Ranindita Maulya 2ND Problem Git

2ndproblem-GIT
Ranindita 405200154
Learning issues
1. MM. Anatomi (Lambung dan duodenum)
2. MM. Histologi (lambung dan duodenum)
3. MM. Fisiologi (Lambung dan duodenum)
4. MM. Biokimia (Lambung dan duodenum)(enzim- enzim)
5. MM. Dyspepsia : GERD : peptic ulcer (gastric ulcer nsaid ulcer) : gastritis : GI
Bleeding : Reflux Esophagitis : Esophagus erosive lesion : functional dyspepsia
(definisi, etiologi, tanda gejala (mengenali dehidrasi), patfis, pemeriksaan
penunjang, DD, tatalaksana (penulisan resep), komplikasi, prognosis, KIE)
ANATOMY
Gastrointestinal System 4th Ed Megan Griffith
Rusheng Chew
Rusheng Chew
• The left gastric artery supplies both anterior and
posterior surfaces of the stomach, running along the
lesser curvature
• The splenic artery follows a tortuous route across the
posterior abdominal wall along the upper border of the
pancreas. It gives rise to the left gastroepiploic (gastro-
omental) artery, which runs along the greater curvature
and anastomoses with the right gastroepiploic artery.
Additionally, short gastric arteries to the fundus arise
from the distal end of the splenic artery
• The common hepatic artery gives rise to the right gastric
artery and the gastroduodenal artery. The gastroduodenal
artery passes behind the first part of the duodenum and
gives rise to the right gastroepiploic and the superior
pancreaticoduodenal arteries.

Rusheng Chew
The duodenum is about 25 cm in length
and extends
from the pylorus to the duodenojejunal
flexure. It is
C-shaped and snakes around the head of
the pancreas
beginning 2–3 cm on the right side of the
median plane
and ending an equal distance from the
median plane,
but to the left. It lies in the umbilical
region and except
for the first 2.5 cm, it is retroperitoneal
and hence is the
most fixed part of the small intestine.

Rusheng Chew
HISTOLOGY
At the esophagogastric junction, stratified squamous epithelium(SSE) of the
The cardia and pylorus function for esophagus is suddenly replaced by simple columnar epithelium(SCE) of the
stomach.
mucus secretion, while the fundus and Also seen here are the mucous esophageal cardiac glands (ECG)
body/corpus are for acid secretion beneath the lamina propria (LP) and muscularis mucosae (MM)
Junqueira basic histology

The mucosa and submucosa of the
empty stomach have large, longitudinally directed
folds called
rugae, which flatten when the stomach fills with
food.
A low-magnification micrograph of the stomach wall at the fundus

shows the relative thickness of the four major layers:
the mucosa (M), the submucosa (SM), the muscularis externa (ME),
and the serosa (S).
Two rugae (folds) cut transversely and consisting of mucosa and
submucosa are included.
blood vessels (V) and lymphatics. (X12; H&E)

The mucosa of the stomach wall contains
invaginations called gastric pits
that lead into gastric glands. These structures are
lined by simple columnar epithelium containing
five functional cell types.
A histologic section of the gastric mucosa shows

the gastric pits (P) and
glands (GG) surrounded by cells of the lamina
propria. The underlying muscularis mucosae
(MM) is also seen. (X60; H&E)

Gp  gastric pits
C chief cell
P  parietal cell
Mm  muscularis mucosae
Sm  siurface mucous cell
Nm  neck mucous cell

Morphological changes in parietal cells.
At rest, the parietal cells
have numerous tubulovesicles derived
from smooth endoplasmic reticulum
(SER). These contain H pumps and
do not connect with the apical surface
membrane. After stimulation of acid
secretion, the tubulovesicles merge and
become deep trough-like
invaginations of the apical surface,
called secretory canaliculi. These
communicate with the lumen of the
gland. The surface area is also
increased by numerous microvilli

Rusheng Chew
PHYSIOLOGY
Rusheng Chew
Seeley−Stephens−Tate:
Anatomy and
Physiology, Sixth
Edition
Seeley−Stephens−Tate:
Anatomy and
Physiology, Sixth
Edition
BIOCHEMISTRY
Gaster
Properties of Gastric Juice

