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THE DIGESTIVE SYSTEM Food is chemical vital for reactions life because occurring it's in the every Page 92 source cell. of Energy energy is that drives needed for the muscle contraction, the conduction of nerve impulses, and the secretory and absorptive activities of many cells. Food as it is consumed, however, is not in a state suitable for use as an energy source by any cell. The food must be broken down into molecule-sized pieces so that it can be transported through the cell membranes. The breaking down of food molecules for use by body cells is called digestion, and the organs that collectively perform this function comprise the digestive system. The medical specialty that deals with the structure, function, diagnosis, and treatment of diseases of the stomach and intestines is called gastroenterology (gastro m stomach; enteron – intestines). REGULATION OF FOOD INTAKE: Within the hypothalamus are two centers related to food intake. One is a cluster of nerve cells in the lateral nuclei called the feeding (hunger) center. When this area is stimulated in animals, they begin to eat heartily , even if they are already full. The second center is a cluster of neurons in the ventromedial nuclei of the hypothalamus referred to as the satiety center. When this center is stimulated in animals, it causes them to stop eating, even if they have been starved for days. Apparently the feeding center is constantly active, but it is inhibited by the satiety center. Other parts of the brain that assume a function in feeding and satiety are the brain stem, amygdala, and limbic system. When blood glucose levels are low, feeding increases. Conversely, when blood glucose levels are high, feeding is depressed. Low levels of amino acids in the blood also enhance feeding, whereas high levels depress eating. This mechanism, however, is not as powerful as that for glucose. Lipids are also believed to be related to the regulation of food intake. As the amount of adipose tissue increases in the body, the rate of feeding decreases. Another factor that affects food intake is body temperature. A cold environment THE DIGESTIVE SYSTEM enhances eating, while a warm environment Page 93 depresses it. Food intake is also regulated by distension of the gastrointestinal tract, particularly the st omach and duodenum. When these organs are stretched, a reflex is initiated that activates the satiety center and depresses the feeding center. Also the hormone cholecystokinin (CCK), secreted when fat enters the small intestine, inhibits eating. DIGESTIVE PROCESSES: The digestive system prepares food for consumption by the cells through five basic activities. 1. INGESTION: taking food into the body (eating). 2. MOVEMENT of food along the digestive tract. 3. DIGESTION: the breakdown of food by both chemical and mechanical processes. 4. ABSORPTION: the passage of digested food from the digestive tract into the cardiovascular and lymphatic systems for distribution to cells. 5. DEFECATION: the elimination of indigestible substances from the body. Chemical digestion is a series of catabolic reactions that break down the large carbohydrate, lipid, and protein molecules that we eat into molecules usable by body cells. walls of eventually These the products digestive into the of digestion organs, body's into cells. are the small blood Mechanical enough and to pass lymph digestion through the capillaries, and consists of various movements that aid chemical digestion. Food is prepared by the teeth before it can be churn swallowed. the food so Then it the is smooth muscles thoroughly mixed of the with stomach the and enzymes small that intesti ne catalyze the reactions. ORGANIZATION: The organs of digestion are traditionally divided into two main groups. First is the gastrointestinal (GI) _ tract or alimentary canal, a continuous tub running through the ventral body cavity and extending from the mouth to the anus. Organs THE DIGESTIVE SYSTEM Page 94 composing the g a s t r o i n t e s t i n a l tract include the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The GI tract contains the food from the time it is eaten until it is digested and prepared for elimination. Muscular contractions in the wall of the GI tract break down the food physically b y churning i t . Secretions produced by cells along the tract break down the food chemically. The second group of organs composing accessory structures--the teeth, the digestive system consists of the tongue, salivary glands, liver, gallbladder, and pancreas. Teeth protrude into the GI tract and aid in the physical breakdown of food. outside The the other tract accessory and structures, produce or store except for secretions the that tongue, aid in lie the totally chemical breakdown of food. These secretions are released i n t o t h e tract t h r o u g h d u c t s . GENERAL HISTOLOGY: The wall of th e GI tract, especially from the e sophagus to the