Bile

Bile (from Latin word bilis) is a yellow-green fluid produced by the liver of most vertebrates that
aids the digestion of lipids in the small intestine. In humans, bile is primarily composed of water,
produced continuously by the liver, and stored and concentrated in the gallbladder. After a human
eats, this stored bile is discharged into the first section of their small intestine.

Figure 1: Bile Duct

Composition
In the human liver, bile is composed of 97–98% water, 0.7% bile salts, 0.2% bilirubin, 0.51% fats
(cholesterol, fatty acids, and lecithin), and 200 meq/L inorganic salts. The two main pigments of
bile are bilirubin, which is yellow, and its oxidised form biliverdin, which is green. When mixed,
they are responsible for the brown color of feces. About 400 to 800 milliliters (14 to 27 U.S. fluid
ounces) of bile is produced per day in adult human beings.

Function
Bile or gall acts to some extent as a surfactant, helping to emulsify the lipids in food.

The Bile salt tend to aggregate around droplets of lipids (triglycerides and phospholipids) to form
micelles. The dispersion of food fat into micelles provides a greatly increased surface area for the
action of the enzyme pancreatic lipase, which digests the triglycerides. A triglyceride is broken
down into two fatty acids and a monoglyceride, which are absorbed by the villi on the intestine
walls. After being transferred across the intestinal membrane, the fatty acids reform into
triglycerides (re-esterified), before being absorbed into the lymphatic system through lacteals.
Without bile salts, most of the lipids in food would be excreted in feces, undigested.
Since bile increases the absorption of fats, it is an important part of the absorption of the fat-soluble
substances such as the vitamins A, D, E, and K.

Besides its digestive function, bile serves also as the route of excretion for bilirubin, a byproduct
of red blood cells recycled by the liver.

Bile tends to be alkaline on average. As an alkali, it also has the function of neutralizing excess
stomach acid before it enters the duodenum, the first section of the small intestine. Bile salts also
act as bactericides, destroying many of the microbes that may be present in the food.

Obstruction
Biliary obstruction refers to a condition when bile ducts which deliver bile from the gallbladder or
liver to the duodenum become obstructed. The blockage of bile might cause a buildup of bilirubin
in the bloodstream which can result in Jaundice.

There are several causes for biliary obstruction including- gallstones, cancer, trauma, cysts or other
causes of bile duct narrowing. The most common cause of bile duct obstruction is when gallstones
are dislodged from the gallbladder into the common bile duct resulting in a blockage. A blockage
of the gallbladder may cause cholecystitis. In some instances of biliary obstruction, the bile may
become infected by bacteria resulting in cholangitis.

Significance
In the absence of bile, fats become indigestible and are instead excreted in feces, a condition called
steatorrhea.
Feces lack their characteristic as instead of brown color it becomes white or gray, and greasy.
Steatorrhea can lead to deficiencies in essential fatty acids and fat-soluble vitamins. In addition, in
the small intestine (which is normally responsible for absorbing fat from food) the gastrointestinal
tract and gut flora are not adapted to processing fats, leading to problems in the large intestine. The
cholesterol contained in bile forms gallstones.

Bile may be forced into the stomach secondary to a weakened valve (pylorus), the presence of
certain drugs including alcohol, or powerful muscular contractions and duodenal spasms. This is
known as biliary reflux.
 Duodenum
In humans, the duodenum is a hollow jointed tube about 25–38 cm (10–15 inches) long connecting
the stomach to the middle part of the small intestine. It begins with the duodenal bulb and ends at
the suspensory muscle of duodenum.

Duodenum can be divided into four parts: the first (superior), the second (descending), the third
(horizontal) and the fourth (ascending) parts.

 The superior part (first part, D1) lies intraperitoneally and is enlarged proximally (duodenal bulb). It
is connected to the liver by the hepatoduodenal ligament. The superior part ends at the superior
duodenal flexure and becomes the descending part.