Volume: 1200 mL/day to 1500mL/day
Reaction: Gastric juice is highly acidic with a pH of 0.9 to 1.2.
Acidity of gastric juice is due to the presence of hydrochloric acid.
Specific gravity: 1.002 to 1.004
Essentials of Medical Physiology (K. Sembulingam, Prema
Functions of Gastric Juice Essentials of Medical Physiology (K. Sembulingam,
Prema Sembulingam)
Seeleys Essentials of Anatomy and Physiology (VanPutte,
Cinnamon, Regan, Jennifer, Russo etc.)
Digestive Function
Acts mainly on proteins. Proteolytic enzymes of the gastric juice are pepsin and rennin. Gastric juice also contains
some other enzymes like gastric lipase, gelatinase, urase, and gastric amylase
Pepsin
● Secreted as inactive pepsinogen and converted into pepsin by hydrochloric acid.
● Optimum pH for activation of pepsinogen is below 6
● Pepsin converts proteins by break its covalent bonds into proteoses, peptones and polypeptides
● Also causes curdling and digestion of milk (casein)
● Pepsin exhibits optimum enzymatic activity at a pH of about 2.0
Gastric lipase
● Weak lipolytic enzyme when compared to pancreatic lipase
● Active only when the pH is between 4 and 5, inactive at a pH below 2.5
● Gastric lipase is a tributyrase and it hydrolyzes tributyrin (butter fat) into fatty acids and glycerols.
Essentials of Medical Physiology (K. Sembulingam, Prema Sembulingam)
Actions of Other Enzymes of Gastric Juice

• Gelatinase: Degrades type I and type V gelatin and type IV and V collagen (which are
proteoglycans in meat) into peptides
• Urase: Acts on urea and produces ammonia
• Gastric amylase: Degrades starch (but its action is insignificant
• Rennin: Curdles milk (present in animals only
Hemopoietic Function Essentials of Medical Physiology (K. Sembulingam, Prema Sembulingam)
Intrinsic factor of Castle

• secreted by parietal cells of gastric glands plays an important role in erythropoiesis. It is necessary for the
absorption of vitamin B12 (which is called extrinsic factor) from GI tract into the blood.
• Vitamin B12 is an important maturation factor during erythropoiesis. Vitamin B12 is important in
deoxyribonucleic acid (DNA) synthesis and in red blood cell production.
• Absence of intrinsic factor in gastric juice causes deficiency of vitamin B12, leading to pernicious anaemia
Protection Function
Mucus
is a mucoprotein, secreted by mucus neck cells of the gastric glands and surface mucus cells in fundus, body and
other parts of stomach. It protects the gastric walls by the following ways:
• Protects the stomach wall from irritation or mechanical injury, by virtue of its high viscosity.
• Prevents the digestive action of pepsin on the wall of the stomach, particularly gastric mucosa.
• Protects the gastric mucosa from hydrochloric acid of gastric juice because of its alkaline nature and its acid-
combining power.
Hydrochloric acid
• Activates pepsinogen into pepsin
• Kills some of the bacteria entering the stomach along with food substances. This action is
called bacteriolytic action
• Provides acid medium, which is necessary for the action of hormones.
Factors that Inhibiting the Secretion of Hydrochloric Acid:

• Secretin
• Gastric inhibitory polypeptide
• Peptide YY
Pancreas
Properties of Pancreatic Juice

Volume: 500 mL/day to 800mL/day
Reaction: Highly alkaline with a pH of 8 to 8.3
Functions of Pancreatic Juice
Essentials of Medical Physiology (K.
Sembulingam, Prema Sembulingam)
Digestive Function
Plays an important role in the digestion of protein and lipids. It also has mild digestive action on
carbohydrates
Digestion of Proteins
Major proteolytic enzymes of pancreatic juice are trypsin and chymotrypsin. Other proteolytic
enzymes are carboxypeptidases, nuclease, elastase and collagenase
Trypsin
● Single polypeptide with a molecular weight of 25,000
● Contains 229 amino acids
● Secreted as inactive trypsinogen which is converted into active trypsin by enterokinase
● Enterokinase/enteropeptidase is secreted by the brush-bordered cells of duodenal mucus
membrane
● Trypsin is activated only when it reaches the small intestine