anal canal, has the same basic arrangement of t is s u e s . The four coats or tunics of th e tract from the inside out are the mucosa, submucosa, musc ularis, and serosa or adventitia. The mucosa, or inner lining of the tract, i s a mucous membrane attached to a thin layer of visceral muscle. Two layers compose the membrane: a lining epithelium, which is in direct contact with the contents of the GI tract, and an underl ying layer of loose connective tissue called th e lamina propria. Under the lamina propria is smooth muscle called the muscularis mucosae. The epithelial layer is composed of nonkeratinized cells that are stratified in the mouth and esophagus, but are simple throughout the rest of the tract, The functions of the s t r a t i f i e d epithelium are protection and secretion. The functions of the simple epithelium are secretion and absorption. The lamina propria is made of loose connective tissue containing many blood and lymph vessels and scattered lymphatic nodules, masses of lymphatic tissue that Page 95 THE DIGESTIVE SYSTEM are not encapsulated. This layer supports the epithelium, binds it to the muscularis mucosae, and provides it with a blood and lymph supply. The blood and lymph vessels are the avenues by which nutrients in the tract reach the other organs of the body. The lymphatic tissue also protects against disease Remember that the GI tract is in contact with the outside environment and contains food that often carries harmful bacteria. Unlike the skin, the mucous membrane of the tract is not protected from bacterial entry by keratin. The muscularis membrane of the mucosae contains intestine into smooth small muscle folds fibers that that increase throw the the mucous digestive and absorptive area. The submucosa consists of loose connective tissue that binds the mucosa to the third tunic, called the muscularis. It is highly vascular and contains a portion of the submucous plex, also known as the plexus of Meissner, or Meissner's plexus, which is part of the autonomic nerve supply to the muscularis mucosae. This plexus is also important in controlling secretions by the GI tract. The muscularis of the mouth, pharynx, and esophagus consists in part of skeletal muscle that produces voluntary swallowing. Throughout the rest of the tract, the muscularis consists of smooth muscle that is generally found in two sheets: an inner ring of circular fibers and an outer sheet of longitudinal fibers. Contractions of the smooth muscles help to break food down physically, mix it with digestive secretions, and propel it through the tract, The muscularis also contains the major nerve supply to the alimentary tract--the myenteric plexus, also known as the plexus of Auerbach or Auerbach's plexus, which consists of fibers from both autonomic divisions. This plexus mostly controls GI motility. The serosa is the outermost layer of most portions of the alimentary canal. It is a serous membrane composed of connective tissue and epithelium. This layer is also called the visceral peritoneum. THE DIGESTIVE SYSTEM Page 96 The peritoneum is the largest serous membrane of the body . Serous membranes are also associated with the heart (pericardium) and lungs (pleurae). Serous membranes consist of a layer of simple squamous epithelium (called mesothelium) and an underlying supporting layer of connective tissue. The parietal peritoneum lines the wall of the abdominal cavity. The visceral peritoneum covers some of the organs and constitutes their serosa. The potential space between the parietal and visceral contains portions serous fluid. of In the peritoneum certain is called diseases, the the peritoneal peritoneal cavity cavity may and become distended by several liters of fluid so that it forms an actual space. Such an accumulation lie on the of serous posterior fluid is abdominal called wall ascites, and are or ascites covered by fluid. Some peritoneum organs on their anterior surfaces only. Such organs, including the kidneys and pancreas, are said to be retroperitoneal. Unlike the pericardium and pleurae, the peritoneum contains large folds that weave in between the viscera. The folds bind the organs to each other and to the walls of the cavity and contain the blood and lymph vessels and the nerves that supply the abdominal organs. One extension of the peritoneum is called the mesentery. It is an outward fold of the serous coat of the small intestine. The tip of the fold is attached to the posterior abdominal wall. The mesentery binds the small intestine to the posterior abdominal wall. A similar fold of parietal peritoneum, called the mesocolon, binds the large intestine to the posterior body wall . It also carries blood vessels and lymphatics to the intestines. Other important peritoneal folds are the falciform ligament, the lesser omentum, and the greater omentum. The falciform ligament attaches the liver to the anterior abdominal wall and diaphragm. The lesser omentum arises as two folds in the