 The descending part (second part, D2) and the rest of the duodenum lie retroperitoneally. The
(common) bile duct and the pancreatic duct unify to a conjoint duct at the hepatopancreatic ampulla
(ampulla of Vater) and empties into the descending part of the duodenum. At the opening there is an
elevation of the mucosa, the major duodenal papilla (=papilla of Vater). The horizontal part (inferior
or third part, D3) runs from right to left ventrally from the abdominal aorta and inferior vena cava.

 The ascending part (fourth part, D4) runs cranially along the left side of the vertebral column. This
last part of the duodenum joins the intraperitoneally lying jejunum at the duodenojejunal flexure.
Here the duodenum is attached to the back of the abdominal wall through the suspensory ligament
of duodenum (=ligament of Treitz). Clinically the ligament of Treitz marks the border between the
upper and lower gastrointestinal tract.

Figure 2: Parts of duodenum

Duodenal epithelium includes the cells that secrete two hormones known as secretin and
cholecystokinin. When excess acid is present in small intestine or duodenum, hormone secretin is
released. On the other hand, cholecystokinin is released in the presence of fatty acids and amino
acids. Both secretin and cholecystokinin encourage secretion of bile and pancreatic juice.

Components of Duodenal juice

Deodenal juice is an alkali secration which increase the pH (8-9, optimum 8).

Table 1: Components of Duodenal juice

Function
The duodenum continues the process of digestion of food that begins in the stomach. Finally,
duodenum absorbs the nutrients and it does it even more than the stomach. After foods mix with
stomach acid, they move into the duodenum. Absorption of vitamins, minerals, and other nutrients
begins in the duodenum.

Its main function is to receive the chyme which is a combination of partially digested food and
stomach acids. The chyme is released into the duodenum through pylorus, which is a small valve
located between the stomach and the duodenum. The duodenum accepts the chyme from the
stomach and continues the digestion.

 To mix food with enzymes and bile to digest it

  Neutralization of the acidic gastric juice through production of alkaline secrets.
 Mechanical processing and digestion of chyme.
 Mixing bile and pancreatic enzymes.
 Regulates the rate of gastric emptying. Gastric emptying represents stomach emptying
which is the process of food going from stomach to the duodenum.
 The duodenum also triggers the hunger signals. Both of these functions are performed with
the help of hormones that are produced and released by the duodenal epithelium.
 The duodenum serves as a key regulator of metabolism by sending neurohormonal signals
to the organs that regulate blood sugar and body weight.

Significance
Ulceration
Ulcers of the duodenum commonly occur because of infection by the bacteria Helicobacter pylori.
These bacteria, through a number of mechanisms, erode the protective mucosa of the duodenum,
predisposing it to damage from gastric acids. The first part of the duodenum is the most common
location of ulcers since it is where the acidic chyme meets the duodenal mucosa before mixing
with the alkaline secretions of the duodenum. Duodenal ulcers may cause recurrent abdominal
pain and dyspepsia, and are often investigated using a urea breath test to test for the bacteria,
and endoscopy to confirm ulceration and take a biopsy. If managed, these are often managed
through antibiotics that aim to eradicate the bacteria, and proton-pump inhibitors and antacids to
reduce the gastric acidity.

Celiac disease
The British Society of Gastroenterology guidelines specify that a duodenal biopsy is required for
the diagnosis of adult celiac disease. The biopsy is ideally performed at a moment when the patient
is on a gluten-containing diet.

Cancer
Duodenal cancer is a cancer in the first section of the small intestine. Cancer of the duodenum is
relatively rare compared to stomach cancer and colorectal cancer; malignant tumors in the
duodenum constitute only around 0.3% of all the gastrointestinal tract tumors but around half of
cancerous tissues that develop in the small intestine. Its histology is often observed to
be adenocarcinoma, meaning that the cancerous tissue arises from glandular cells in the epithelial
tissue lining the duodenum.

Inflammation
Inflammation of the duodenum is referred to as duodenitis. There are multiple known causes.