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PHYSIOLOGY, GASTROINTESTINAL

Physiology, Gastrointestinal
Article Author:
Ifeanyichukwu Ogobuiro
Article Author:
Justin Gonzales
Article Editor:
Faiz Tuma
Updated:
4/16/2020 6:59:15 PM
PubMed Link:
Physiology, Gastrointestinal

Introduction
The digestive system comprises the gastrointestinal tract and accessory organs. The
gastrointestinal tract consists of the oral cavity, pharynx, esophagus, stomach, small intestine,
and large intestine. The accessory organs are the teeth, tongue, and the glandular organs such
as salivary gland, liver, gallbladder, and pancreas.
The digestive system functions to provide mechanical processing, digestion, absorption of food,
secretion of water, acids, enzymes, buffer, and salt, as well as excretion of waste products.

Function
The function of the digestive system is to digest and absorb food and then excrete the waste
products with the help of the liver, gallbladder, pancreas, small intestine, large intestine, and
rectum. Each of these organs plays a specific role in the digestive system.
The oral cavity functions to provide:

• sensory analysis of food material before swallowing

• mechanical processing via the action of the teeth, tongue, and palatal surfaces
• lubrication by mixing food material with mucus and salivary gland secretion
• limited digestion of carbohydrates and lipids

Starting with the oral mucosa, which is lined by both keratinized (seen in the superior surface of
the tongue and the hard palate) and nonkeratinized squamous epithelial cells (seen in cheeks,
lips, and inferior surface of the tongue), these cells are not known to absorb molecules except
for the mucosa inferior to the tongue.
Functions of the tongue include mechanical processing by compression, abrasion, and
distortion; manipulation to assist in chewing and prepare material for swallowing; sensory
analysis by touch, temperature, and taste receptors; and secretion of mucins and lingual lipase.
The lingual lipase has a broad pH and breaks down lipids (mainly triglyceride). The pH of 3.5 - 6
allows lingual lipase to work even in the acid environment of the stomach.[1]
Within the oral cavity, there are three pairs of salivary glands. The first pair is the parotid salivary
glands located inferior to the zygomatic arch and posterolateral to the mandible. The parotid
glands produce serous secretions containing a large amount of salivary amylase, which breaks
down carbohydrate complexes. Next are the sublingual salivary glands located at the floor of the
mouth. The sublingual glands produce a mucous secretion that serves as both a buffer and
lubricant. The third is the submandibular salivary glands, located at the floor of the mouth within
the mandibular groove. They function by secreting a mixture of buffers, glycoproteins called
mucins, and salivary amylase.
Altogether, these glands produce 1.0 - 1.5 liters of saliva each day[2] Close to 99.4% of the
saliva produced is water, and the remaining 0.6% consists of electrolytes, buffers, glycoproteins
(mucins), antibodies, enzymes, and waste products. These function to lubricate the mouth to
prevent friction between the mucosa of the oral cavity and the food material; moisten the food
material for easy swallowing process; and initiation of lipid and carbohydrate complex digestion.
The teeth provide a mechanical breakdown of food materials; for instance, the connective tissue
of meat and plant fibers in vegetables. This process also saturates the salivary secretions and
enzymes within the food material for better digestion.
The pharynx serves as a passageway of food material to the esophagus although it also has a
respiratory function for air movement into the lung. During swallowing, closure of nasopharynx
and larynx occur to maintain proper direction of food. This process is achieved by cranial nerves
IX and X. From the pharynx, food material goes to the esophagus.
The esophagus's primary function is to empty food materials into the stomach via waves of
contraction of its longitudinal and circular muscle known as peristalsis. The upper one-third of
the esophagus is predominantly skeletal muscle. The middle one-third is a mixture of both the
skeletal muscle and smooth muscle. The lower one-third is mainly smooth muscle. However,
during the act of deglutition, the buccal phase is the only voluntary phase where one can still
control the swallowing process. The skeletal muscles found in the pharynx and upper esophagus
are all under the control of the swallow reflex; hence the pharyngeal and esophageal phase of
swallowing are under involuntary control with the help of afferent and efferent fibers of
glossopharyngeal and vagus nerves. The smooth muscles of the esophagus are arranged in a
circular and longitudinal fashion and aid in peristaltic movement during swallowing.[3][4]
Once the food material arrives in the stomach, it can be temporarily stored and mechanically and
chemically broken down by the actions of stomach acids and enzymes. The secretion of intrinsic
factor produced by the stomach helps with proper absorption of B12.[5] The ability of the
stomach to store food stems from its compliance and ability to change size. On average, the
lesser curvature of the stomach has a length of approximately 10cm and the larger curvature has
a length of approximately 40cm. The stomach typically spans from vertebrae T7 and L3 giving it
the ultimate ability to hold on to a large amount of food.
The stomach's function in breaking down food materials mechanically is due to its sophisticated
muscular dimensions. The stomach has 3 muscular layers: an inner oblique layer, a middle
circular layer, and an external longitudinal layer. The contraction and relaxation of these 3
muscular layers of the stomach assist in the mixing and churning activities essential in the
formation of chyme. Then the chemical breakdown of food material in the stomach
is propagated by the gastric glands produced majorly by the parietal cells, the chief cells, G-
cells, the foveolar cells, and the mucous neck cells. The parietal cells secrete intrinsic factor and
hydrochloric acid. The intrinsic factor produced is essential in the absorption of vitamin B12. It
binds to B12 allowing for proper absorption at the ileum of the small intestine.[6] The
hydrochloric acid produced by the parietal cell keeps the stomach pH between 1.5-2.0. The
acidity of the stomach brought on by hydrochloric acid destroys most of the microorganisms
ingested with food; denatures protein and breaks down plant cell walls; and is essential for the
activation and function of pepsin, a protein-digesting enzyme secreted by chief cells. The chief
cells produce a zymogen called pepsinogen, which gets activated at pH between 1.5-2 to
become pepsin. Pepsin is a protein digesting enzyme. The foveolar cells and mucous neck cells
produces mucous, which protects the gastric epithelium from acidic corrosion[7]. The G cells are
abundant within the pyloric section of the stomach. They produces gastrin which stimulates
secretions from the parietal and chief cells. Within the pyloric section of the stomach, D cells
produces somatostatin, which inhibits the release of gastrin.[8]
The small intestine is the next location where digestion take place. But unlike the stomach, which
has minor absorptive property, 90% of food absorption occurs in the small intestine. The small
intestine has three segments: the duodenum, the jejunum, and the ileum. The duodenum
receives chyme from the stomach as well as digestive material from the pancreas and the liver.
The jejunum is where the bulk of chemical digestion and absorption occur. The ileum also has
digestion and absorption function. The ileum is the last segment of the small intestine and has
the ileocecal valve, a sphincter that controls the flow of material from the ileum to the cecum of
the large intestine. The mucosa of the small intestine has villi and each villus has multiple
microvilli; thereby increasing the surface area exponentially for optimal absorption.[9] There are
extensive networks of capillaries within the villi that carry absorbed nutrients to the hepatic portal
circulation. Also, there is a vast quantity of lymphatic capillaries called lacteals that aid in
chylomicron transportation to the venous circulation.
The intestine has both endocrine and exocrine glands that produce hormones, enzymes, and
alkaline mucinous material. The hormones released by the small intestine include[10][11]:

• Gastrin produced by G-cells in the upper small intestine (but mostly found in the stomach)
• Cholecystokinin (CCK) produced by I-cells in the upper small intestine;
• secretin produced by the S-cells in the upper small intestine in response to decreased
upper intestine pH;
• Gastric inhibitory peptide (GIP) produced by K-cells in the upper small intestine in
response to fat, amino acids, and glucose
• Pro-glucagon produced by the L-cells in distal ileum and colon in response to glucose
and fat
• Somatostatin produced by D-cells in the small intestine including stomach and pancreas
• Vasoactive intestinal polypeptide (VIP) produced by parasympathetic ganglia in the small
intestine in response to distention
• Motilin produced by M-cells in the upper small intestine

The enzymes produced by the small intestine include lipase for fats digestion; peptidase for
peptide breakdown; sucrase, maltase, and lactase for sucrose, maltose, and lactose breakdown
respectively. Then there are the Brunner glands mostly found in the duodenum that produce
bicarbonate for acid neutralization.[12]
Within the duodenum of the small intestine, accessory digestive organs such as the liver and the
pancreas release digestive secretions. The liver is the largest internal organ and the largest gland
in the human body. It has numerous functions; but as an accessory organ of the digestive
system, it produces bile which emulsifies fats and various kinds of lipids for optimal digestion.
Bile produced in the liver is stored in the gallbladder. The gallbladder contracts to release bile
into the duodenum when fat containing food is present.[13] The pancreas also has exocrine
glands that are essential for the food digestion process. The exocrine glands of the pancreas
produce multiple enzyme precursors and enzymes which includes trypsinogen,
chymotrypsinogen, and procarboxypeptidase which are activated by enteropeptidase in the
small intestine; active alpha amylase; lipases and colipase which act on triglycerides and
phospholipids; and several other enzymes like ribonuclease, elastase and collagenase.[14]
The unabsorbed and undigested food material progresses to the large intestine. At this point, it
is called feces. The large intestine is about 6 feet long and starts with the cecum, ascending
colon, transverse colon, descending colon, and sigmoid colon. The large intestine absorbs water
and electrolytes.[15][16] Also, due to the trillions of microbes that live in the large intestine, these
organisms can break down the undigested food material. In addition, nutrients such as vitamin K
are produced and absorbed in the large intestine.[17] Peristaltic movement of the large intestine
move the feces into the rectum. In the rectum, there are stretch receptors that signal for the
defecation process to start which includes a reflexive relaxation of internal anal sphincter smooth
muscle and conscious relaxation of the external anal sphincter skeletal muscle.[18]

