NURSING PATHSHALA

YOUR ULTIMATE DESTINATION FOR QUALITY EDUCATION

ANATOMY & PHYSIOLOGY OF DIGESTIVE SYSTEM

The digestive system describes the alimentary canal, its accessory organs and a variety of digestive
processes that prepare food eaten in the diet for absorption. The alimentary canal begins at the
mouth, passes through the thorax, abdomen and pelvis, and ends at the anus. The activities of the
digestive system can be grouped under five main headings-

Ingestion This is the taking of food into the alimentary tract, i.e. eating and drinking.
Propulsion This mixes the contents and moves them along the alimentary tract.
Digestion This consists of mechanical breakdown of food by, for example, mastication (chewing)
chemical digestion of food into small molecules by the action of enzymes present in secretions
produced by glands and accessory organs of the digestive system.

Absorption This is the process by which the products of digestion pass through the walls of some
organs of the alimentary canal into the blood and lymph capillaries for circulation and use by body
cells.
Elimination Food that has been eaten but cannot be digested and absorbed is excreted from the
alimentary canal in faeces by the process of defaecation.

The parts of digestive system are as follows-

• mouth • pharynx • oesophagus • stomach • small intestine • large intestine • rectum and anal
canal.

Accessory organs-
Various secretions are released into the alimentary tract some by glands in the membrane lining
certain organs, e.g. gastric juice secreted by glands in the lining of the stomach, and some by glands
situated outside the tract. The latter are the accessory organs of digestion and their secretions pass
through ducts to enter the tract. They consist of:

• three pairs of salivary glands

• the pancreas

• the liver and biliary tract.

The layers of alimentary canal-

The walls of the alimentary tract are formed by four layers of tissue:

• adventitia or serosa - outer covering

• muscle layer

• submucosa

• mucosa- mucosal lining.

Adventitia or serosa This is the outermost

layer. In the thorax it consists of loose fibrous
tissue, and in the abdomen the organs are
covered by a serous membrane (serosa) called
peritoneum.

The peritoneum is the largest serous membrane

of the body. It is a single membrane, forming a
closed sac and containing a small amount of
serous fluid. within the abdominal cavity. It is richly supplied with blood and lymph vessels, and
contains many lymph nodes. It provides a physical barrier to local spread of infection and can isolate
an infective focus such as appendicitis, preventing involvement of other abdominal structures. It has
two layers:

• the parietal peritoneum, which lines the abdominal wall

• the visceral peritoneum, which covers the organs (viscera) within the abdominal and pelvic
cavities.

Muscle layer With some exceptions, this consists of two layers of smooth (involuntary) muscle.
The muscle fibres of the outer layer are arranged longitudinally, and those of the inner layer are
circular. Between these two muscle layers are blood vessels, lymph vessels and a plexus (network) of
sympathetic and parasympathetic nerves, called the myenteric plexus. These nerves supply the
adjacent smooth muscle and blood vessels.

Submucosa This layer consists of loose areolar connective tissue containing collagen and some
elastic fibres, which binds the muscle layer to the mucosa. Within it are blood vessels, nerves, lymph
vessels and varying amounts of lymphoid tissue. The blood vessels are arterioles, venules and
capillaries.

Mucosa The mucosa is the lining of the tract. Its most superficial layer is the mucous membrane,
which is made from columnar epithelium and has three main functions: protection, secretion and
absorption. Below this lies a thin layer of loose connective tissue that supports the blood vessels and
the protective and lymphatic tissue. The deepest layer is a thin layer of smooth muscle that provides
features of the tract wall, e.g. gastric glands and villi.

Nerve supply: The alimentary canal and its related accessory organs are supplied by nerves
from both divisions of the autonomic nervous system, i.e. both parasympathetic and sympathetic
parts. Their actions are generally antagonistic to each other and, at any partiru1ar time, one has a
greater influence than the other, according to body needs. Increased parasympathetic activity to the
digestive organs promotes digestive processes, and increased sympathetic activity inhibits them.

The parasympathetic supply One pair of cranial nerves, the vagus nerves, supplies most of
the alimentary canal and the accessory organs. Sacral nerves supply the most distal part of the GI
tract. The effects of parasympathetic stimulation on the digestive system are:

• increased muscular activity, especially peristalsis, stimulated by increased activity of the myenteric
plexus

• increased glandular secretion, through increased activity of the submucosal plexus.

The sympathetic supply This is provided by numerous nerves that emerge from the spinal
cord in the thoracic and lumbar regions. These form plexuses (ganglia) in the thorax. abdomen and
pelvis, from which nerves pass to the organs of the alimentary tract. The effects of sympathetic
stimulation on the digestive system are to:

• decrease muscular activity, especially peristalsis, because there is reduced stimulation of the
myenteric plexus

• decrease glandular secretion, as there is less stimulation of the submucosal plexus.

MOUTH
The mouth or oral cavity is formed by muscles and bones:

Anteriorly - by the lips

Posteriorly - it is continuous with the oropharynx

Laterally - by the muscles of the cheeks

Superiorly - by the bony hard palate and
muscular soft palate

Inferiorly - by the muscular tongue and the

soft tissues of the floor of the mouth.

Tongue The tongue is composed of

voluntary muscle. It is attached by its base
to the hyoid bone and by a fold of its
mucous membrane covering, called the
frenulum. to the floor of the mouth. The superior surface consists of stratified squamous epithelium,
with numerous papillae (little projections). Many of these contain sensory receptors (specialised
nerve endings) for the sense of taste in the taste buds.

The tongue plays an important part in: • chewing (mastication) • swallowing (deglutition) • speech •
taste.

teeth

The teeth are embedded in the alveoli. or sockets, of the alveolar ridges of the mandible and the
maxilla (Fig. 12.9). Babies are born with two sets, or dentitions: the temporary or deciduous (baby)
teeth and the
permanent teeth (Fig.
12.10). The teeth of
both dentitions are
present, in immature
form, in the mandible
and maxilla at birth.

