
PTU use has been associated with ANCA-positive vasculitis.
Methimazole is a possible teratogen (can cause aplasia cutis).

Levothyroxine, liothyronine
MECHANISM Hormone replacement for T4 (levothyroxine; levo = 4 letters) or T3 (liothyronine; lio = 3 letters).
Avoid levothyroxine with antacids, bile acid resins, or ferrous sulfate ( absorption).
CLINICAL USE Hypothyroidism, myxedema. May be misused for weight loss. Distinguish exogenous
hyperthyroidism from endogenous hyperthyroidism by using a combination of TSH receptor
antibodies, radioactive iodine uptake, and/or measurement of thyroid blood flow on ultrasound.
ADVERSE EFFECTS Tachycardia, heat intolerance, tremors, arrhythmias.

Hypothalamic/pituitary drugs
DRUG CLINICAL USE
Conivaptan, tolvaptan ADH antagonists
SIADH (block action of ADH at V2-receptor)
Demeclocycline ADH antagonist, a tetracycline
SIADH (interferes with ADH signaling)
Desmopressin ADH analog
Central DI, von Willebrand disease, sleep enuresis, hemophilia A
GH GH deficiency, Turner syndrome
Oxytocin Induction of labor (stimulates uterine contractions), control uterine hemorrhage
Somatostatin Acromegaly, carcinoid syndrome, gastrinoma, glucagonoma, esophageal varices
(octreotide)

Fludrocortisone
MECHANISM Synthetic analog of aldosterone with glucocorticoid effects. Fluidrocortisone retains fluid.
CLINICAL USE Mineralocorticoid replacement in 1° adrenal insufficiency.
ADVERSE EFFECTS Similar to glucocorticoids; also edema, exacerbation of heart failure, hyperpigmentation.

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 Endocrine   
endocrine—Pharmacology SEC TION III 361

Cinacalcet
MECHANISM Sensitizes calcium-sensing receptor (CaSR) in parathyroid gland to circulating Ca2+ Ž  PTH.
Pronounce “Senacalcet.”
CLINICAL USE 2° hyperparathyroidism in patients with CKD receiving hemodialysis, hypercalcemia in 1°
hyperparathyroidism (if parathyroidectomy fails), or in parathyroid carcinoma.
ADVERSE EFFECTS Hypocalcemia.

Sevelamer
MECHANISM Nonabsorbable phosphate binder that prevents phosphate absorption from the GI tract.
CLINICAL USE Hyperphosphatemia in CKD.
ADVERSE EFFECTS Hypophosphatemia, GI upset.

Cation exchange resins Patiromer, sodium polystyrene sulfonate, zirconium cyclosilicate.

MECHANISM Bind K+ in colon in exchange for other cations (eg, Na+, Ca2+) Ž K+ excreted in feces.
CLINICAL USE Hyperkalemia.
ADVERSE EFFECTS Hypokalemia, GI upset.

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 362 SEC TION III ENDOCRINE   
ENDOCRINE—PHARMACOLOGY

NOTES
` 

FAS1_2023_08-Endocrine.indd 362 11/17/22 9:00 PM

 HIGH-YIELD SYSTEMS

Gastrointestinal

“A good set of bowels is worth more to a man than any quantity of brains.”­­ ` Embryology 364
—Josh Billings
` Anatomy 367
“Man should strive to have his intestines relaxed all the days of his life.”
—Moses Maimonides ` Physiology 378
“All right, let’s not panic. I’ll make the money by selling one of my livers. I ` Pathology 383
can get by with one.”
—Homer Simpson, The Simpsons ` Pharmacology 405
“The truth does not change according to our ability to stomach it
emotionally.”
—Flannery O’Connor

When studying the gastrointestinal system, be sure to understand the

normal embryology, anatomy, and physiology and how the system is
affected by various pathologies. Study not only disease pathophysiology,
but also its specific findings, so that you can differentiate between
two similar diseases. For example, what specifically makes ulcerative
colitis different from Crohn disease? Also, be comfortable with basic
interpretation of abdominal x-rays, CT scans, and endoscopic images.

