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GIT Motility -

Medicine (Queen's University Belfast)

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GIT MOTILITY

1. MOUTH AND OESOPHAGUS

Chewing is essentially a voluntary activity involving skeletal muscle of the mouth and jaw,
although there is a reflex component.
 Intra-oral pressure due to the presence of food causes reflex inhibition of the
muscles of mastication
 leading to jaw drop,
 activation of the stretch reflex
 and rebound contraction
 thus aiding repetitive opening and closing of the mouth.
Mastication has 3 main functions: (1) to prevent airway obstruction by large lumps of food;
(2) mixing with saliva for lubrication and digestion; (3) to increase the surface area for
exposure to GI secretions.
The process of chewing is
co-ordinated by the
motor branch of the
trigeminal nerve and
brain stem nuclei.

Swallowing is dependent
on co-ordination by the
swallowing centre in the
medulla. There are 3
stages: oral, pharyngeal
and oesophageal. After
the oral phase swallowing
becomes an automatic
process.
 Stimulation of pharyngeal mechanoreceptors around the opening activates the brain
stem via sensory afferents of mainly the glossopharyngeal nerve.
 The early events of swallowing are geared to protecting the respiratory tract: the
main mechanism is approximation of the vocal cords with closure of the epiglottis
acting as a safeguard.
 Movement of the larynx enlarges the oesophageal opening, the sphincter relaxes
and a propulsive wave of contraction (peristalsis) is initiated by the vagus nerve.
 The pharyngeal stage last < 6 seconds so does not interrupt respiration.
 The peristaltic wave continues into the oesophagus (primary peristalsis) and is aided
by gravity.
 If this is inadequate to propel food into the stomach, then secondary peristalsis is
initiated by the myenteric plexus.
 Motor pathways involve both somatic (glossopharyngeal) and parasympathetic
(vagus) nerves since the upper oesophagus is striated (voluntary) muscle while the
lower oesophagus is smooth (involuntary) muscle.

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 When the peristaltic wave approaches the stomach myenteric inhibitory nerves
cause relaxation of the lower oesophageal sphincter and stomach (receptive
relaxation).

2. STOMACH

The stomach serves 3 functions:

 storage of food after meals, which is assisted by receptive relaxation via the
vagovagal reflex;
 mixing, which is mediated by slow spontaneous rhythmic contractions (controlled by
the myenteric nervous system) spreading from the body to antrum where they are
strongest. The pyloric sphincter remains constricted forcing the bulk of the stomach
contents backwards;
 mixing with gastric secretions produces semi-liquid chyme which is propelled into
the duodenum in regular amounts, depending on the degree of sphincter
constriction . Although external nerves are not necessary for spontaneous activity,
the rate of gastric contraction/emptying can be modified by neurohumoral reflexes.

Food in the stomach initiates regular peristaltic waves at a rate of 3-4 per minute. This
spontaneous activity occurs in 2 forms:
 slow waves, which are due to undulating changes in resting membrane potential.
There is growing evidence that slow waves may be mediated by specialised cells
known as interstitial cells of Cajal, acting as the electrical pacemaker;
 spike potentials are true actions potentials which occur when resting membrane
potential reaches threshold (~ -40 mV). The current is carried by sodium and calcium,
and their frequency progressively increases from the fundus to antrum and may be
influenced by both stretch and acetylcholine in a positive manner, whilst being
inhibited by noradrenaline. The frequency of spike potentials is so high at the pylorus
that it results in tonic constriction of the sphincter, thus regulating emptying.

The rate of gastric emptying is not regulated by increased pressure within the stomach,
rather the balance between strength of antral contractions and the degree of pyloric
resistance, which are controlled by neurohumoral factors.
Receptors in the duodenum and jejunum sense various factors, including acid, fat digestion
products, hyperosmotic chyme and amino acids, stimulating release of hormones, such as
secretin, cholecystokinin, GIP and gastrin, which decrease gastric emptying.
Similarly central sympathetic
stimulation can decrease gastric
emptying, whereas it is
increased by parasympathetic
activation.

Vomiting results in expulsion of the

gastric contents from the mouth,
and involves a complex set of motor
functions co-ordinated by the
vomiting centre in the medulla.

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Vomiting is usually associated with nausea and is preceded by sweating, pallor and elevated
heart rate, due to increased sympathetic activity. The vomiting centre receives various
afferent inputs. It should be noted that the propulsive force is generated by an increase in
abdominal pressure which compresses the flaccid stomach, with little contribution from
gastric contraction. Loss of NaCl, H2O and H+ may lead to dehydration and metabolic
alkalosis may result.

3. Small intestine

The small intestine is comprised of the duodenum, jejunum and ileum. The majority of
digestion and absorption occurs within the proximal 50 %. Spontaneous activity of intestinal
smooth muscle leads to 3 types of movement:
 segmentation contractions, which are responsible for mixing of the intestinal
contents;
 peristalsis, which propels chyme along the intestine;
 migratory motility complex, which stimulates mass clearance of the intestine.