There are 20 temporary

teeth, 10 in each jaw.
They begin to erupt at
about 6 months of age,
and should all be
present by 24 months.
The permanent teeth begin to replace the deciduous teeth between the ages of 6 and 13 years. This
dentition, consisting of 32 teeth, is usually complete by the age of 20. The third molars (wisdom
teeth) are the last to erupt.

Functions Teeth have different shapes, depending on their functions. Incisors and canine teeth
are the cutting teeth and are used for biting off pieces of food, whereas the premolar and molar
teeth, with broad, flat surfaces, are used for grinding or chewing food.

Salivary glands
The salivary glands release their secretions into ducts that lead into the mouth. There are three main
pairs: the parotid glands, the submandibular glands and the sublingual glands. There are also
numerous smaller salivary glands scattered around the mouth.

Parotid glands These are situated one on each side of the face, just below the external acoustic
meatus. Each gland has a parotid duct opening into the
mouth at the level of the second upper molar tooth.

Submandibular glands These lie one on each side of

the face under the angle of the jaw. The two
submandibular ducts open on the floor of the mouth, one
on each side of the frenulum of the tongue

Sublingual glands These glands lie under the mucous

membrane of the float of the mouth in front of the
submandibular glands. They have numerous small ducts
that open into the floor of the mouth.

SALIVA- Saliva is the combined secretions from the salivary glands and the small mucus-
secreting glands of the oral mucosa. About 1.5litres of saliva is produced daily and it consists of:

• water • mineral salts • salivary amylase - a digestive enzyme • mucus • antimicrobial substances-
immunoglobulins (antibodies) and the enzyme lysozyme.

Secretion of saliva is controlled by the autonomic nervous system. Parasympathetic stimulation

causes profuse secretion of watery saliva with a relatively low content of enzymes and other organic
substances. Sympathetic stimulation results in secretion of small amounts of saliva rich in organic
material especially from the submandibular glands.

Functions of saliva-
Chemical digestion of polysaccharides- Saliva contains the enzyme amylase, which begins the
breakdown of complex sugars, including starches, reducing them to the disaccharide maltose. The
optimum pH for the action of salivary amylase is 6.8 (slightly acid). Salivary pH ranges from 5.8 to
7.4, depending on the rate of flow; the higher the flow rate, the higher the pH.

Lubrication of food The high water content means that dry food entering the mouth is moistened
and lubricated by saliva before it can be made into a bolus ready for swallowing.
Cleaning and lubrication of the mouth An adequate flow of saliva is necessary to keep the mouth
clean, moist and pliable. This also helps to prevent damage to the mucous membrane by rough or
abrasive food.

Non-specific defence Lysozyme and immunoglobulins (antibodies) present in saliva combat invading
microbes.

Taste The taste buds are stimulated only by chemical substances in solution and therefore dry foods
stimulate the sense of taste only after thorough mixing with saliva. The senses of taste and smell are
closely linked and involved in the enjoyment of food.

Pharynx
The pharynx is divided for descriptive purpose into three parts: the nasopharynx, oropharynx and
laryngopharynx. The nasopharynx is important in respiration. The oropharynx and laryngopharynx
are passages common to both the respiratory and the digestive systems. Food passes from the oral
cavity into the pharynx and then to the oesophagus below, with which it is continuous.

The walls of the pharynx consist of three layers of tissue. The lining membrane (mucosa) is stratified
squamous epithelium continuous with the lining of the mouth at one end and the oesophagus at the
other. This provides a thick, sturdy lining well suited to the wear and tear of swallowing ingested
food. The middle layer consists of connective tissue, which becomes thinner towards the lower end
and contains blood and lymph vessels and nerves. The outer layer consists of involuntary muscles
that are involved in swallowing. When food reaches the pharynx, swallowing becomes reflexive, i.e.
is no longer under voluntary control.

Blood supply The blood supply to the pharynx is by several branches of the facial arteries. Venous
drainage is into the facial veins and the internal jugular veins.

Nerve supply This is from the pharyngeal plexus and consists of parasympathetic and
sympathetic nerves. Parasympathetic supply is mainly by the glossopharyngeal and vagus nerves,
and sympathetic supply is from the cervical ganglia.

Oesophagus
The oesophagus is about 25 cm long and about 2 cm in diameter; it lies in the median plane in the
thorax in front of the vertebral column and behind the trachea and the
heart. It is continuous with the pharynx above, and just below the
diaphragm it joins the stomach. It passes between muscle fibres of the
diaphragm behind the central tendon at the level of the 1Oth thoracic
vertebra. Immediately the oesophagus has passed through the diaphragm it
curves upwards, before opening into the stomach. This sharp angle is
believed to be one of the factors that prevents the regurgitation (backflow)
of gastric contents into the oesophagus. The upper and lower ends of the
oesophagus are closed by sphincters. The upper oesophageal sphincter
prevents the passage of air into the oesophagus during inspiration and the
aspiration of oesophageal contents. The lower oesophageal (cardiac)
sphincter prevents the reflux of acid gastric contents into the oesophagus.
There is no thickening of the circular muscle in this area and this sphincter
is therefore 'physiological', i.e. this region can act as a sphincter without the presence of the
anatomical features. When intra-abdominal pressure is raised, e.g. during inspiration and
defaecation. The tone of the lower oesophageal sphincter increases. There is an added pinching
effect by the contracting muscle fibres of the diaphragm.

Functions of the mouth, pharynx and oesophagus

Formation of a bolus When food is taken into the mouth, it is chewed (masticated) by the
teeth and moved around the mouth by the tongue and muscles of the cheeks. It is mixed with saliva
and formed into a soft mass, or bolus, ready for swallowing. The length of time that food remains in
the mouth largely depends on the consistency of the food. Some foods need to be chewed longer
than others before the individual feels that the bolus is ready for swallowing.