363

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 364 SEC TION III Gastrointestinal   
gastrointestinal—Embryology

GASTROINTESTINAL—EMBRYOLOGY
` 

Normal Foregut—esophagus to duodenum at level of pancreatic duct and common bile duct insertion
gastrointestinal (ampulla of Vater).
embryology ƒ 4th-6th week of development—stomach rotates 90° clockwise.
ƒ Left vagus becomes anteriorly positioned, and right vagus becomes posteriorly positioned.
Midgut—lower duodenum to proximal 2/3 of transverse colon.
ƒ 6th week of development—physiologic herniation of midgut through umbilical ring.
ƒ 10th week of development—returns to abdominal cavity rotating around superior mesenteric
artery (SMA), 270° counterclockwise (~180° before 10th week, remaining ~90° in 10th week).
Hindgut—distal 1/3 of transverse colon to anal canal above pectinate line.

Pharyngeal origin
Foregut
Midgut
Hindgut

Celiac trunk

Aorta

Superior
mesenteric
artery
Inferior
mesenteric
artery

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 Gastrointestinal   
gastrointestinal—Embryology SEC TION III 365

Ventral wall defects Developmental defects due to failure of rostral fold closure (eg, sternal defects [ectopia cordis]),
lateral fold closure (eg, omphalocele, gastroschisis), or caudal fold closure (eg, bladder exstrophy).
Gastroschisis Omphalocele
PRESENTATION Paraumbilical herniation of abdominal contents Herniation of abdominal contents through
through abdominal wall defect umbilicus
COVERAGE Not covered by peritoneum or amnion A ; Covered by peritoneum and amnion B (light
“the guts come out of the gap (schism) in the gray shiny sac); “abdominal contents are sealed
letter G” in the letter O”
ASSOCIATIONS Not associated with chromosome abnormalities; Associated with congenital “Onomalies” (eg,
good prognosis trisomies 13 and 18, Beckwith-Wiedemann
syndrome) and other structural abnormalities
(eg, cardiac, GU, neural tube)
A B

Congenital umbilical Failure of umbilical ring to close after physiologic herniation of midgut. Covered by skin C .
hernia Protrudes with  intra-abdominal pressure (eg, crying). May be associated with congenital
C disorders (eg, Down syndrome, congenital hypothyroidism). Small defects usually close
spontaneously.

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 366 SEC TION III Gastrointestinal   
gastrointestinal—Embryology

Tracheoesophageal Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common (85%)
anomalies and often presents as polyhydramnios in utero (due to inability of fetus to swallow amniotic fluid).
Neonates drool, choke, and vomit with first feeding. TEFs allow air to enter stomach (visible on
CXR). Cyanosis is 2° to laryngospasm (to avoid reflux-related aspiration). Clinical test: failure to
pass nasogastric tube into stomach.
In H-type, the fistula resembles the letter H. In pure EA, CXR shows gasless abdomen.
Trachea Esophagus Tracheoesophageal
fistula

Esophageal
atresia

Normal anatomy Pure EA Pure TEF EA with distal TEF

(atresia or stenosis) (H-type) (most common)

Gastric
bubble

Normal Gasless stomach Prominent gastric bubble

Intestinal atresia Presents with bilious vomiting and abdominal distension within first 1–2 days of life.
A
Duodenal atresia—failure to recanalize. X-ray A shows “double bubble” (dilated stomach,
proximal duodenum). Associated with Down syndrome.
Jejunal and ileal atresia—disruption of mesenteric vessels (typically SMA) Ž ischemic necrosis
of fetal intestine Ž segmental resorption: bowel becomes discontinuous. X-ray may show “triple
bubble” (dilated stomach, duodenum, proximal jejunum) and gasless colon. Associated with cystic
fibrosis and gastroschisis. May be caused by tobacco smoking or use of vasoconstrictive drugs
(eg, cocaine) during pregnancy.