● Trypsin inhibitor: an inhibitor protein that prevent activation of trypsin in pancreas (if activated
may hydrolyze the pancreatic tissue proteins  pancreatic damage
● Actions of Trypsin:
o Digestion of proteins: Trypsin is the most powerful proteolytic enzyme. It is an endopeptidase
and breaks the interior bonds of the protein molecules and converts proteins into proteoses and
polypeptides
o Curdling of milk: It converts caseinogen in the milk into casein
o Blood clotting: It accelerates blood clotting
o It activates the other enzymes of pancreatic juice:
a. Chymotrypsinogen into chymotripsin
b. Procarboxypeptidases into carboxypeptidases
c. Proelastase into elastase
d. Procolipase into colipase
● Trypsin also activates collagenase, phospholipase A and phospholipase B
Chymotripsin
● Polypeptide with a molecular weight of 25,700 and 246 amino acids
● It is secreted as inactive of chymotrypsinogen, which is activated into chymotrypsin by trypsin
● Actions of chymotrypsin:
i. Digestion of proteins: Chymotrypsin is also an endopeptidase and it converts proteins into polypeptides
ii. Digestion of milk: Chymotrypsin digests caseinogen faster than trypsin. Combination of both enzymes causes
rapid digestion of milk
iii. On blood clotting: No action.
Carboxypeptidases
● are carboxypeptidases A and B
● derived from the precursor procarboxypeptidase A and B
● procarboxypeptidases activated by trypsin into carboxypeptidase
● actions of carboxypeptidases:
o Carboxypeptidases are exopeptidases and break the terminal bond of protein molecules
● Carboxypeptidase A splits the proteins into amino acids having aromatic or aliphatic side
chains
● Carboxypeptidase B converts the proteins into amino acids having basic side chains
Nucleases
Nucleases of pancreatic juice are ribonuclease and deoxyribonuclease, which are responsible for the
digestion of nucleic acids. These enzymes convert the ribonucleic acid (RNA) and deoxyribonucleic
acid (DNA) into mononucleotides.
Elastase
Elastase is secreted as inactive proelastase, which is activated into elastase by trypsin. Elastase
digests the elastic fibers.
Collagenase
Collagenase is secreted as inactive procollagenase, which is activated into collagenase by trypsin. It
digests collagen.
Digestion of Lipids
Lipolytic enzymes present in pancreatic juice are pancreatic lipase, cholesterol ester hydrolase,
phospholipase A, phospholipase B, colipase and bile-salt -activated lipase.
Pancreatic lipase
● It digests triglycerides into monoglycerides and fatty acids
● Activity of pancreatic lipase is accelerated in the presence of bile
● Optimum pH required for activity of this enzyme is 7 to 9
● Digestion of fat by pancreatic lipase requires two more factors:
o Bile salts, which are responsible for the emulsification of fat, prior to their digestion
o Colipase, which is a coenzyme necessary for the pancreatic lipase to digest the dietary lipids.
Cholesterol ester hydrolase or cholesterol esterase

converts cholesterol ester into free cholesterol and fatty acids by hydrolisis
Phospholipase A
● Activated by trypsin
● Digests phospholipids, namely lecithin and cephalin and converts them into lysophospholipids
● It converts lecithin into lysolecithin and cephalin into lysocephalin.
Phospholipase B
● Activated by trypsin
● Converts lysophospholipids (lysolecithin and lysocephalin) to phosphoryl choline and free
fatty acids
Colipase
● A small coenzyme
● Secreted as inactive procolipase and activated into colipase by trypsin
● Facilitates digestive action of pancreatic lipase on fats
Bile-salt-activated lipase
• Is the lipolytic enzyme activated by bile salt
• Also called carboxyl ester lipase or cholesterol esterase
• This enzyme has a weak lipolytic action than pancreatic lipase
• It hydrolyses a variety of lipids such as phospholipids, cholesterol esters and triglycerides
Digestion of Carbohydrates
Pancreatic amylase is the amylolytic enzyme present in pancreatic juice. Like salivary amylase, the pancreatic
amylase also converts starch into dextrin and maltose.
Neutralizing Action of Pancreatic Juice

• When acid chyme enters intestine from stomach, pancreatic juice with large quantity of bicarbonate is released
into intestine. Makes the pancreatic juice highly alkaline. This alkaline pancreatic juice neutralizes acidity of
chyme in the intestine.
• Neutralizing action is an important function of pancreatic juice because it protects the intestine from the
destructive action of acid in the chyme.
Essentials of Medical Physiology (K. Sembulingam, Prema
Liver & Gallbladder
Properties of Bile
Volume: 800 mL/day to1200mL/day
Reaction: Alkaline
pH: 8 to 8.6
Colour: Golden yellow or green
Storage of Bile
Most of the bile from liver enters the gallbladder, where it
is stored. It is released from gallbladder into the intestine
whenever it is required.
When bile is stored in gallbladder, it undergoes many

changes both in quality and quantity such as:
• Volume is decreased because of absorption of a large
amount of water and electrolytes (except calcium and
potassium)
• Concentration of bile salts, bile pigments, cholesterol,
fatty acids and lecithin is increased because of
absorption of water and electrolytes
• The pH is decreased slightly
• Specific gravity is increased
• Mucin is added to bile

