ANATOMY OF STOMACH AND SMALL INTESTINE

GASTER
The muscle layers of the oesophageal and
gastric walls
Arterial Supply to Stomach
Veins of stomach, duodenum, and spleen
 Innervation of stomach
• The parasympathetic nerve
supply of the stomach is from
the anterior and posterior vagal
trunks and their branches,
which enter the abdomen
through the esophageal hiatus.
• The sympathetic nerve supply of
the stomach from the T6
through T9 segments of the
spinal cord passes to the celiac
plexus through the greater
splanchnic nerve and is
distributed through the
plexuses around the gastric and
gastro-omental arteries Distribution of the vagal nerves to the stomach. The
two commonest variations in the anterior vagus are
shown in pink. A, Multiple main trunks. B, Low origin
of the hepatic/pyloric branch lying close to the lesser
curvature.
SMALL INTESTINE
• The duodenum is divisible into
four parts:
a. Superior (first) part: short
(approximately 5 cm) and lies
anterolateral to the body of the L1
vertebra.
b. Descending (second) part: longer
(7-10 cm) and descends along the
right sides of the L1-L3 vertebrae.
c. Horizontal (third) part: 6-8 cm long
and crosses the L3 vertebra.
d. Ascending (fourth) part: short (5
cm) and begins at the left of the L3
vertebra and rises superiorly as far
as the superior border of the L2
vertebra.
Artery of duodenum
JEJUNUM - ILEUM
• Jejunum
– begins at the
duodenojejunal flexure
where the alimentary
tract resumes an
intraperitoneal course
• Ileum
– ends at the ileocecal
junction, the union of the
terminal ileum and the
cecum
Artery of Jejunum-Ileum
HISTOLOGY OF STOMACH AND SMALL INTESTINE
 GASTER

Junqueira LC, Carneiro J. Basic Histology Text and Atlas. 13th ed. McGraw-Hill; 2013
Junqueira LC, Carneiro J. Basic Histology Text and Atlas. 13th ed. McGraw-Hill; 2013
 In the cardia and pylorus
regions, the mucosa also
contains tubular glands,
with long pits, branching
into coiled secretory
portions, called cardial
glands and pyloric glands

Junqueira LC, Carneiro J. Basic Histology Text and Atlas. 13th ed. McGraw-Hill; 2013
PHYSIOLOGY OF STOMACH AND SMALL
INTESTINE
Sherwood L. Introduction to human physiology.
8th ed. United States: Brooks/Cole-Cengage
 Sherwood L. Introduction to human
physiology. 8th ed. United States:
Brooks/Cole-Cengage Learning; 2013.
 HCl SECRETION
• Functions of HCl
– Activates pepsinogen to active
enzyme pepsin and provides acid
medium for optimal pepsin activity
– Aids in breakdown of connective
tissue and muscle fibers in foods
– Denatures protein
– Along with salivary lysozyme, kills
most of the microorganisms
ingested with food

Sherwood L. Introduction to human

physiology. 5th ed. United States:
Brooks/Cole-Thomson Learning; 2007.
Pepsinogen, activated  protein digestion

Pepsin’s autocatalytic activity

 Regulatory pathways  parietal & chief cells

• Acetylcholine  short local reflexes & vagal

stimulation  parietal & chief cells, G & ECL cells
• G cells  secrete gastrin
– Main factor for increased HCl secretion by stimulating ECL
cells to release histamine
• Enterochromaffin like cells  paracrine histamine
– Speed up HCl secretion, potentiates ACh & gastrin
• D cells  paracrine somatostatin
– Negative feedback fashion
Control of gastric secretion
 Small Intestine
• The small intestine is the site where most
digestion and absorption take place
• It is arbitrarily divided into three segments—
the duodenum, the jejunum, and the ileum
• Small-intestine motility includes segmentation
and the migrating motility complex.
Segmentation
 Migrating Motility Complex
• Sweeping any remnants of the
preceding meal plus mucosal
debris and bacteria forward
toward the colon
• After the end of the small
intestine is reached, the cycle
begins again and continues to
repeat itself until the next meal
• Motilin  regulate migrating
motility complex, secreted
during the unfed state
• When the next meal arrives,
segmental activity is triggered
again, and the migrating motility
complex ceases.
Secretions
 Exocrine gland cells of small
intestine mucosa secrete
about 1.5 liters of an aqueous
salt and mucus solution
called succus entericus.
 Functions: provides
protection and lubrication
also provides plenty of H2O
to participate in the digestion
of food
 No digestive enzymes are
secreted inti the intestinal
juice.
 DIgestion
 Digestion within the small
intestine lumen is
accomplished by pancreatic
enzymes with fat digestion
being enhanced by bile
secretion.
 This digestion is completed by
special hairlike projections of
luminal surface of small
instine epithelial cell,
microvilli
Absorption
 All products of carbohydrate,
protein and fat digestion, as
well as electrolytes, vitamin
and water are absorbed by
small intestine
indiscriminately. Only
absorption calcium and iron is
adjusted by body needs.
 Most absorption occurs in
duodenum and jejunum, very
little in ileum (normally only
B12 and bile salt are
absorbed by ileum)
BIOCHEMISTRY OF STOMACH AND SMALL
INTESTINE
Biochemistry of gaster
STOMACH AND SMALL INTESTINE INFECTION
 GASTRITIS
Definition is an inflammation, irritation, or erosion of the lining of the
stomach. It can occur suddenly (acute) or gradually (chronic).