Clinical Significance
The diseases of the gastrointestinal system are numerous, involving the mouth to the anal canal.
In the mouth, there are salivary gland tumors such as pleomorphic adenoma, mucoepidermoid
carcinoma, and Warthin tumor that affect proper salivary content and production. Within the
esophagus, there is a wide range of pathologies which include scleroderma esophageal
dysmotility, esophageal strictures, esophagitis, achalasia, and esophageal varices that can affect
the movement of food into the stomach. In the stomach, there is gastritis that can have an acute
onset caused by NSAIDs or mucosal ischemia and gastritis with chronic onset caused by
Helicobacter pylori or autoimmune disease. The small and large bowel can be affected by celiac
disease, tropical sprue, Whipple disease, Crohn disease, and ulcerative colitis, that impact
digestion and absorption of food material. Additionally, congenital diseases such as
Hirschprung, biliary atresia, intestinal atresia, malrotation of the intestine, and pyloric stenosis
occur in infancy and may be life-threatening as adequate nutrients cannot be absorbed.
Within the accessory organs for digestion, there are hereditary hyperbilirubinemia disorders such
as the Gilbert syndrome, Dubin-Johnson syndrome, and Crigler-Najjar syndrome. There are also
diseases like hemochromatosis, Wilson's disease, biliary tract diseases, pancreatitis, and
diseases of the gallbladder such as cholelithiasis, choledocholithiasis, and cholecystitis that
impact the digestive system.
All these diseases warrant proper work-up starting with a thorough history and physical exam.
Obtaining a history of present illness is essential to the diagnosis of the gastrointestinal system
disease and questions on the location and duration of the pain, any radiation or change in
intensity, precipitating factors, associated symptoms such as fever, chills, nausea, vomiting,
changes in bowl habitus and stool color are necessary. Inquiries on any previous episode of
illness or similar illness and also previous surgeries,[19] medication list, and allergies are crucial.
Physical examination starting with inspection is imperative in the workup of gastrointestinal
system diseases. All four quadrants of the abdomen must be inspected to appreciate the general
abdominal contour.[20] This inspection allows for proper identification of surgical scars, bulges,
hemangiomas, and dilated veins of a caput medusa when present. Patients may be asked to
cough to check for abdominal herniation. Next is auscultation which entails listening to the right
upper quadrant for liver rubs and bowel sounds; listening to the left upper quadrant for rubs or
bruits within the splenic region along with bowel sounds, the periumbilical region for aortic or
renal bruit; and the lower left and right quadrant for bowel sounds. The pitch, intensity, and
duration of the sounds heard during auscultation should be appreciated.
Palpation is performed subsequently, starting at the right upper quadrant to outline the size of
the liver and detect any tenderness. The left upper quadrant, periumbilical, left and right lower
quadrants are then palpated to identify any unusual mass and discomfort. Percussion of the
abdomen is conducted to assess liver and spleen size, and any abnormal gas collection. Ascites
assessment is by percussion and examining for shifting abdominal dullness. The rectal exam
includes a thorough inspection of the anal area to identify any skin lesion, scars, fistula
tracts,[21] or external hemorrhoids, and careful palpation of the anal wall to identify any
hypertrophic papillae, inflamed crypts, strictures, and abnormal sphincter tone that might affect
the normal passage of stool.[22]

References
Liao TH,Hamosh P,Hamosh M, Fat digestion by lingual lipase: mechanism of lipolysis in the stomach and upper
[1]
small intestine. Pediatric research. 1984 May [PubMed PMID: 6728567]

Chojnowska S,Baran T,Wilińska I,Sienicka P,Cabaj-Wiater I,Knaś M, Human saliva as a diagnostic material.
[2]
Advances in medical sciences. 2018 Mar [PubMed PMID: 29149764]

Vegesna AK,Chuang KY,Besetty R,Phillips SJ,Braverman AS,Barbe MF,Ruggieri MR,Miller LS, Circular smooth
[3]muscle contributes to esophageal shortening during peristalsis. World journal of gastroenterology. 2012 Aug
28 [PubMed PMID: 22969194]

Nicosia MA,Brasseur JG,Liu JB,Miller LS, Local longitudinal muscle shortening of the human esophagus from
[4]high-frequency ultrasonography. American journal of physiology. Gastrointestinal and liver physiology. 2001
Oct [PubMed PMID: 11557523]

Levine JS,Allen RH, Intrinsic factor within parietal cells of patients with juvenile pernicious anemia. A retrospective
[5]
immunohistochemical study. Gastroenterology. 1985 May [PubMed PMID: 3884427]