Hypertrophic pyloric Most common cause of gastric outlet obstruction in infants. Palpable olive-shaped mass (due to
stenosis hypertrophy and hyperplasia of pyloric sphincter muscle) in epigastric region, visible peristaltic
waves, and nonbilious projectile vomiting at ∼ 2–6 weeks old. More common in firstborn males;
associated with exposure to macrolides.
Narrow Results in hypokalemic hypochloremic metabolic alkalosis (2° to vomiting of gastric acid and
pyloric
channel subsequent volume contraction).
Ultrasound shows thickened and lengthened pylorus.
Treatment: surgical incision of pyloric muscles (pyloromyotomy).
Thickened and
lengthened
pylorus

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 367

Pancreas and spleen Pancreas—derived from foregut. Ventral pancreatic bud contributes to uncinate process. Both
embryology ventral and dorsal buds contribute to pancreatic head and main pancreatic duct.
A Annular pancreas—abnormal rotation of ventral pancreatic bud forms a ring of pancreatic tissue
Ž encircles 2nd part of duodenum; may cause duodenal narrowing (arrows in A ) and vomiting.
Associated with Down syndrome.
stomach Pancreas divisum—ventral and dorsal parts fail to fuse at 7 weeks of development. Common
anomaly; mostly asymptomatic, but may cause chronic abdominal pain and/or pancreatitis.
Spleen—arises in mesentery of the stomach (dorsal mesogastrium, hence, mesodermal), but has
foregut supply (celiac trunk Ž splenic artery).

GASTROINTESTINAL—ANATOMY
` 

Retroperitoneal Retroperitoneal structures A are posterior to SAD PUCKER:

structures (and outside of) the peritoneal cavity. Injuries Suprarenal (adrenal) glands [not shown]
to retroperitoneal structures can cause blood Aorta and IVC
or gas accumulation in retroperitoneal space. Duodenum (2nd through 4th parts)
Pancreas (except tail)
Ureters [not shown]
Colon (descending and ascending)
Kidneys
Esophagus (thoracic portion) [not shown]
Duodenum Duodenum/jejunum Rectum (partially) [not shown]
Ascending Peritoneum Descending
colon colon A
Right Left
Pancreas

Asc Desc
Liver Colon Colon
IVC Kidney
Aorta
IVC Ao

R. Kid L. Kid

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 368 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Important gastrointestinal ligaments

Falciform Diaphragm
ligament Liver
Liver
Hepatogastric
ligament Stomach
Stomach
Hepatoduodenal Spleen
Portal triad ligament

Spleen Gastrosplenic
ligament Transverse
colon
Kidney
Splenorenal
ligament
Gastrocolic
ligament

LIGAMENT CONNECTS STRUCTURES CONTAINED NOTES

Falciform ligament Liver to anterior abdominal Ligamentum teres hepatis Derivative of ventral mesentery
wall (derivative of fetal umbilical
vein), patent paraumbilical
veins
Hepatoduodenal Liver to duodenum Portal triad: proper hepatic Derivative of ventral mesentery
ligament artery, portal vein, common Pringle maneuver—ligament is
bile duct compressed manually or with
a vascular clamp in omental
foramen to control bleeding
from hepatic inflow source
(portal vein, hepatic artery) vs
outflow (hepatic veins, IVC)
Borders the omental foramen,
which connects the greater
and lesser sacs
Part of lesser omentum
Hepatogastric Liver to lesser curvature of Gastric vessels Derivative of ventral mesentery
ligament stomach Separates greater and lesser sacs
on the right
May be cut during surgery to
access lesser sac
Part of lesser omentum
Gastrocolic ligament Greater curvature and Gastroepiploic arteries Derivative of dorsal mesentery
transverse colon Part of greater omentum
Gastrosplenic Greater curvature and spleen Short gastrics, left Derivative of dorsal mesentery
ligament gastroepiploic vessels Separates greater and lesser sacs
on the left
Part of greater omentum
Splenorenal ligament Spleen to left pararenal space Splenic artery and vein, tail of Derivative of dorsal mesentery
pancreas