Etiology Irritation (excessive alcohol use), chronic vomiting, stress, use of certain
medications (aspirin or other anti-inflammatory drugs), pernicious
anemia, bile reflux, nfections caused by bacteria and viruses (Helicobacter
pylori, etc)

Symptoms -Nausea or recurrent upset stomach

-Abdominal bloating
-Abdominal pain
-Vomiting
-Indigestion
-Burning or gnawing feeling in the stomach between meals or at
night
-HiccupsLoss of appetite
Source: http://www.webmd.com/digestive-disorders/digestive-diseases-gastritis
-Vomiting blood
 Infection of H. PILORY

gastritis TH 1 motility
H.Pylory infects
gaster
urease
protective TH2
Vac A Urea
ammonia
+CO2
Provides a survival needs for bacteria
Causes epithelial injury
Diagnosis -A radiographic (Barium study; single contrast barium or double
contrast barium)
-Upper endoscopy
-Biopsy
-Urea breath test
-Serologic testing
-Fecal H.pylori antigen test
-Urinary H.pylori antigen test
-Serum gastrin and gastric acid analysis or sham feeding
Treatment -Taking antacids and other drugs (such as proton pump inhibitors
or H-2 blockers) to reduce stomach acid.
-Avoiding hot and spicy foods.For gastritis caused by H. pylori
infection, used antibiotics plus an acid blocking drug (used for
heartburn).
-Gastritis caused by pernicious anemia, B12 vitamin shots will be
given.
-Eliminating irritating foods such as lactose from dairy or gluten
from wheat.
Prognosis Most people with gastritis improve quickly once treatment has
begun.
 Diagnostic evaluation
• Barium study

• Endoscopy
 GASTROENTERITIS
Definition When you have diarrhea and vomiting, you may say you have the
"stomach flu. In gastroenteritis, the stomach and intestines are
irritated and inflamed. The cause is typically a viral or bacterial
infection.
Etiology -Virus (rotavirus and norovirus)
-Bacteria (E. coli, salmonella, shigella)
-Contact with someone who has the virus
-Contaminated food or water
-Unwashed hands after going to the bathroom or changing a diaper
-Parasites (giardia and cryptosporidium) in contaminated swimming pools
or by drinking contaminated water
-Heavy metals (arsenic, cadmium, lead, or mercury) in drinking water
-Eating a lot of acidic foods, like citrus fruit and tomatoes
-Toxins that might be found in certain seafood
-Medications such as antibiotics, antacids, laxatives, and
chemotherapy drugs

Source: http://www.webmd.com/digestive-disorders/gastroenteritis
Symptoms -Watery diarrhea and vomiting
-Stomach pain, cramping, fever, nausea, and a headache.
-Dehydrated

Treatment -Keep children with gastroenteritis out of day care or school until all
symptoms are gone. Check with your doctor before giving your child
any medicine. Drugs used to control diarrhea and vomiting aren't
usually given to children younger than 5.
-To help prevent rotavirus, there are two vaccines that can be given
to infants

Source: http://www.webmd.com/digestive-disorders/gastroenteritis
 PEPTIC ULCER
Etiology Bacteria called Helicobacter pylori
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and
ibuprofen