DYSPEPSIA
dyspepsia
● Definition : Dyspepsia comes from the Greek language which means "dys" meaning bad,
and "pepsia" meaning digestion
Dyspepsia is a general term encompassing several symptoms which originate in the
gastrointestinal tract. Although most of the time no abnormality is found, if a patient has
‘alarm symptoms’ they require a rapid referral for further investigations to exclude serious
gastrointestinal disease. This should be unusual in patients <55 years.
● clinical manifestations : nausea, vomiting, bloating, feeling full quickly, pain in the
epigastrium, belching heartburn, indigesti
● Treatment : PPI, amntacid, h2 blocker
Gastrointestinal System 4th Ed Megan Griffith Rusheng Chew

ILMU
PENYAKIT
DALAM
FKUI JILID
2
ILMU
PENYAKIT
DALAM
FKUI JILID
2
Dyspepsia functional
Harrison’s Gastroenterology
and Hepatology
The American Journal of
GASTROENTEROLOGY
Dyspepsia organic
gastritis
● Definition : Gastritis (inflammation of the stomach) may be acute or chronic.
● Acute : This involves an acute inflammatory reaction at the superficial mucosa, with the
infiltration of neutrophils. Acute gastritis is almost always caused by drugs (especially
NSAIDs such as aspirin) or by alcohol (the most common cause) causing chemical
exfoliation of the surface epithelial cells and decreasing the secretion of protective mucus.
● Chronic : Chronic inflammatory changes in the mucosa with the infiltration of
lymphocytes and cause by atrophy and epithelial metaplasia. It can be classified according
to aetiology.
• Autoimmune
• Bacterial infection
• Reflux

acute : inflammatory reaction at the superficial mucosa,
with the infiltration of neutrophils
Chronic : inflammatory changes in the mucosa with the
infiltration of lymphocytes
Illustration : osmosis.org
Acute gastritis
Harrison’s Gastroenterology and Hepatology

Chronic gastritis
Inflammation is mediated by antibodies against gastric

parietal cells (90%) and intrinsic factor (60%). Intrinsic
factor is needed to absorb vitamin B12. In its absence,
macrocytic anaemia develops once liver stores of vitamin B12 have been used up
Helicobacter pylori infection is present

in about 90%
of cases of active chronic infective
gastritis. It provokes an acute
inflammatory response and the release
of proteases, which destroy gastric
glands, leading to atrophy
treatment

Peptic ulcer (gastric and duodenal ulcer)
● definition : Ulcers arise when damaging factors, particularly gastric secretions,
overwhelm the natural protection of the mucosal lining of the gastrointestinal tract.
They can result from a decrease in protective factors, an increase in damaging
factors, or both.
● Peptic ulcers can be divided into acute and chronic forms. The former are usually
caused by the same factors as acute erosive gastritis, and in the same locations.
Chronic peptic ulcers occur in the upper gastrointestinal tract where gastric acid and
pepsin are present. They are caused by hyperacidity, H. pylori infection (the
commonest cause), reflux of duodenal contents, NSAIDs and smoking

The Gastrointestinal System
At Glance Satish Keshav
Adam Bailey
Gastric ulcers
● Definition: Seventy per cent of GU are associated with H. pylori, with the rest mainly
associated with NSAID treatment. Gastric ulcers may also occur in response to acute
gastritis or extreme hyperacidity, as in Zollinger–Ellison syndrome. The epigastric pain
is characteristically associated with food. Zollinger–Ellison syndrome is a rare
condition due to gastrin-secreting pancreatic adenomas causing excess acid production.
It can lead to acute ulcers in the antrum, duodenum and, in severe cases, the jejunum.
● Complications of chronic peptic ulcer include:
• Haemorrhage
• Perforation, leading to peritonitis
• Penetration, where the ulcer penetrates through the stomach or duodenal wall into underlying tissue. Usually
it is the pancreas or liver which is affected

Duodenal ulcers
● Definition : Duodenal ulcers (DU) are two to three times more common than gastric
ulcers (GU), occurring in about 15% of the population. Approximately 90% of DU
are associated with H. pylori. Classically the epigastric pain is said to be relieved by
food or antacids, and exacerbated by hunger.