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 369

Digestive tract Layers of gut wall A (inside to outside—MSMS):

anatomy ƒ Mucosa—epithelium, lamina propria, muscularis mucosa
ƒ Submucosa—includes submucosal nerve plexus (Meissner), secretes fluid
ƒ Muscularis externa—includes myenteric nerve plexus (Auerbach), motility
ƒ Serosa (when intraperitoneal), adventitia (when retroperitoneal)
Ulcers can extend into submucosa, inner or outer muscular layer. Erosions are in mucosa only.
Frequency of basal electric rhythm (slow waves), which originate in the interstitial cells of Cajal:
duodenum > ileum > stomach.
A
Mucosa
Epithelium
Lamina propria Tunica mucosa
Muscularis mucosa
Mesentery
Tunica submucosa
Submucosa
Vein Submucosal gland
Artery
Lymph vessel

Lumen
Submucosal nerve
plexus (Meissner)
Muscularis
Inner circular layer
Myenteric nerve plexus Tunica muscularis
(Auerbach)
Outer longitudinal layer Tunica serosa
Serosa (peritoneum)

Digestive tract histology

Esophagus Nonkeratinized stratified squamous epithelium. Upper 1/3, striated muscle; middle and lower 2/3
smooth muscle, with some overlap at the transition.
Stomach Gastric glands A . Parietal cells are eosinophilic (pink), chief cells are basophilic.
Duodenum Villi B and microvilli  absorptive surface. Brunner glands (bicarbonate-secreting cells of
submucosa), crypts of Lieberkühn (contain stem cells that replace enterocytes/goblet cells and
Paneth cells that secrete defensins, lysozyme, and TNF), and plicae circulares (distal duodenum).
Jejunum Villi, crypts of Lieberkühn, and plicae circulares (taller, more prominent, numerous [vs ileum]) Ž
feathered appearance with oral contrast and  surface area.
Ileum Villi, Peyer patches (arrow in C ; lymphoid aggregates in lamina propria, submucosa), plicae
circulares (proximal ileum), crypts of Lieberkühn. Largest number of goblet cells in small
intestine.
Colon Crypts of Lieberkühn with abundant goblet cells, but no villi D .
A B C D

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 370 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Abdominal aorta and branches

Arteries supplying GI structures are single and
Abdominal Superior and inferior
aorta mesenteric artery branch anteriorly.
watershed
Arteries supplying non-GI structures are paired
Superior
mesenteric Splenic flexure and branch laterally and posteriorly.
artery
Two areas of the colon have dual blood supply
from distal arterial branches (“watershed
areas”) Ž susceptible in colonic ischemia:
ƒ Splenic flexure—SMA and IMA
ƒ Rectosigmoid junction—IMA branches (last
sigmoid arterial branch and superior rectal
Inferior mesenteric
artery artery)
Nutcracker syndrome—compression of left
renal vein between superior mesenteric artery
and aorta. May cause abdominal (flank) pain,
gross hematuria (from rupture of thin-walled
Hypogastric artery renal varicosities), left-sided varicocele.
(internal iliac artery) Inferior mesenteric
and hypogastric
artery watershed
Superior mesenteric artery syndrome—
characterized by intermittent intestinal
obstruction symptoms (primarily postprandial
Rectosigmoid junction pain) when SMA and aorta compress
transverse (third) portion of duodenum.
Typically occurs in conditions associated with
diminished mesenteric fat (eg, rapid weight
Duodenum loss, low body weight, malnutrition, gastric
Aorta bypass surgeries).