serosa of the stomach and duodenum suspending the stomach and duodenum from the liver. The greater omentum is a four-layered fold in the serosa of the stomach that hangs down like an apron over the front of the intestines. It then passes up to part of the large intestine (the transverse colon), wraps itself around it, and finally attaches to the parie tal peritoneum of the posterior wall of the abdominal cavity. Because the greater omentum contains large quantities THE DIGESTIVE SYSTEM Page 97 of adipose tissue, it is commonly called the "fatty apron." The greater omentum contains numerous lymph nodes. If an infection occurs in the intestine, plasma cells formed in the Lymph nodes combat the infection and help prevent it from spreading to the peritoneum. MOUTH (ORAL CAVITY): The mouth, also referred to as the oral, or buccal cavity is formed by the cheeks, hard and soft palates, and tongue. Forming the lateral walls of the oral cavity are the cheeks--muscular structures covered on the outside by skin and lined by nonkeratinized stratified squamous epithelium. The anterior portions of the cheeks terminate in the superior and inferior lips. The lips (labia) are fleshy folds surrounding the orifice of the mouth. They are covered on transition the outside zone where by skin and two kinds the on of the inside covering by a mucous tissue meet membrane. is called The the vermilion. This portion of the lips is nonkeratinized, and the color of the blood in the underlying blood vessels is visible through the transparent surface layer of the vermilion. The inner surface of each lip is attached to its corresponding gum by a midline fold of mucous membrane called the labial frenulum. The orbicularis integumentary oris covering muscle and and the connective internal tissue mucosal lie lining. between During the external chewing, the cheeks and lips help to keep food between the upper and lower teeth. The also assist in speech. The vestibule of the oral cavity is bounded externally by the cheeks and lips and internally by the gums and teeth. The oral cavity proper extends from the vestibule to the fauces, the opening between the oral cavity and the pharynx or throat. Page 98 THE DIGESTIVE SYSTEM The hard palate, the anterior portion of the roof of the mouth, is formed by the maxillae and palatine bones, is covered by mucous membrane, and forms a bony partition between the oral and nasal cavities. The soft palate forms the posterior portion of the roof of the mouth. It is an arch-shaped muscular between the oropharynx and nasopharynx and is lined by mucous membrane. Hanging from the free border of the soft palate is a conical muscular process called the uvula. On either side of the base of the uvula are two muscular folds that run down the lateral side of the soft palate. Anteriorly, the palatoglossal arch (anterior pillar) extends inferiorly, laterally, and anteriorly to the side of the base of the tongue. Posteriorly, the platopharvngeal arch (posterior pillar) projects inferiorly, laterally, and posteriorly to the side of the pharynx. The palatine tonsils are situated between the arches, and the lingual tonsil is situated at the base of the tongue. At the posterior border of the soft palate, the mouth opens into the oropharynx through the fauces. TONGUE: The tongue, together with its associated muscles, forms the floor of the oral cavity. It is an accessory structure of the digestive system composed of skeletal muscle covered with mucous membrane. The tongue is divided into symmetrical lateral halves by a median septum extending through its entire length and the tongue is attached inferiorly to the hyoid bone. Each half of the tongue consists of an identical complement of extrinsic and intrinsic muscles. The extrinsic muscles of the tongue originate outside the tongue and insert into it. The extrinsic muscles move the tongue from side to side and in and out. These movements maneuver food for chewing, shape the food into a rounded mass, called a bolus, and force the food to the back of the mouth for swallowing. They also form the floor of the mouth and hold the tongue in position. The intrinsic muscles originate and insert within the tongue and alter the shape and size of the tongue for speech and swallowing. The lingual frenulum, a fold of mucous membrane in the midline of the undersurface of the tongue, aids in limiting the Page 99 THE DIGESTIVE SYSTEM movement of the tongue posteriorly. If the lingual frenulum is too short, tongue movements are restricted, speech is faulty, and the person is said to be "tonguetied." This congenital problem is referred to as ankyloglossia. It can be corrected by cutting the lingual frenulum. The upper surface and sides of the tongue are covered with papillae, projections of the lamina propria covered with epithelium. Filiform papillae are conical projections distributed in parallel rows over the anterior two-thirds of the tongue. They are whitish and contain no taste