Treatment
ILMU PENYAKIT DALAM FKUI JILID 2

gerd
● Definition : GERD disease is a pathological
condition as a result of reflux of gastric contents
into the esophagus, with various types of
symptoms that arise due to involvement of the
esophagus, larynx, pharynx and airways.
● Chronic reflux can also induce metaplastic change
in the epithelial lining of the lower oesophagus,
which is normally a non cornified stratified
squamous epithelium, and can change it to a simple
columnar epithelium with gastric or small
intestinal features. This specialized intestinal
metaplasia is known as Barrett’s oesophagus,
which may undergo dysplasia and can go on to
develop into adenocarcinoma
The Gastrointestinal System At Glance

Satish Keshav Adam Bailey
Risk factor
diagnosis
GERD: A practical
approach
Andrew Young, DO
, Mythri
Anil Kumar, MD an
d Prashanthi
N. Thota, MD,
FACG
treatment
● Lifestyle changes such as having smaller meals, giving up smoking
● reducing alcohol intake, losing weight and
● sleeping with the head of the bed raised can effectively reduce symptoms.
● Ppi 6-8weeks
The Gastrointestinal System At Glance Satish Keshav Adam Bailey

Helicobacter pylori infection
hydrolysis of urea to
carbon dioxide and
ammonia
Gastrointestinal bleeding
● Definition : Gastrointestinal (GI) bleeding can be caused by a number of conditions.
It can manifest as overt GI bleeding with hematemesis, melena, or hematochezia, or
as occult GI bleeding, with nonspecific symptoms related to iron deficiency anemia.
GI bleeding can be classified as upper GI bleeding (UGIB) if the site of hemorrhage
is proximal to the ligament of Treitz (e.g., esophageal variceal bleeding, bleeding
peptic ulcer) or as lower GI bleeding (LGIB) if the site of hemorrhage is distal to the
ligament of Treitz (e.g., diverticular bleeding, malignancy, small bowel bleeding).
https://
calgaryguide.u
calgary.ca/
upper-gi-
bleed-
etiologies-and-
clinical-
findings/
Harrison’s
Gastroenterology and
Hepatology
https://www.bmj.com/content/363/bmj.k4023/rapid-
responses
JILID 2
ILMU PENYAKIT DALAM FKUI
PRESCRIPTION
dr RXX
sip : 405200154
Adress : jl taman s parman A7 grogol Jakarta barat
Date : august 28th2022
R/lansoprazole 30mg no XXVIII

S. 2 d d 1
R/metronidazole 500mg no XXVIII

S. 3 d d 1
R/ clarithromycin 500mg no XXVIII

S. 2 d d1
Pro : bapak Toni 35tahun

reference
● The American Journal of GASTROENTEROLOGY (
https://www.cag-acg.org/images/publications/CAG_CPG_Dyspepsia_AJG_Aug2017.pdf)
● The Gastrointestinal System At Glance Satish Keshav Adam Bailey
● ILMU PENYAKIT DALAM FKUI JILID 2
● Gastrointestinal System 4th Ed Megan Griffith Rusheng Chew
● Junqueira basic histology
● https://www.bmj.com/content/363/bmj.k4023/rapid-responses

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2ndproblem-GIT

Gastrointestinal System 4th Ed Megan Griffith

Gastrointestinal System 4th Ed Megan Griffith

Junqueira basic histology

A low-magnification micrograph of the stomach wall at the fundus

Junqueira basic histology

A histologic section of the gastric mucosa shows

Junqueira basic histology

Junqueira basic histology

Gastrointestinal System 4th Ed Megan Griffith

Properties of Gastric Juice

Actions of Other Enzymes of Gastric Juice

Intrinsic factor of Castle

Factors that Inhibiting the Secretion of Hydrochloric Acid:

Properties of Pancreatic Juice

● Trypsin is activated only when it reaches the small intestine

Cholesterol ester hydrolase or cholesterol esterase

Neutralizing Action of Pancreatic Juice

Liver & Gallbladder

When bile is stored in gallbladder, it undergoes many

Essentials of Medical Physiology (K. Sembulingam, Prema Sembulingam)

● Treatment : PPI, amntacid, h2 blocker

Gastrointestinal System 4th Ed Megan Griffith Rusheng Chew

Gastrointestinal System 4th Ed Megan Griffith Rusheng Chew

Harrison’s Gastroenterology and Hepatology

Inflammation is mediated by antibodies against gastric

Helicobacter pylori infection is present

Harrison’s Gastroenterology and Hepatology

Gastrointestinal System 4th Ed Megan Griffith Rusheng Chew

Gastrointestinal System 4th Ed Megan Griffith Rusheng Chew

Gastrointestinal System 4th Ed Megan Griffith Rusheng Chew

ILMU PENYAKIT DALAM FKUI JILID 2

The Gastrointestinal System At Glance

The Gastrointestinal System At Glance Satish Keshav Adam Bailey

R/lansoprazole 30mg no XXVIII

R/metronidazole 500mg no XXVIII

R/ clarithromycin 500mg no XXVIII

Pro : bapak Toni 35tahun

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