SMA

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 371

Gastrointestinal blood supply and innervation

EMBRYONIC PARASYMPATHETIC VERTEBRAL
GUT REGION ARTERY INNERVATION LEVEL STRUCTURES SUPPLIED
Foregut Celiac Vagus T12/L1 Pharynx (vagus nerve only) and lower esophagus
(celiac artery only) to proximal duodenum;
liver, gallbladder, pancreas, spleen (mesoderm)
Midgut SMA Vagus L1 Distal duodenum to proximal 2/3 of transverse
colon
Hindgut IMA Pelvic L3 Distal 1/3 of transverse colon to upper portion of
anal canal
Sympathetic innervation arises from abdominal prevertebral ganglia: celiac, superior mesenteric, and inferior mesenteric.

Celiac trunk Branches of celiac trunk: common hepatic, splenic, and left gastric. These constitute the main
blood supply of the foregut.
Strong anastomoses exist between:
ƒ Left and right gastroepiploics
ƒ Left and right gastrics

Celiac trunk
Abdominal aorta

Common hepatic
Left hepatic
Esophageal branches

Right hepatic
Left gastric
Splenic
Cystic Short gastric

Left gastroepiploic

Proper hepatic

Gastroduodenal

Posterior superior
pancreaticoduodenal Areas supplied by:

Anterior superior Left gastric artery

pancreaticoduodenal
Splenic artery
Common hepatic artery
Right gastric
Anastomosis
Right gastroepiploic

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 372 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Portosystemic
anastomoses

Azygos vein Pathologic blood in portal hypertension

Esophageal veins Flow through TIPS, reestablishing
IVC normal flow direction
Normal venous drainage
Hepatic vein Systemic venous system
Left gastric vein
Portosystemic Portal venous system
shunt

Portal vein

Splenic vein

Paraumbilical
vein
Inferior mesenteric
vein
Umbilicus

Epigastric Superior rectal

veins vein

Middle rectal veins

Inferior rectal veins

SITE OF ANASTOMOSIS CLINICAL SIGN PORTAL ↔ SYSTEMIC

Esophagus Esophageal varices Left gastric ↔ esophageal
(drains into azygos)
Umbilicus Caput medusae Paraumbilical ↔ small
epigastric veins (branches
of inferior and superficial
epigastric veins) of the
anterior abdominal wall
Rectum Anorectal varices Superior rectal ↔ middle and
inferior rectal
Varices of gut, butt, and caput (medusae) are commonly seen with portal hypertension.
 reatment with a Transjugular Intrahepatic Portosystemic Shunt (TIPS) between the portal
T
vein and hepatic vein relieves portal hypertension by shunting blood to the systemic circulation,
bypassing the liver. TIPS can precipitate hepatic encephalopathy due to  clearance of ammonia
from shunting.

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 373

Pectinate line Also called dentate line. Formed where endoderm (hindgut) meets ectoderm.
Above pectinate line: internal hemorrhoids,
Nerves Arteries Veins
Lymphatics adenocarcinoma.
Visceral innervation Superior rectal Superior rectal vein
Drain to internal
(inferior hypogastric artery (branch → IMV → splenic
iliac LN Internal hemorrhoids—abnormal distention of
plexus [T12–L3]) of IMA) vein → portal vein
anal venous plexus A . Risk factors include older
age and chronic constipation. Receive visceral
innervation and are therefore not painful.
A

Pectinate line

Below pectinate line: external hemorrhoids,

anal fissures, squamous cell carcinoma.
External hemorrhoids—receive somatic
innervation (inferior rectal branch of
pudendal nerve) and are therefore painful if
Inferior rectal vein
Somatic innervation Inferior rectal artery → internal pudendal thrombosed.
Drain to superficial
(pudendal nerve (branch of internal vein → internal iliac inguinal LN
[S2–S4]) pudendal artery) vein → common iliac Anal fissure—tear in anoderm below
vein → IVC pectinate line. Pain while pooping; blood
on toilet paper. Located in the posterior
midline because this area is poorly
perfused. Associated with low-fiber diets and
constipation.