buds. Fungiform papillae are mushroornlike elevations distributed among the filiform papillae, and are more numerous near the tip of the tongue. They appear as red dots on the surface of the tongue, and most of them contain taste buds. Circumvallate papillae (least numerous), 10 to 12 in number, are arranged in the form of an inverted V on the posterior surface of the tongue, and all of them contain taste buds. Although the tip of the tongue reacts to all four primary taste sensations, it is highly sensitive to sweet and salty substances. The posterior portion of the tongue is highly sensitive to bitter substances, the lateral edges of the tongue are more sensitive to sour substances. SALIVARY GLANDS: Saliva is a fluid that is continuously secreted by glands in or near the mouth. Ordinarily, just enough saliva is secreted to keep the mucous membranes of the mouth moist, but when food enters the mouth, secretion increases so the saliva can lubricate, dissolve, and begin the chemical breakdown of the food. The mucous membrane lining the mouth contains many small glands, the buccal glands, that secrete small amounts of saliva. However, the major portion of saliva is secreted by the salivary glands, accessory structures that lie outside the mouth and pour their contents into ducts that empty into the oral cavity. There are three pairs of salivary glands: parotid, submandibular (submaxillary), and sublingual glands. THE DIGESTIVE SYSTEM Page 100 The parotid glands are located under and in front of the ears between the skin and masseter muscle. They are compound tubuloacinar glands. Each secretes into the oral cavity vestibule via a duct, called the parotid (Stensen's) __ duct, that pierces the buccinator muscle to open into the vestibule opposite the upper second molar tooth. The submandibular glands, which are compound acinar glands, are found beneath the base of the tongue in the posterior part of the floor of the mouth. Their ducts, the submandibular, also known as Wharton's ducts, run superficially under the mucosa on either side of the midline of the floor of the mouth and enter the oral cavity proper just behind the central incisors. The Sublingual glands, also compound acinar glands, are anterior to the submandibular glands, and their ducts, the lesser sublingual ducts, also known as Rivinus's ducts, open into the floor of the mouth in the oral cavity proper. Mumps is an inflammation and enlargement of the parotid glands accompanied by moderate fever, malaise, and extreme pain in the throat, especially when swallowing sour foods or acid juices. Composition of Saliva: The fluids secreted by the buccal glands and the three pairs of salivary glands constitute saliva. approximately 1,000 Amounts to 1,500 of saliva secreted ml. Chemically, daily saliva is vary 99.5% from water between and 0.5% solutes. Among the solutes are salts--chlorides, bicarbonates, and phosphates of sodium and potassium. Some dissolved gases and various organic substances including urea and uric acid, serum albumin and globulin, mucin, the bacteriolytic enzyme lysozyme, and the digestive enzyme salivary amylase are also present. The water is saliva provides a medium for dissolving foods so they can be tasted and for initiating digestive reactions. The pH of saliva is 6.35 to 6.85 which is slightly acidic. Mucus which is part of saliva lubricates the food so it can be easily turned in the mouth, formed into a ball called a bolus, and swallowed. The enzyme lysozyme destroys bacteria, thereby protecting the mucous membrane from infection and also protecting the teeth from decay. THE DIGESTIVE SYSTEM Salivation is entirely under nervous control. Page 101 Normally, moderate amounts of saliva are continuously secreted in response to parasymphatetic stimulation to keep the mucous membranes moist and to lubricate the movements of the tongue and lips during speech. The saliva is then swallowed and reabsorbed to prevent fluid loss. Impulses are conveyed from the receptors in the tongue to two salivary nuclei in the brain stem called the superior and inferior salivary nuclei. The nuclei are located at about the junction of the medulla and pons. Returning parasymphatetic autonomic impulses from the nuclei activate the secretion of saliva. The smell, sight, touch, or sound of food preparation also stimulates increased saliva secretion. Saliva continues to be secreted heavily sometime after food is swallowed. This flow of saliva washes out the mouth and dilutes and buffers the chemical remnants of irritating substances. TEETH: The teeth or dentes are accessory structures of the digestive system located in sockets of the alveolar processes of the mandible and maxillae. The alveolar processes are covered by the gingivae or gums, which extend slightly into each socket forming the gingival sulcus. The sockets are lined by the periodontal ligament, which consists of dense fibrous connective tissue and is attached to the socket walls and the cemental