Swallowing (deglutition) Swallowing occur in three stages after chewing is complete and the
bolus has been formed. It is initiated voluntarily but completed by a reflex (involuntary) action.

1. Oral stage with the mouth closed, the voluntary muscles of the tongue and cheeks push the bolus
backwards into the pharynx.

2.Pharyngeal stage The muscles of the pharynx are stimulated by a reflex action initiated in the walls
of the oropharynx and coordinated by the swallowing centre in the medulla. Involuntary contraction
of these muscles propels the bolus down into the oesophagus. All other routes that the bolus could
take are closed. The soft palate rises up and closes off the nasopharynx; the tongue and the
pharyngeal folds block the way back into the mouth; and the larynx is lifted up and forwards so that
its opening is occluded by the overhanging epiglottis, preventing entry into the airway (trachea).

3. Oesophageal stage The presence of the bolus in the pharynx stimulates a wave of peristalsis that
propels the bolus through the oesophagus to the stomach. Peristaltic waves pass along the
oesophagus only after swallowing begins. Otherwise the walls are relaxed. Ahead of a peristaltic
wave, the lower oesophageal sphincter guarding the entrance to the stomach relaxes to allow the
descending bolus to pass into the stomach. Usually, constriction of the lower oesophageal sphincter
prevents reflux of gastric acid into the oesophagus.

The walls of the oesophagus are lubricated by mucus, which assists the passage of the bolus during
the peristaltic contraction of the muscular wall.

Stomach
The stomach s-shaped dilated portion of the alimentary tract situated in the epigastric, umbilical and
left hypochondriac regions of the abdominal cavity. Organs associated with the stomach

Anteriorly -left lobe of liver and anterior abdominal wall

Posteriorly - abdominal aorta, pancreas, spleen. left kidney and adrenal gland.

Superiorly - diaphragm, oesophagus and left lobe of liver.

Inferiorly - transverse colon and small intestine.

To the left - diaphragm and spleen.

To the right - liver and duodenum.

The stomach is continuous with the oesophagus at the lower oesophageal sphincter and with the
duodenum at the pyloric sphincter. The stomach is divided into three regions:

• the fundus

• the body

• the pylorus.

At the distal end of the pylorus is the pyloric sphincter, guarding the opening between the stomach
and the duodenum. When the stomach is inactive the pyloric sphincter is relaxed and open, and
when the stomach contains food the sphincter is closed.

Walls of the stomach The four layers of tissue that comprise the basic structure of the
alimentary canal are found in the stomach but with some modifications.

Muscle layer This consists of three layers of smooth muscle

fibres:

• an outer layer of longitudinal fibres

• a middle layer of circular fibres

• an inner layer of oblique fibres.

In this respect the stomach is different from other regions of

the alimentary tract, as it has three layers of muscle instead of
two. This arrangement allows for the churning action characteristic of gastric activity, as well as
peristaltic movement. Circular muscle is strongest between the pylorus and the pyloric sphincter.

Mucosa Numerous gastric glands are situated below the surface in the mucous membrane and
open on to it. They contain specialised cells, including chief cells and parietal cells which secrete
constituents of gastric juice into the stomach as well as enteroendocrine cells.
Blood supply Arterial supply to the stomach is by the left gastric artery, a branch of the coeliac
artery, the right gastric artery and the gastroepiploic arteries.

Gastric juice and functions of the stomach

Stomach size varies with the volume of food it contains, which may be 1.5 litres or more in an adult.
After a meal, food accumulates in the stomach in layers, the last part of the meal remaining in the
fundus for some time. Mixing with the gastric juice takes place gradually and it may be some time
before the food is sufficiently acidified to stop the action of salivary amylase. The gastric muscle
generates a churning action that breaks down the bolus and mixes it with gastric juice. Peristaltic
waves in the stomach wall propel the contents towards the pylorus.

When the stomach is active the pyloric sphincter closes. Strong peristaltic contraction of the pylorus
forces chyme, gastric contents after they are sufficiently liquefied, through the pyloric sphincter into
the duodenum in small spurts. Parasympathetic stimulation increases the motility of the stomach
and secretion of gastric juice; sympathetic stimulation has the opposite effect.

Gastric juice About 2litres of gastric juice are secreted daily by specialised secretory glands in the
mucosa. It consists of:

• water • mineral salts • mucus secreted by mucous neck cells in the glands and surface mucous
cells on the stomach surface • hydrochloric acid & intrinsic factor (secreted by parietal cells in the
gastric glands) • inactive enzyme precursors - pepsinogens secreted by chief cells in the glands.

Functions of gastric juice

• Water further liquefies the food swallowed.

• Hydrochloric acid:

- acidifies the food and stops the action of salivary amylase

- kills ingested microbes

- provides the acid environment needed for the action of pepsins.

• Pepsinogens are activated to pepsins by hydrochloric acid and by pepsins already present in the
stomach. These enzymes begin the digestion of proteins, breaking them into smaller molecules.
Pepsins have evolved to act most effectively at a very low pH, between 1.5 and 3.5.

• Intrinsic factor (a protein) is necessary for the absorption of vitamin B12 from the ileum.
(Deficiency leads to pernicious anaemia)

• Mucus prevents mechanical injury to the stomach wall by lubricating the contents. It also prevents
chemical injury by acting as a barrier between the stomach wall and the highly corrosive gastric
juice; hydrochloric acid is present in potentially damaging concentrations and pepsins would digest
the gastric tissues.

Secretion of gastric juice There is always a small quantity of gastric juice present in the
stomach even when it contains no food. This is known as fasting juice. Secretion reaches its
maximum level about 1 hour after a meal, then declines to the fasting level after about 4 hours.
Functions of the stomach
These include:

• Temporary storage - allows time for the digestive enzymes, pepsins, to act.