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 374 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Liver tissue The functional unit of the liver is made up of
architecture hexagonally arranged lobules surrounding the
A
central vein with portal triads on the edges
(consisting of a portal vein, hepatic artery, bile
ducts, as well as lymphatics) A .
Apical surface of hepatocytes faces bile
canaliculi. Basolateral surface faces sinusoids.
Kupffer cells (specialized macrophages) located
in sinusoids clear bacteria and damaged or
senescent RBCs.
Hepatic stellate (Ito) cells in space of Disse
store vitamin A (when quiescent) and produce
extracellular matrix (when activated).
Responsible for hepatic fibrosis.
Dual blood supply to liver: portal vein (~80%)
and hepatic artery (~20%).
Zone I—periportal zone:
ƒ Affected 1st by viral hepatitis
ƒ Best oxygenated, most resistant to circulatory
compromise
ƒ Ingested toxins (eg, cocaine)
Zone II—intermediate zone:
ƒ Yellow fever
Zone III—pericentral (centrilobular) zone:
ƒ Affected 1st by ischemia (least oxygenated)
ƒ High concentration of cytochrome P-450
ƒ Most sensitive to metabolic toxins (eg,
ethanol, CCl4, rifampin, acetaminophen)
ƒ Site of alcoholic hepatitis

Central vein (drains

into hepatic vein)

Sinusoids

Stellate cell

Space of Disse

Kupffer cell

Blood flow

Zone 1 Branch of
hepatic artery Bile flow
Zone 2
Branch of
Zone 3 portal vein
Bile ductule

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 375

Biliary structures Cholangiography shows filling defects in gallbladder (blue arrow in A ) and common bile (red
A
arrow in A ).
Gallstones that reach the confluence of the common bile and pancreatic ducts at the ampulla of
Vater can block both the common bile and pancreatic ducts (double duct sign), causing both
cholangitis and pancreatitis, respectively.
Tumors that arise in head of pancreas (usually ductal adenocarcinoma) can cause obstruction of
common bile duct Ž enlarged gallbladder with painless jaundice (Courvoisier sign).

Cystic duct
Liver
Gallbladder
Common hepatic duct

Common bile duct

Tail
Accessory Neck Body
pancreatic duct
Pancreas
Head
Sphincter of Oddi
Ampulla of Vater
Main pancreatic duct
Duodenum

Femoral region
ORGANIZATION Lateral to medial: nerve-artery-vein-lymphatics. You go from lateral to medial to find your
navel.
Femoral triangle Contains femoral nerve, artery, vein. Venous near the penis.
Femoral sheath Fascial tube 3–4 cm below inguinal ligament.
Contains femoral vein, artery, and canal (deep
inguinal lymph nodes) but not femoral nerve.

External iliac vessels Inferior epigastric

vessels
Iliopsoas
Rectus abdominis
Anterior superior
iliac spine Inguinal (Hesselbach)
triangle
Femoral nerve
Femoral artery
Inguinal ligament Femoral vein
Femoral ring
Fascia lata
Lymphatics
Saphenous opening Femoral triangle

Satorius Femoral sheath

Adductor longus

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 376 SEC TION III Gastrointestinal   
gastrointestinal—Anatomy

Inguinal canal
Deep (internal)
inguinal ring Inferior epigastric
site of protrusion of vessels
indirect hernia Abdominal wall
site of protrusion of
ANTEROLATERAL ABDOMINAL Medial umbilical ligament
direct hernia
WALL LAYERS Median umbilical ligament
Rectus abdominis muscle
Parietal peritoneum
Pyramidalis muscle
Extraperitoneal tissue
Conjoint tendon
Transversalis fascia Linea alba
Transversus abdominis muscle
Internal oblique muscle SPERMATIC CORD LAYERS
Aponeurosis of external (ICE tie)
oblique muscle
External spermatic fascia
(external oblique)
Superficial (external) Cremasteric muscle and fascia
Inguinal ligament inguinal ring (internal oblique)
Internal spermatic fascia
(transversalis fascia)