surface of the roots. Thus it anchors the teeth in position and also acts as a shock absorber to dissipate the forces of chewing. A typical tooth consists of three principal portions. The crown is the portion above the level of the gums. The root consists of one to three projections embedded in the socket. The neck is the constricted junction line of the crown and the root. Teeth are composed primarily of dentin, a bonelike substance that gives the tooth its basic shape and rigidity. The dentin encloses a cavity. The enlarged THE DIGESTIVE SYSTEM Page 102 part of the cavity, the pulp cavity, lies in the crown and is filled with pulp, a connective tissue containing blood vessels, nerves, and lymphatics. Narrow extensions of the pulp cavity run through the root of the tooth are called root canals. Each root canal has an opening at its base, the apical foramen. Through the foramen enter blood vessels bearing nourishment, lymphatics affording protection, and nerves providing sensation. The dentin of the crown is covered by enamel that consists primarily of calcium phosphate and calcium carbonate. Enamel is the hardest substance in the body and protects the tooth from the wear of chewing. It is also a barrier against acids that easily dissolve the dentin. The dentin of the root is covered by cementum, another bonelike substance, which attaches the root to the periodontal ligament. The branch of dentistry that is concerned with the prevention, diagnosis, and treatment of diseases that affect the pulp, root, periodontal ligament, and alveolar bone is known as endodontics. Everyone has two dentitions, or sets of teeth. The first of these, the deciduous teeth, also known as milk teeth, or baby teeth, begin to erupt at about 6 months of age, and one pair appears at about each month thereafter until all 20 are present. The incisors, which are closes to the midline, are chisel-shaped and adapted for incisors, on cutting the into basis food. They are referred of their position. Next to as to central, the or incisors, lateral moving posteriorly, are the cuspids (canines), which have a pointed surface called a cusp. Cuspids are used to tear and shred food. The incisors and cuspids have only one root apiece. Behind them lie the first, and second molars, which have four cusps. Upper molars have three roots; lower molars have two roots. The molars crush and grind food. All the deciduous teeth are lost--generally between 6 and 12 years of age--and are replaced by the permanent dentition. The permanent dentition consists of 32 teeth that appear between the age of 6 and adulthood. It resembles the deciduous dentition with the following exceptions. The deciduous molars are replaced with the first and second premolars (bicuspids), which have two cusps and one root THE DIGESTIVE SYSTEM Page 103 (upper first biscuspids have two roots) and are used for crushing and grinding. The permanent molars erupt into the mouth behind the bicuspids. They do not replace any deciduous teeth and erupt as the jaw grows to accommodate them--the first molars at age 6, the second molars at age 12, and the third molars also known as wisdom teeth after age 18. The human jaw has become smaller through time and often does not afford enough room behind the second molars for the eruption of the third molars. In this case, the third molars remain embedded in the alveolar bone and are said to be "impacted." Most often they cause pressure and pain and must be surgically removed. DIGESTION IN THE MOUTH: 1. MechanicalDigestion - Through chewing, or mastication, the tongue manipulates food, the teeth grind it, and the food is mixed with saliva. As a result, the food is reduced to a soft, flexible bolus that is easily swallowed. 2. Chemical Digestion - The enzyme salivary amylase, formerly known as ptyalin, initiates the breakdown of starch. This is the only chemical digestion that occurs in the mouth. Carbohydrates are either monosaccharide and disaccharide sugars or polysaccharide starches. Most of the carbohydrates we eat are polysaccharides. Since only monosaccharides can be absorbed into the bloodstream, ingested disaccharides and polysaccharides must be broken down. The function of salivary amylase is to break the chemical bonds between some of the monosaccharides in the starches to reduce the long-chain polysaccharides to the disaccharide maltose. Food is usually swallowed too quickly for all of the starches to be reduced to disaccharides in the mouth. However, salivary amylase in the swallowed food continues to act on starches for another 15 to 30 minutes in the stomach before the stomach acids eventually inactivate it. DEGLUTITION: Swallowing, or deglutition, is the mechanism that moves food from the mouth to the stomach. It is facilitated by saliva and mucus and involves the mouth, pharynx, and esophagus. Swallowing is conveniently divided into three stages: (1) The voluntary stage of swallowing, in which the bolus is moved into the