• Chemical digestion - pepsins break proteins into polypeptides.

• Mechanical breakdown- the three smooth muscle layers enable the stomach to act as a churner.
gastric juice is added and the contents are liquefied to chyme. Gastric motility and secretion are
increased by parasympathetic nerve stimulation.

• Limited absorption- water, alcohol and some lipid-soluble drugs.

• Non-specific defence against microbes - provided by hydrochloric acid in gastric juice. Vomiting
may occur in response to ingestion of gastric irritants, e.g. microbes or chemicals.

• Preparation of iron for absorption - the acid environment of the stomach solubilises iron salts,
essential for iron absorption in the small intestine.

• Production and secretion of intrinsic factor- needed for absorption of vitamin B12
in the terminal ileum.

• Regulation of the passage of gastric contents into the duodenum-when the chyme is sufficiently
acidified and liquefied, the pylorus forces small jets of gastric contents through the pyloric sphincter
into the duodenum. The sphincter is normally closed, preventing backflow of chyme into the
stomach.

• Secretion of the hormone gastrin.

Small intestine
The small intestine is continuous with the stomach at the pyloric sphincter. The small intestine is
about 2.5 cm in diameter and a little over 5 metres long; it leads into the large intestine at the
ileocaecal valve. It lies in the abdominal cavity, surrounded by
the large intestine. In the small intestine the chemical
digestion of food is completed and absorption of most
nutrients takes place. The small intestine is comprised of
three continuous parts.

Duodenum This is about 25 cm long and curves around the

head of the pancreas. Secretions from the gall bladder and
pancreas merge in a common structure - the
hepatopancreatic ampulla - and enter the duodenum at the
duodenal papilla. The duodenal papilla is guarded by a ring of
smooth muscle, the hepatopancreatic sphincter (of Oddi).

Jejunum This is the middle section of the small intestine and is about 2 metres long.

Ileum This terminal section is about 3 metres long and ends at the ileocaecal valve, which controls
the flow of material from the ileum to the caecum, the first part of the large intestine, and prevents
backflow.
Structure The walls of the small intestine are composed of the four layers of tissue. Some
modifications of the peritoneum and mucosa (mucous membrane lining) are described below.

Peritoneum The mesentery, a double layer of peritoneum, attaches the jejunum and ileum to the
posterior abdominal wall. The attachment is quite short in comparison with the length of the small
intestine, it is therefore fan-shaped. The large blood vessels and nerves lie on the posterior
abdominal wall and the branches to the small intestine pass between the two layers of the
mesentery.

Mucosa The surface area of the small intestine mucosa is greatly increased by permanent circular
folds, villi and microvilli. The permanent circular folds, unlike the rugae of the stomach, are not
smoothed out when the small intestine is distended. They promote mixing of chyme as it passes
along.

The villi are tiny finger-like projections of the mucosal layer into the intestinal lumen, about 0.5-1
mm long. Their covering consists of columnar epithelial cells, or enterocytes, with tiny microvilli
(1µm long) on their free border. Goblet cells, which secrete mucus, are interspersed between the
enterocytes. The villi contain a network of blood capillaries and a central lymph capillary.

The intestinal glands are simple tubular glands situated below the surface between the villi. The
epithelial cells of these glands migrate upwards to form the walls of the villi, replacing those at the
tips as they are rubbed off by the passage of intestinal contents. The entire epithelium is replaced
every 3-5 days. During migration, epithelial cells produce digestive enzymes that lodge in the
microvilli and, together with intestinal juice, complete the chemical digestion of carbohydrates,
protein and fats.

Numerous lymph nodes are found in the mucosa at irregular intervals throughout the length of the
small intestine.

Blood supply The superior mesenteric artery supplies the whole of the small intestine. Venous
drainage is by the superior mesenteric vein, which joins other veins to form the portal vein.

Intestinal juice About 1500 mL of intestinal juice are secreted daily by the glands of the small
intestine. It is slightly basic (alkaline) and consists of water, lubricating mucus and bicarbonate to
neutralise gastric acid.

Functions These are:

• onward movement of its contents by peristalsis, which is increased by parasympathetic stimulation

• secretion of intestinal juice, also increased by parasympathetic stimulation

• completion of chemical digestion of carbohydrates, protein and fats in the enterocytes of the villi

• protection against infection by microbes that have survived the antimicrobial action of the
hydrochloric acid in the stomach by both solitary and aggregated lymph follicles

• secretion of the hormones CCK and secretin

• absorption of nutrients.
Chemical digestion in the small intestine
When acidic chyme passes into the small intestine it is mixed with pancreatic juice, bile and
intestinal juice, and is in contact with the absorptive enterocytes of the villi. The digestion of all
nutrients is completed:

• Carbohydrates are broken down to monosaccharides.

• Proteins are broken down to amino acids.

• Fats are broken down to fatty acids and glycerol.

Pancreatic juice Pancreatic juice is secreted by the exocrine pancreas and enters the duodenum
at the duodenal papilla. It consists of:

• water • mineral salts

• enzymes: amylase, lipase, nucleases that digest the nucleic acids, DNA and RNA

• inactive enzyme precursors including: trypsinogen & chymotrypsinogen.

Pancreatic juice is basic (alkaline, pH 8) because it contains significant quantities of bicarbonate ions,
which are basic (alkaline) in solution. When acid stomach contents enter the duodenum they are
mixed with pancreatic juice and bile, and the pH is raised to between 6 and 8. This is the pH at which
the pancreatic enzymes, amylase and lipase, act most effectively.