Myopectineal orifice
Anterior superior iliac spine

Evagination of
transversalis fascia INGUINAL CANAL CONTENTS
Internal (deep) inguinal ring
Female: round ligament of uterus
Male: ductus (vas) deferens
Ilioinguinal nerve
Internal spermatic vessels

INGUINAL (HESSELBACH) TRIANGLE Femoral nerve

Pubic tubercle External iliac vessels
Pubis symphysis Femoral ring

Anterior abdominal wall

(viewed from inside)

Hernias Protrusion of peritoneum through an opening, usually at a site of weakness. Contents may be at
risk for incarceration (not reducible back into abdomen/pelvis) and strangulation (ischemia and
necrosis). Complicated hernias can present with tenderness, erythema, fever.
Spigelian hernia Also called spontaneous lateral ventral hernia or hernia of semilunar line. Occurs through defects
between the rectus abdominis and the semilunar line in the Spigelian aponeurosis.
Most occur in the lower abdomen due to lack of the posterior rectus sheath.
Presentation is variable but may include abdominal pain and a palpable lump along the Spigelian
fascia.
Diagnosis: ultrasound and CT scan.

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 Gastrointestinal   
gastrointestinal—Anatomy SEC TION III 377

Hernias (continued)
Diaphragmatic hernia Abdominal structures enter the thorax. Bowel sounds may be heard on chest auscultation. Most
A
common causes:
ƒ Infants—congenital defect of pleuroperitoneal membrane Ž left-sided herniation (right
hemidiaphragm is relatively protected by liver) A .
ƒ Adults—laxity/defect of phrenoesophageal membrane Ž hiatal hernia (herniation of stomach
through esophageal hiatus).
Sliding hiatal hernia—gastroesophageal
junction is displaced upward as gastric cardia Herniated
gastric cardia Herniated
slides into hiatus; “hourglass stomach.” Most gastric fundus
common type. Associated with GERD.
Paraesophageal hiatal hernia—
gastroesophageal junction is usually normal
but gastric fundus protrudes into the thorax.
Sliding hiatal hernia Paraesophageal hiatal hernia

Indirect inguinal Goes through the internal (deep) inguinal

hernia ring, external (superficial) inguinal ring, and Peritoneum

B
into the groin. Enters internal inguinal ring Deep
inguinal ring
lateral to inferior epigastric vessels. Caused Inguinal canal
by failure of processus vaginalis to close (can Superficial
form hydrocele). May be noticed in infants or inguinal ring
discovered in adulthood. Much more common Intestinal loop
within spermatic
in males B . cord
Follows the pathway of testicular descent.
Testis
Covered by all 3 layers of spermatic fascia.

Direct inguinal hernia Protrudes through inguinal (Hesselbach) Peritoneum

triangle. Bulges directly through parietal Deep
Intestinal inguinal
peritoneum medial to the inferior epigastric loop ring
vessels but lateral to the rectus abdominis.
Superficial
Goes through external (superficial) inguinal inguinal ring
ring only. Covered by external spermatic
fascia. Usually occurs in older males due to Spermatic cord
acquired weakness of transversalis fascia.
MDs don’t lie:
Testis
Medial to inferior epigastric vessels =
Direct hernia.
Lateral to inferior epigastric vessels = indirect
hernia.
Femoral hernia Protrudes below inguinal ligament through
femoral canal below and lateral to pubic
tubercle. More common in females, but
overall inguinal hernias are the most common.
More likely to present with incarceration or
strangulation (vs inguinal hernia). Intestinal loop
beneath inguinal
ligament

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 378 SEC TION III Gastrointestinal   
gastrointestinal—Physiology