oropharynx. (2) The pharyngeal stage of swallowing, the involuntary passage of the bolus through the pharynx into the esophagus. (3) The esophageal stage of swallowing, the involuntary passage of the bolus through the esophagus into the stomach. THE DIGESTIVE SYSTEM Page 104 Swallowing starts when the bolus is forced to the back of the mouth cavity and into the oropharynx by the movement of the tongue upward and backward against the palate. This represents the voluntary stage of swallowing. With the passage of the bolus into the oropharynx, the involuntary pharvnaeal stage of swallowing begins. The respiratory interrupted. The bolus passageways stimulates close receptors and in breathing the is temporarily oropharynx, which send impulses to the deglutition center in the medulla and lower pons of the brain stem. The returning impulses cause the soft palate and uvula to move upward to close off the nasopharynx, and the larynx is pulled forward and upward under the tongue. As the larynx rises, it meets the epiglottis, which seals of the glottis. The movement of the larynx also pulls the vocal cords together, further sealing off the respiratory tract, and widens the opening between the laryngopharynx and esophagus. The bolus passes through the laryngopharynx and enters the esophagus in 1 to 2 seconds. The respiratory passageways then reopen and breathing resumes. ESOPHAGUS: The esophagus, the third principal organ involved in deglutition, is a muscular, collapsible tube that lies behind the trachea. It is about 23 to 25 cm (10 inches) long and begins at the end of the laryngopharynx, passes through the mediastinium anterior to the vertebral column, pierces the diaphragm through an opening called the esophageal hiatus, and terminates in the superior portion of the stomach. HISTOLOGY: The mucosa of the esophagus is lined by nonkeratinized stratified squamous epithelium, lamina propria, and a muscularis mucosae. The submucosa contains connective tissue and blood vessels. The muscularis of the upper third is striated, the middle third is striated and smooth, and the lower third is smooth. The outer layer is known as the adventitia rather than the serosa because the loose connective tissue of the layer is not covered by epithelium and because the connective structures. tissue merges with the connective tissue of surrounding THE DIGESTIVE SYSTEM The esophagus does not produce digestive Page 105 enzymes and does not carry on absorption. It secretes mucus and transports food to the stomach. The passage of food from the laryngopharynx into the esophagus is regulated by a sphincter at the entrance to the esophagus called the upper esophageal sphincter. During the esophageal stage of swallowing, food is pushed through the esophagus by involuntary smooth muscular movements called peristalsis. Peristalsis is a function of the muscularis and is controlled by the medulla. In the section of the esophagus lying just above and around the top of the bolus, the circular muscle fibers contract. The contraction constricts the esophageal wall and squeezes the bolus downward. Meanwhile, longitudinal fibers lying around the bottom of and just below the bolus also contract. Contraction of the longitudinal fibers shortens this lower section, pushing its walls outward so it can receive the bolus. The contracts are repeated in a wave that moves down the esophagus, pushing the food toward the stomach. Passage of the bolus is further facilitated by glands secreting mucus. The passage of solid or semisolid food from the mouth to the stomach takes 4 to 8 seconds. Very soft foods and liquids pass through in about 1 second. Just above the level of the diaphragm, the esophagus is slightly narrowed. This narrowing has been attributed to a physiological sphincter in the inferior part of the esophagus known as the lower esophageal (gastroesophageal) sphincter. The lower esophageal sphincter relaxes during swallowing and thus aids the passage of the bolus from the esophagus into the stomach. If the lower esophageal sphincter fails to relax normally as food approaches, the condition is called achalasia. If, on the the other hand, the lower esophageal sphincter fails to close adequately after food has entered the stomach, the stomach contents can enter the lower esophagus. Hydrochloric acid from the stomach contents can irritate the esophageal wall, resulting in a burning sensation. This sensation is known as heartburn because it is experienced in the region over the heart although it is not related to any cardiac problem. EXHIBIT 24-1 DIGESTION IN THE MOUTH STRUCTURE Cheeks Lips ACTIVITY RESULT Keep food between teeth during mastication. Foods uniformly chewed Keep food between teeth during mastication Foods uniformly chewed STRUCTURE Pharynx Tongue Extrinsic Muscles Intrinsic Muscles Taste Buds Buccal glands Salivary Move tongue from side to side and in and out. Alter shape of tongue. Serve as receptors for food stimulus. Secrete saliva. Secrete