Functions

Digestion of proteins- Trypsinogen and chymotrypsinogen are inactive enzyme precursors activated
by enterokinase, an enzyme in the microvilli. which converts them into the active proteolytic
enzymes trypsin and chymotrypsin. These enzymes break polypeptides down into tripeptides,
dipeptides and amino acids.

Digestion of carbohydrates- Pancreatic amylase converts all digestible polysaccharides (starches) not
acted on by salivary amylase to disaccharides.

Digestion of fats- Lipase converts fats to fatty acids and glycerol. To aid the action of lipase, bile salts
emulsify fats, i.e. reduce the size of the globules, increasing their surface area.

Control of secretion The secretion of pancreatic juice is stimulated by secretin and CCK, produced by
endocrine cells in the walls of the duodenum. The presence in the duodenum of acid chyme from
the stomach stimulates the production of these hormones.

Bile Bile, secreted by the liver, is unable to enter the duodenum when the hepatopancreatic
sphincter is closed; it therefore passes from the hepatic duct along the cystic duct to the gall
bladder, where it is stored. Bile has a pH of around 8 and between 500 and 1000 mL is secreted
daily. It consists of:

• water • mineral salts • mucus • bile salts • bile pigments, mainly bilirubin • cholesterol

Functions The functions of bile are-

• emulsification of fats in the small intestine - bile salts

• making cholesterol and fatty acids soluble, enabling their absorption along with the fat-soluble
vitamins - bile salts

• excretion of bilirubin (a waste product from the breakdown of red blood cells), most of which is in
the form of stercobilin.

Release from the gall bladder After a meal, the duodenum secretes the hormones secretin
and CCK during the intestinal phase of gastric secretion. They stimulate contraction of the gall
bladder and relaxation of the hepatopancreatic sphincter, expelling both bile and pancreatic juice
through the duodenal papilla into the duodenum. Secretion is markedly increased when chyme
entering the duodenum contains a high proportion of fat.

Chemical digestion in enterocytes Most of the digestive enzymes in the small intestine are
contained in the enterocytes of the epithelium that covers the villi. The enzymes that complete
chemical digestion of food at the surface of the enterocytes are:

• peptidases • lipase • sucrase, maltase and lactase.

Peptidases such as trypsin break down polypeptides into smaller peptides and amino acids.
Peptidases are secreted in an inactive form from the pancreas (to prevent them from digesting it)
and must be activated by enterokinase in the duodenum. The final stage of breakdown of all
peptides to amino acids takes place at the surface of the enterocytes.

Lipase completes the digestion of emulsified fats to fatty acids and glycerol in the intestine.

Sucrase, maltase and lactase complete the digestion of carbohydrates by splitting disaccharides such
as sucrose, maltose and lactose into monosaccharides at the surface of the enterocytes.

Absorption of nutrients
• Monosaccharides and amino acids are actively co-transported with sodium ions into the
blood capillaries in the villi.
• Fatty acids and glycerol diffuse into the lacteals and are transported along lymphatic vessels
to the thoracic duct, where they enter the circulation.
• A small number of proteins and other large substances are absorbed unchanged, e.g.
antibodies present in breast milk and oral vaccines, such as poliomyelitis vaccine.
• Other nutrients, such as vitamins, mineral salts and water, are also absorbed from the small
intestine into the blood capillaries.
• Fat-soluble vitamins are absorbed into the lacteals along with fatty acids and glycerol.
Vitamin B12 combines with intrinsic factor in the stomach and is actively absorbed in the
terminal ileum.
• Large amounts of fluid enter the alimentary tract each day. Of this, only about 1500 mL is
not absorbed by the small intestine and passes into the large intestine.
 Large intestine, rectum and anal canal
The large intestine is about 1.5 metres long, beginning at the caecum in the right iliac fossa and
terminating at the rectum and anal canal Its lumen is about 6.5 cm in diameter, larger than that of
the small intestine. It forms an arch round the coiled-up small intestine.

For descriptive purposes the large intestine is divided into the caecum, colon, rectum and anal canal.

Caecum This is the first part of the large intestine. It is a dilated region that has a blind end
inferiorly and is continuous with the ascending colon superiorly. Just below the junction of the two,
the ileocaecal valve opens from the ileum.

The vermiform appendix (meaning 'worm-like', and often known simply as 'the appendix') is a fine
tube, closed at one end, which leads from the caecum. It is about 8-9 cm long and has the same
structure as the walls of the large intestine but contains more lymphoid tissue. The appendix has no
digestive function but can cause significant problems when it
becomes inflamed.

Colon The colon has four parts, which have the same
structure and functions:

• The ascending colon passes upwards from the caecum to

the level of the liver, where it curves acutely to the left at the
hepatic flexure to become the transverse colon.

• The transverse colon extends across the abdominal cavity

in front of the duodenum and the stomach to the area of the
spleen. where it forms the splenic flexure and curves acutely
downwards to become the descending colon.

• The descending colon passes down the left side of the abdominal cavity, then curves towards the
midline. At the level of the iliac crest it is known as the sigmoid colon.

• The sigmoid colon is an S-Shaped curve in the pelvic cavity that continues downwards to become
the rectum.

Rectum This is a slightly dilated section of the large intestine and is about 13 cm long. It leads from
the sigmoid colon and terminates in the anal canal.

Anal canal This is a short passage about 3.8 cm long in the adult and leads from the rectum to the
exterior. Two muscular sphincters control the anus: the internal sphincter, consisting of smooth
muscle, is under the control of the autonomic nervous system, and the external sphincter, formed
by skeletal muscle, is under voluntary control.

Structure The four layers of tissue described in the bask structure of the gastrointestinal tract
are present in the caecum. colon, rectum and anal canal.
Blood supply
Arterial supply This is mainly by the superior and inferior mesenteric arteries. The superior
mesenteric artery supplies the caecum, ascending colon and most of the transverse colon. The
inferior mesenteric artery supplies the remainder of the colon and the proximal part of the rectum.
The middle and inferior rectal arteries, branches of the internal iliac arteries, supply the distal
section of the rectum and the anus.