Segmentation contractions are the dominant type of motility and are initiated by stretch.
They occur in different patterns, but typically as one set of contractions disappears another
set is generated between the previous contractions resulting in a chopping/mixing action.

The frequency of contraction decreases from the duodenum (12 per minute) to ileum (9 per
minute), which is dictated by slow waves, favouring slow movement in that direction.

Spike potentials are required for effective contractions and the force (not frequency) of
activity may be increased by parasympathetic stimulation and the gastroenteric reflex,
which may be mediated by gastrin and cholecystokinin.

Sympathetic stimulation decreases the force of activity.

 Localised peristalsis is mainly initiated by distension, which results in contraction
proximal to the point of stimulation.
 This sets up a peristaltic wave which travels a small distance along the intestine
before dying out, only to start up again more distally.
 This helps to slowly propel the intestinal contents towards the caecum and to
distribute the chyme for digestion and absorption.
 Unidirectional tranmission of the peristaltic wave is aided by receptive relaxation,
the mechanism for which is unknown.
 This type of motility is mediated by the myenteric plexus and the gastroenteric
reflex.
 Several hours post-prandially, when absorption is essentially complete, a much more
powerful propulsive wave occurs, known as the migratory motility complex.
 This is initiated in the stomach by intense bursts of vagal activity due to the release
of motilin, and causes forceful contraction towards the ileum.
 The effect is to sweep the intestinal residue into the colon via the ileocaecal valve,
thus inhibiting migration of colonic bacteria and limiting bacterial overgrowth.
 This only occurs in the fasted state and is suppressed by eating, with a return to
segmentation.

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Emptying of the small intestine is controlled by the ileocaecal valve, which protrudes into
the colon. It’s principal function is to prevent backflow of faecal contents and is closed by
excessive pressure in the colon. The narrow opening provides resistance to emptying of the
ileum, and allows chyme to pass into the colon at a rate at which it can be absorbed.
Opening of the ileocaecal valve may be promoted by local peristalsis and the gastrocolic
reflex after a meal and inhibited by pressure and chemical irritation in the colon, such as
that causes by inflammation of the appendix.

4. Large intestine

The functions of the colon are twofold:

 absorption of water and electrolytes in the proximal portion;
 storage of faecal matter in the distal portion.

Movements in the large intestine are much slower than in the small intestine, typically
taking 8-15 hours, allowing stasis and bacterial overgrowth. However, the pattern is similar.

Sustained slow segmentation contractions occur at a rate of 2-4 per hour, due to stimulation
of the circular muscles and teniae coli, resulting in characteristic haustrations. This type of
activity facilitates mixing of the colon contents with minor forward propulsion and favours
reabsorption by gradual exposure to the mucosa - <200 mL faeces are usually produced per
day. Segmentation contractions are increased by parasympathetic stimulation and
decreased by sympathetic activity.

One to three times per day the colon undergoes sustained contraction of the circular
muscle, known as a mass movement, often occurring immediately after eating. This
is a modified form of peristalsis and may be mediated by increased parasympathetic activity
and the gastrocolic reflex, due to release of gastrin and cholecystokinin.

Mass movements may last for ~30 seconds, sustained circular contraction results in distal
relaxation and loss of haustrations, promoting rapid forward propulsion. The rectum is
normally empty due to a weak sphincter and sharp angulation at the end of the sigmoid
colon. Mass movements result in distension of the rectum and sensory activation of the
myenteric plexus, which accentuates contraction of the sigmoid colon, causes reflex
relaxation of the internal anal sphincter and initiates the defecation reflex.

This reflex response is relatively weak and is fortified by parasympathetic output from the
sacral segments of the spinal cord. Rectal distension also gives rise to a conscious urge to
defecate but if inappropriate, it can be overridden by contraction of the striated muscle in
the external anal sphincter via the pudendal nerve. After a time colonic contraction and
rectal distension dissipate, as does the urge to defecate, until the next mass movement.
When appropriate, the external anal sphincter is allowed to remain in its resting, relaxed
state and the defecation reflex proceeds, which is often assisted by conscious effort.

Diarrhoea is an increased frequency of defecation which functions primarily to clear the gut
of debilitating bacteria. It can occur due to:

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 infection which causes increased bowel motility in response to inflammation e.g.

enteritis;
 malabsorption of nutrient molecules leading to osmotic retention of fluid in the
intestine;
 excess secretion by intestinal mucosa e.g. in response to bacterial toxins;
 emotional factors leading to increased parasympathetic stimulation.

In contrast to vomiting there is no central control. Diarrhoea results in dehydration with loss
of K+ and HCO3 (both of which are secreted in the colon), resulting in hypokalaemia and
metabolic acidosis.

Vomiting or diarrhoea are normally treated by food cessation and H2O replacement
supplemented with NaCl (water absorbed with Na+) and sucrose (Na+) mainly absorbed as
part of the nutrient co-transport process). In extreme cases, drugs which decrease
gut motility and intravenous fluids may be used.

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