GASTROINTESTINAL—PHYSIOLOGY
` 

Gastrointestinal regulatory substances

REGULATORY SUBSTANCE SOURCE ACTION REGULATION NOTES
Gastrin G cells (antrum  gastric H+ secretion  by stomach  by chronic PPI use
of stomach,  growth of gastric mucosa distention/  in chronic atrophic gastritis
duodenum)  gastric motility alkalinization, (eg, H pylori)
amino acids,  in Zollinger-Ellison
peptides, vagal syndrome (gastrinoma)
stimulation via
gastrin-releasing
peptide (GRP)
 by pH < 1.5
Somatostatin D cells  gastric acid and  by acid Inhibits secretion of various
(pancreatic islets, pepsinogen secretion  by vagal hormones (encourages
GI mucosa)  pancreatic and small stimulation somato-stasis)
intestine fluid secretion Octreotide is an analog used
 gallbladder contraction to treat acromegaly, carcinoid
 insulin and glucagon syndrome, VIPoma, and
release variceal bleeding
Cholecystokinin I cells (duodenum,  pancreatic secretion  by fatty acids, Acts on neural muscarinic
jejunum)  gallbladder contraction amino acids pathways to cause pancreatic
 gastric emptying secretion
 sphincter of Oddi
relaxation
Secretin S cells  pancreatic HCO3–  by acid, fatty  HCO3– neutralizes gastric
(duodenum) secretion acids in lumen acid in duodenum, allowing
 gastric acid secretion of duodenum pancreatic enzymes to
 bile secretion function
Glucose- K cells Exocrine:  by fatty acids, Also called gastric inhibitory
dependent (duodenum,   gastric H+ secretion amino acids, peptide (GIP)
insulinotropic jejunum) Endocrine: oral glucose Oral glucose load  insulin
peptide   insulin release compared to IV equivalent
due to GIP secretion
Motilin Small intestine Produces migrating motor   in fasting state Motilin receptor agonists (eg,
complexes (MMCs) erythromycin) are used to
stimulate intestinal peristalsis.
Vasoactive Parasympathetic  intestinal water and  by distention VIPoma—non-α, non-β islet
intestinal ganglia in electrolyte secretion and vagal cell pancreatic tumor that
polypeptide sphincters,  relaxation of intestinal stimulation secretes VIP; associated
gallbladder, smooth muscle and  by adrenergic with Watery Diarrhea,
small intestine sphincters input Hypokalemia, Achlorhydria
(WDHA syndrome)
Nitric oxide  smooth muscle Loss of NO secretion is
relaxation, including implicated in  LES tone of
lower esophageal achalasia
sphincter (LES)
Ghrelin Stomach  appetite (“ghrowlin’   in fasting state  in Prader-Willi syndrome
stomach”)   by food  after gastric bypass surgery

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 Gastrointestinal   
gastrointestinal—Physiology SEC TION III 379

Gastrointestinal secretory products

PRODUCT SOURCE ACTION REGULATION NOTES
Gastric acid Parietal cells  stomach pH  by histamine, Autoimmune destruction
(stomach A ) vagal of parietal cells Ž chronic
Intrinsic factor Parietal cells Vitamin B12–binding stimulation gastritis and pernicious
(stomach) protein (required for B12 (ACh), gastrin anemia
uptake in terminal ileum)  by somatostatin,
GIP,
prostaglandin,
secretin
Pepsin Chief cells Protein digestion  by vagal Pepsinogen (inactive) is
(stomach) stimulation converted to pepsin (active) in
(ACh), local the presence of H+
acid
Bicarbonate Mucosal cells Neutralizes acid  by pancreatic Trapped in mucus that covers
(stomach, and biliary the gastric epithelium
duodenum, secretion with
salivary glands, secretin
pancreas) and
Brunner glands
(duodenum)

A
Gastric pit Surface epithelium

Upper glandular Mucous cell

layer Parietal cell
Deeper glandular Chief cell
layer Enterochromaffin-like
Muscularis mucosa cell
Submucosa

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