Venous drainage This is mainly by the superior and inferior mesenteric veins which drain blood
from the parts supplied by arteries of the same names. These veins join the splenic and gastric veins
to form the portal vein. Veins draining the distal part of the rectum and the anus join the internal
iliac veins, meaning that blood from this region returns directly to the inferior vena cava. bypassing
the liver and portal circulation.

Functions
Absorption The contents of the ileum that pass through the ileocaecal valve into the caecum are
still fluid, even though a large amount of water has been absorbed in the small intestine. In the large
intestine, absorption of water, by osmosis, continues until the familiar semisolid consistency of
faeces is achieved. Mineral salts, vitamins and some drugs are also absorbed into blood capillaries
from the large intestine.

Microbial activity The large intestine is heavily colonised by certain types of bacteria, which
synthesise vitamin K and folic acid. They include Escherichia coli, Enterobacter aerogenes,
Streptococcus faecalis and Clostridium perfringens. These microbes are normally harmless in
humans. However, they may become pathogenic if transferred to another part of the body; for
example, E. coli may cause cystitis if it gains access to the urinary bladder.

Gases in the bowel consist of some of the constituents of air, mainly nitrogen, swallowed with food
and drink. Hydrogen, carbon dioxide and methane are produced by bacterial fermentation of
unabsorbed nutrients, especially carbohydrate. Gases pass out of the bowel as flatus (wind).

Mass movement The large intestine does not exhibit peristaltic movement as do other parts of
the digestive tract. Only at fairly long intervals (4-6 times a day in adults) a wave of strong peristalsis
sweeps along the transverse colon, forcing its contents into the descending and sigmoid colons. This
is known as mass movement and it is often precipitated by the entry of food into the stomach. This
combination of stimulus and response is called the gastro-colic reflex.

Defaecation The rectum is usually empty, but when a mass movement forces the contents of the
sigmoid colon into the rectum the nerve endings in its walls are stimulated by stretch. In infants,
defaecation occurs by reflex (involuntary) action. However, during the second or third year of life,
children develop voluntary control of bowel function. In practical terms, this acquired voluntary
control means that the brain can inhibit the reflex until it is convenient to defaecate. The external
anal sphincter is under conscious control through the pudendal nerve. Thus, defaecation involves
involuntary contraction of the muscle of the rectum and relaxation of the internal anal sphincter.
Contraction of the abdominal muscles and lowering of the diaphragm during a forced expiration
(Valsalva's manoeuvre) increase the intra-abdominal pressure and so assist defaecation. When the
need to pass faeces is voluntarily postponed, it tends to fade until the next mass movement occurs
and the reflex is initiated again. Repeated suppression of the reflex may lead to constipation (hard
faeces) as more water is absorbed.

Constituents of faeces The faeces consist of a semisolid brown mass. The brown colour is due
to the presence of stercobilin. Even though absorption of water takes place in the small and large
intestines, water still makes up about 60-70% of the weight of the faeces. The remainder consists of:
• fibre (indigestible cellular plant and animal material)

• dead and live microbes

• epithelial cells shed from the walls of the tract

• fatty adds

• mucus secreted by the epithelial lining of the large intestine.

Mucus helps to lubricate the faeces, and an adequate amount of dietary fibre, mainly non-starch
polysaccharides (NSPs) and commonly known as 'roughage', ensures that the contents of the large
intestine are sufficiently bulky to stimulate defaecation.

Pancreas
The pancreas is a creamy pink gland weighing about 60 g. It is about 12-15 cm long and is situated in
the epigastric and left hypochondriac regions of the abdominal cavity. It consists of a broad head, a
body and a narrow tail.

The head lies in the curve of the duodenum, the body behind the stomach. and the tail in front of
the left kidney, just reaching the spleen. The abdominal aorta and the inferior vena cava lie behind
the gland.

The pancreas is both an exocrine and an endocrine gland.

Exocrine pancreas This consists of a large number of lobules made up of small acini, the walls of
which are composed of secretory cells. Each lobule is drained by a tiny duct and these eventually
unite to form the pancreatic duct which extends along the whole length of the gland and opens into
the duodenum. Just before entering the duodenum the
pancreatic duct joins the common bile duct to form the
hepatopancraeatic ampulla. The duodenal opening of
the ampulla is controlled by the hepatopancreatic
sphincter (of Oddi) at the duodenal papilla.

The function of the exocrine pancreas is to produce

pancreatic juice containing enzymes, some in the form
of inactive precursors, which digest carbohydrates,
proteins and fats. As in the alimentary tract,
parasympathetic stimulation increases the secretion of
pancreatic juice and sympathetic stimulation depresses
it.

Endocrine pancreas Distributed throughout the

gland, in close proximity to the capillary networks, are groups of specialised cells called the
pancreatic islets (of Langerhans). The islets have no ducts, so the hormones diffuse directly into the
blood. The endocrine pancreas secretes the hormones insulin and glucagon, which are principally
concerned with control of blood glucose levels.

Blood supply The splenic and mesenteric arteries supply the pancreas, and venous drainage is by
veins of the same names that join other veins to form the portal vein.

Liver
The liver is the largest gland in the body; it is reddish brown in colour and weighs between 1 and 2.3
kg. Situated in the upper part of the abdominal cavity, it occupies the greater part of the right
hypochondriac region and part of the epigastric region. and extends into the left hypochondriac
region. Its upper and anterior surfaces are smooth and curved to fit the under-surface of the
diaphragm, its posterior surface is irregular in outline.

Organs associated with the liver

Superiorly and anteriorly - diaphragm and anterior abdominal wall.

Inferiorly – stomach, bile ducts, duodenum, hepatic flexure

of the colon. right kidney and adrenal gland.