Risk factor Stress: The parasympathetic nervous system, which is responsible for the
function of the digestive organs, ceases to act when the sympathetic
nervous system,
Smokers develop ulcers much more often than non-smokers.
A poor diet is one that includes spicy foods, citrus foods, soda pop,
caffeine, and alcohol, junk foods and refined & processed foods.
Food and allergies can cause problems as well. Milk allergies are strongly
linked to gastric problems. Doctors once prescribed milk as
A low antioxidant status appears to predispose one to ulcers.
have relatives who have peptic ulcers

Source: http://www.webmd.com/digestive-disorders/gastroenteritis
Symptoms -A burning pain in the gut is the most common symptom
-Pain 1-2 hours after meals
-Heartburn
-Local tenderness
-Nausea
-Vomiting
-Weight loss
Diagnostic Endoscopy
Tests for H.Pylori
•Invasive: Tissue specimens, rapid urease test
•Nonivasive: IgG, urea breath test (by product of H.Pylori)

Complications Hemorrhage
Perforation-most lethal, severe abdominal pain that spreads
throughout abdomen, shoulder pain, absent bowel sounds
Obstruction
pathology of peptic ulceration

45
Treatment
Eradication of H. pylori
 STOMACH CANCER
Definition is a common condition and usually describes a group of symptoms
rather than one predominant symptom.

Etiology Infection of H. pylori, which causes ulcers., Inflammation in gut

called gastritis, Long-lasting anemia, Growths in stomach called
polyps, smoking, being overweight or obese, a diet (high in
smoked, pickled, or salty foods), stomach surgery for an ulcer,
type-A blood, epstein-Barr virus infection, certain genes, working
in (coal, metal, timber, or rubber industries), exposure to asbestos
Investigation -Physical exam
-Medical history
-Blood tests
-Upper endoscopy
-Upper GI series test
-CT scan
Diagnosis Indigestion, feeling bloated after eat a meal
Slight nausea
Loss of appetite, weight loss for no reason
Stomach pain
Blood in stool
Vomiting, trouble swallowing
Yellowish eyes or skin
Swelling in your stomach
Constipation or diarrhea
Weakness or feeling tired
Heartburn
Treatment Surgery
Chemotherapy
Radiation
Chemoradiation
Targeted drugs

Prevention Treat stomach infections

Eat healthy
Don’t smoke
Watch aspirin or NSAID use
DYSPEPSIA AND GERD
 STOMACH CANCER
Definition begins when cancer cells form in the inner lining of stomach. These
cells can grow into a tumor. Also called gastric cancer, the disease
usually grows slowly over many years.
Symptoms Belly pain or discomfort, bloating, feeling uncomfortably full after
eating, nausea, loss of appetite, heartburn, burping up food or liquid
(regurgitation), burping
Etiology Burped-up stomach juices and gas (regurgitation or reflux) caused by
gastoesophageal reflux disease (GERD) or a hiatal hernia
A disorder that affects movement of food through the intestines,
such as irritable bowel syndrome
Peptic (stomach) ulcer or duodenal ulcer
An inability to digest milk and dairy products (lactose intolerance)
Gallbladder pain (biliary colic) or inflammation (cholecystitis)
Anxiety or depression
Side effects of caffeine, alcohol, or medicines. Examples of medicines
that may cause dyspepsia are aspirin and similar drugs, antibiotics,
steroids, digoxin, and theophylline
Swallowed air
Stomach cancer
 Functional dyspepsia
• Is a situation where GI tract endoscopy did not reveal a
potential cause for dyspepsia (the cause is not clear)
• Sometimes called non ulcer dyspepsia/idiophatic
dyspepsia
• Pathophysiological mecanism underlying FD are :
– Delayed gastric emptying
– Increased gastric acid
– Hypersensitivity to gastric distention
– Altered duodenal sensitivity to lipids or acids
– Infection of Helicobacter pylori
– etc
 Functional dyspepsia
Factors are affected prevalence of
FD are : Divided into 2 subtypes :
– Body mass index – Epigastric pain syndrome
– Smokers – Postprandial distress syndrome
– Alchoholic
– Psychological factors
– Diet and environment
– Hormones (CCK & secretin)
 Organic dyspepsia
• Is a versus of functional dyspepsia
• Cause :
– Peptic ulcer
– GERD
– Esophageal / gastric cancer
– Pancreatic / billiary disorders
– Intolerance of food or drug
– infection / systemic disease
– Malignancy
Investigation Laboratory : for exlude the other causes of organic dyspepsia
(pancreatitis, diabetic mellitus, etc).
FD : usually normal
Endoscopy (esofagogastro-duodenoscopy) : usually normal and not
specific in FD
Gastric emptying time : about 30-50% patients with FD have delayed
emptying time of gaster
Electrogastrografi : delayed emptying time of gaster
Hp test
Treatment Functional dyspepsia :
Non pharmacologic : life style, psycological treatment
Pharmacologic : empiric therapy (therapy based on the subtype)
for 4 weeks (PPI, prokinetics, citoprotective, antidepressan, eradication of
Hp, antasida, etc)
DD GERD
Ulcus pepticum
Carbohydrate malabsorption
Kolelitiasis & koledokolitiasis
Chronic pancreatis
Systemic disease: DM, thyroid-hypothyroid-hyperthyroid
Chronic ischemic in mesenterica arteries
 Reflux esophaghitis
• Gastroesophageal reflux disease (GERD) is a
condition in which the stomach contents leak
backwards from the stomach into the
esophagus (the tube from the mouth to the
stomach). This can irritate the esophagus and
cause heartburn and other symptoms.
 Causes
• When you eat, food passes from the throat to the
stomach through the esophagus. A ring of muscle
fibers in the lower esophagus prevents swallowed
food from moving back up. These muscle fibers are
called the lower esophageal sphincter, or LES.
• When this ring of muscle does not close all the way,
stomach contents can leak back into the esophagus.
This is called reflux or gastroesophageal reflux.
Reflux may cause symptoms. Harsh stomach acids
can also damage the lining of the esophagus.
 The risk factors
• Use of alcohol
• Hiatal hernia (a condition in which part of the
stomach moves above the diaphragm, which is the
muscle that separates the chest and abdominal
cavities)
• Obesity
• Pregnancy
• Scleroderma
• Smoking
Heartburn and gastroesophageal reflux can be brought on
or made worse by pregnancy. Symptoms can also be caused
by certain medicines, such as:

• Anticholinergics (e.g., for seasickness)

• Beta-blockers for high blood pressure or heart disease
• Bronchodilators for asthma
• Calcium channel blockers for high blood pressure
• Dopamine-active drugs for Parkinson's disease
• Progestin for abnormal menstrual bleeding or birth
control
• Sedatives for insomnia or anxiety
• Tricyclic antidepressants
 Symptoms

• Common symptoms of GERD include:

• Feeling that food is stuck behind the breastbone

• Heartburn or a burning pain in the chest
• Nausea after eating
• Less common symptoms are:

• Bringing food back up (regurgitation)

• Cough or wheezing
• Difficulty swallowing
• Hiccups
• Hoarseness or change in voice
• Sore throat
• Symptoms may get worse when you bend over or lie down, or when you eat. Symptoms
may also be worse at night.
 Exams and Tests
• upper endoscopy (EGD) : This is a test to
examine the lining of the esophagus (the tube that
connects your throat to your stomach), stomach, and
first part of the small intestine.
• It is done with a small camera (flexible endoscope)
that is inserted down the throat.
• A test that measures how often stomach acid
enters the tube that leads from the mouth to the
stomach (called the esophagus) : A test to measure
the pressure inside the lower part of the esophagus
(esophageal manometry). A positive stool occult
blood test may diagnose bleeding that is coming from
the irritation in the esophagus, stomach, or intestines.
 Treatment
• lifestyle changes to help treat your symptoms.
• Diet
• Avoid drugs such as aspirin, ibuprofen (Advil, Motrin), or naproxen
(Aleve, Naprosyn). Take acetaminophen (Tylenol) to relieve pain.
• Take all of your medicines with plenty of water. When your doctor
gives you a new medicine, ask whether it will make your heartburn
worse.
• Proton pump inhibitors (PPIs) decrease the amount of acid produced in
your stomach
• H2 blockers also lower the amount of acid released in the stomach
• Anti-reflux surgery may be an option for patients whose symptoms do
not go away with lifestyle changes and drugs. Heartburn and other
symptoms should improve after surgery. But you may still need to take
drugs for your heartburn.
• There are also new therapies for reflux that can be performed through
an endoscope (a flexible tube passed through the mouth into the
stomach).
 Complications

• Worsening of asthma
• A change in the lining of the esophagus that can
increase the risk of cancer (Barrett's esophagus)
• Bronchospasm (irritation and spasm of the airways
due to acid)
• Chronic cough or hoarseness
• Dental problems
• Ulcer in the esophagus
• Stricture (a narrowing of the esophagus due to
scarring)