Posteriorly- oesophagus, inferior vena cava, aorta, gall

bladder, vertebral column and diaphragm.

Laterally- lower ribs and diaphragm.

The liver has four lobes. The two most obvious are the large
right lobe and the smaller, wedge-Shaped left lobe. The
other two, the caudate and quadrate lobes, are areas on
the posterior surface.

Portal fissure This is the name given to the region on the

posterior surface of the liver where various structures enter
and leave the gland:

• The portal vein enters, carrying blood from the stomach.

spleen, pancreas and small and large intestines.

• The hepatic artery enters, carrying arterial blood. It is a

branch from the coeliac artery, which branches from the
abdominal aorta.

• Nerve fibres, sympathetic and parasympathetic. enter

here.

• The right and left hepatic ducts leave, carrying bile from the liver to the gall bladder.

• Lymph vessels leave the liver, draining lymph to abdominal and thoracic nodes.

Blood supply The hepatic artery and the portal vein take blood to the liver.
Venous return is by a variable number of hepatic veins that leave the posterior surface and
immediately enter the inferior vena cava just below the diaphragm.
Structure
The lobes of the liver are made up of tiny functional units,
called lobules, which are just visible to the naked eye. Liver
lobules are hexagonal in outline and are formed by cuboidal
cells, the hepatocytes, arranged in pairs of columns radiating
from a central vein. Between two pairs of columns of cells are
sinusoids (blood vessels with incomplete walls) containing a
mixture of blood from the tiny branches of the portal vein and
hepatic artery.

This arrangement allows the arterial blood and portal venous

blood (with a high concentration of nutrients) to mix and
come into close contact with the liver cells. Among the cells
lining the sinusoids are hepatic macrophages (Kupffer cells),
whose function is to ingest and destroy worn-out blood cells and any foreign particles present in the
blood flowing through the liver.

Functions
The liver is extremely active metabolically, with multiple interrelated functions, including
metabolism of key nutrients, synthesis of many vital proteins, detoxification of unwanted chemicals
and production of bile.

Carbohydrate metabolism The liver has an important role in maintaining plasma glucose
levels. After a meal, when levels rise, glucose is converted to glycogen for storage under the
influence of the hormone insulin. Later, when glucose levels fall, the hormone glucagon stimulates
conversion of glycogen into glucose again, keeping levels within the normal range.

Fat metabolism Stored fat can be converted to a form in which it can be used by the tissues to
provide energy.

Protein metabolism
Deamination at amino acids This process:

• removes the nitrogenous portion from excess amino acids; urea is formed from this nitrogenous
portion and is excreted in urine

• breaks down nucleic acids (genetic material e.g. DNA) to form uric acid, which is excreted in the
urine.

Transamination This process removes the nitrogenous portion of amino acids and attaches it to
other carbohydrate molecules, forming new non-essential amino acids.

Synthesis of plasma proteins The liver produces 90% of the plasma proteins contained in the
bloodstream. including albumins, globulins and blood clotting factors.
Breakdown of erythrocytes and defence against microbes These processes are carried out by
phagocytic hepatic macrophages (Kupffer cells) in the sinusoids, although breakdown of red blood
cells also takes place in the spleen.

Detoxification of drugs and toxic substances These include ethanol (alcohol), waste products and
microbial toxins. Some drugs are extensively inactivated by the liver and are therefore not very
effective when given by mouth (orally), e.g. glyceryl trinitrate.

Inactivation of hormones These include insulin, glucagon, cortisol, aldosterone, thyroid and sex
hormones.

Production of heat The liver uses a considerable amount of energy, has a high metabolic rate and
consequently produces a great deal of heat. It is the main heat-producing organ of the body.

Secretion of bile The hepatocytes synthesise the constituents of bile from the mixed arterial and
venous blood in the sinusoids. These include bile salts, bile pigments and cholesterol.

Storage Stored substances include:

• glycogen

• fat-soluble vitamins: A, D, E, K

• iron, copper

• some water--soluble vitamins, e.g. vitamin B12.

Composition of bile Between 500 and 1000 mL of bile is secreted by the liver daily. Bile
consists of:

• water • mineral salts • mucus • bile pigments, mainly bilirubin • bile salts • cholesterol

Functions of bile
Fat digestion The bile acids, cholic and
chenodeoxycholic add, are synthesised by hepatocytes
from cholesterol. then secreted into bile as sodium or
potassium salts. In the small intestine they emulsify
fats by dispersing them into tiny droplets, thus aiding
their digestion by lipases. Fatty acids are insoluble in
water, which makes them very difficult to absorb
through the intestinal wall. Bile salts make cholesterol
and fatty acids more water-soluble, enabling both
these and the fat-soluble vitamins (vitamins A, D, E
and K) to be readily absorbed. In the terminal ileum
most of the bile salts are reabsorbed and return to the
liver in the portal vein. This enterohepatic circulation
recycles bile salts, ensuring that large amounts of bile
salts enter the small intestine daily from a relatively
small bile acid pool.

Excretion of bilirubin Bilirubin is one of the products

of haemolysis of erythrocytes by macrophages.
Bilirubin is insoluble in water and is carried in the blood bound to the plasma protein albumin. It is
conjugated (combined) with glucuronic acid by hepatocytes in the liver and becomes water-soluble
enough to be excreted in bile. Microbes in the large intestine convert bilirubin into stercobilin, which
is excreted in the faeces. Stercobilin colours and deodorises the faeces. A small amount is
reabsorbed and excreted in urine as urobilinogen. Jaundice is yellow pigmentation of the tissues,
seen in the skin and conjunctiva, caused by excess blood bilirubin.

Bile ducts The right and left hepatic ducts join to form the common hepatic duct just outside
the portal fissure. The hepatic duct passes downwards for about 3 cm and is then joined by the
cystic duct from the gall bladder. The cystic and hepatic ducts merge, forming the common bile duct,
which passes downwards behind the head of the pancreas. The common bile duct is joined by the
main pancreatic duct at the hepatopancreatic ampulla. It opens into the duodenum at the duodenal
papilla, which is controlled by the hepatopancreatic sphincter (of Oddi). The common bile duct is
about 7.5 cm long and has a diameter of about 6mm.

Structure The walls of the bile ducts have the same layers of tissue as those of the basic structure
of the alimentary canal (see Fig. 12.2). In the cystic duct the mucous membrane lining is arranged in
irregular circular folds, which have the effect of a spiral valve. Bile passes through the cystic duct
twice: once on its way into the gall bladder, and again when it is expelled from the gall bladder into
the common bile duct and then on to the duodenum.

Gall bladder
The gall bladder is a pear-shaped sac attached to the posterior surface of the liver by connective
tissue. It has a fundus or expanded end, a body or main part, and a neck, which is continuous with
the cystic duct.

Structure The wall of the gall bladder has the same layers of tissue as those of the basic structure
of the alimentary canal, with some modifications.

Peritoneum This covers only the inferior surface because the upper surface of the gall bladder is in
direct contact with the liver and held in place by the visceral peritoneum that covers the liver.

Muscle Layer There is an additional layer of oblique muscle fibres.

Mucous membrane This displays small rugae when the gall bladder is empty; these then disappear
when it becomes distended with bile.

Blood supply The cystic artery, a branch of the hepatic artery, supplies the gall bladder. Blood is
drained away by the cystic vein, which joins the portal vein.

Functions These include:

• storage of bile

• concentration of the bile by up to 10-or 15-fold, by absorption of water through the walls of the
gall bladder

• release of stored bile.

When the muscle wall of the gall bladder contracts, bile is expelled into the bile ducts and then
enters the duodenum. Contraction is stimulated by the hormone CCK secreted by the duodenum,
and by the presence of fat and acid chyme in the duodenum. Relaxation of the hepatopancreatic
sphincter (of Oddi) is caused by CCK and is a reflex response to contraction of the gall bladder.

Summary of digestion and absorption of

nutrients:

Metabolism: Metabolism constitutes all the chemical reactions that occur in the body to
provide the chemical energy essential for all cellular activities.

catabolism Catabolic processes break down large molecules into smaller ones, releasing chemical
energy, which is stored as adenosine triphosphate (ATP), and heat. The heat generated maintains
core body temperature at the optimum level for chemical activity (36.8°C). Excess heat is lost, mainly
through the skin.

Anabolism This is building up, or synthesis, of large molecules from smaller ones and requires a
source of energy, usually ATP.

Energy All body cells require energy to carry out their metabolic processes, including multiplication
for replacement of worn-out cells, muscle contraction and synthesis of glandular secretions. The
energy produced in the body may be measured and expressed in units of work (joules) or units of
heat (kilocalories).

A kilocalorie (kcal) is the amount of heat required to raise the temperature of 1 litre of water by 1
degree Celsius (1 °C).

The nutritional value of carbohydrates, protein and fats eaten in the diet may be expressed in either
kJ per gram or kcal per gram.

1 g of carbohydrate provides 17 kJ (4 kcal)

1 g of protein provides 17 kJ (4 kcal)

1 g of fat provides 38 kJ (9 kcal)

Energy balance is important as it determines changes in body weight. Body weight remains constant,
when energy intake is equal to energy use. When intake exceeds requirement body weight
increases, which, when continual, will lead to obesity. Conversely, body weight decreases when
nutrient intake does not meet energy requirements.

Metabolic rate
The metabolic rate is the rate at which energy is released from the fuel molecules inside cells. As
most of the processes involved require oxygen and produce carbon dioxide as waste, the metabolic
rate can be estimated by measuring oxygen
uptake or carbon dioxide excretion.

The basal metabolic rate (BMR) is the rate of

metabolism when the individual is at rest in a
warm environment and is in the post
absorptive state, (i.e. has not had a meal for
at least 12 hours). In this state the release of
energy is sufficient to meet only the essential
(basal) needs of vital organs, such as the
heart, lungs, nervous system and kidneys.

Anabolism and catabolism usually involve a series of chemical reactions, known as metabolic
pathways. These are linked sequences of 'small steps' that permit controlled, efficient and gradual
transfer of energy from ATP rather than large intracellular 'explosions'. Metabolic pathways are
switched on and off by hormones, providing fine control of metabolism and meeting individual
requirements. Both catabolic and anabolic processes occur continually in all cells. Very active tissues,
such as muscle and liver, need a large energy supply to support their metabolic requirements.

Central metabolic pathways

Much of the metabolic effort of cells is concerned with energy production to fuel cellular activities.
Certain common pathways are central to this function. Fuel molecules enter these central energy-
producing pathways and in a series of steps, during which a series of intermediate molecules are
formed and energy is released, these fuel molecules are chemically broken down. The end results of
these processes are production of energy, carbon dioxide and water (called metabolic water). Much
of the energy is stored as ATP, although some is lost as heat. The carbon dioxide is excreted through
the lungs and excess water excreted in urine.

The preferred fuel molecule is glucose but alternatives, should glucose be unavailable, include amino
acids, fatty acids, glycerol and occasionally nucleic adds. Each of these may enter the central energy
producing pathways and be converted to energy, carbon dioxide and water. There are three central
metabolic pathways

• glycolysis

• the citric acid (Krebs) cycle

• oxidative phosphorylation.

Products from glycolysis enter the citric acid cycle, and products from the citric acid cycle proceed to
oxidative phosphorylation.

Prepared from: ROSS & WILSON, Anatomy &

Physiology (13th edition)

Prepared by: NURSING PATHSHALA MENTOR