saliva. glands Food rnaneuvered for mastication, shaped into bolus, and maneuvered for deglutition. Deglutition and speech. Secretion of saIiva stimulated by nerve impulses from taste buds to salivatory nuclei in brain stem to salivary glands. ACTIVITY RESULT Pharyngeal stage of deglutition. Moves bolus from oropharynx to Iaryngopharynx and into esophagus; closes air passageways. Moves bolus from laryngopharynx into esophagus. Relaxation of upper esophageal sphincter. Esophagus Esophageal stage of deglutition (peristalsis). Relaxation of lower esophageal sphincter. Secretion of mucus. Forces bolus down esophagus. Moves bolus into stomach. Lubricates esophagus for smooth passage of bolus. Lining d mouth and pharynx moistened and lubricated. Lining of mouth and pharynx moistened and lubricated. Saliva softens, moist-ens, and dissolves food, coats food with mucin, cleanses mouth and teeth. Salivary amylase reduces polysaccharides to the disaccharide maltose. Teeth Cut, tear, and pulverize food. Solid foods reduced to smaller particles for swallowing. THE DIGESTIVE SYSTEM Page 107 STOMACH: The stomach is a J-shaped enlargement of the GI tract directly under the diaphragm in the epigastric, umbilical, and left hypochondriac regions of the abdomen. The superior portion of the stomach is a continuation of the esophagus. The inferior portion empties into the duodenum, the first part of the small intestine. The empty stomach is about the size of a large sausage but it can stretch to accommodate large amounts of food. ANATOMY: The stomach is divided into four areas: cardia, fundus, body, and pylorus. The cardia surrounds the lower esophageal sphincter. The rounded portion above and to the left of the cardia is the fundus. Below the fundus is the large central portion of the stomach, called the body. The narrow, inferior region is the pylorus. The superior concave medial border of the stomach is called the lesser curvature, and the inferior convex lateral border is the greater curvature. The pylorus communicates with the duodenum of the small intestine by way of a sphincter called the pyloric sphincter or pyloric valve. Pylorospasm is characterized by opening the of pyloric failure sphincter to of relax the muscle fibers encircling the normally. Pyloric stenosis is a narrowing of the pyloric sphincter caused by a tumor-like mass that apparently is formed by enlargement of the circular muscle fibers. HISTOLOGY: The stomach wall is composed of the same four basic layers as the rest of the alimentary canal, with certain modifications. When the stomach is empty, the mucosa lies in large folds, called rugae that can be seen with the naked eye. Microscopic inspection epithelium containing of the mucosa many narrow reveals openings that a layer of simple extend down into columnar the lamina propria. These pits, known as gastric glands, are lined with several kinds of THE DIGESTIVE SYSTEM Page 108 secreting cells: zymogenic, parietal, mucous, and enteroendocrine. The zymogenic (peptic) cells secrete the principal gastric enzyme precursor, pepsinogen. Hydrochloric acid, involved in the conversion of pepsinogen to the active enzyme pepsin, and intrinsic factor, involved in the absorption of vitamin B12 for red blood cell production, are produced by the parietal (oxyntic) cells. The mucous, cells, secrete mucus. Secretions of the zymogenic, parietal, and mucous cells are collectively called gastric juice. The enteroendocrine cells secrete stomach gastrin, a hormone that stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower esophageal sphincter, mildly increases motility of the GI tract, and relaxes the pyloric sphincter and relaxes the ileocecal sphincter. The submucosa of the stomach is composed of loose areolar connective tissue, which connects the mucosa to the muscularis. The muscularis, unlike that in other areas of the alimentary canal, has three layers of smooth muscle, an outer longitudinal layer, a middle circular layer, and an inner oblique layer. This arrangement of fibers allows the stomach to contract in a variety of ways to churn food, break it into small particles, mix it with gastric juice, and pass it to the duodenum. The serosa covering the stomach is part of the visceral peritoneum. At the lesser curvature, the two layers of the visceral peritoneum come together and extend upward to the liver as the lesser omentum. At the greater curvature, the visceral peritoneum continues downward as the greater omentum hanging over the intestines. DIGESTION IN THE STOMACH: 1. Mechanical - Several minutes after food enters the stomach, gentle, rippling, peristaltic movements called mixing waves pass over the stomach every 15 to 25 seconds. These waves macerate food, mix it with the secretions of the gastric glands, and reduce it into a thin liquid called chyme. Few mixing waves are observed in the fundus, which is primarily a THE DIGESTIVE SYSTEM Page 109 storage area. Foods may remain in the fundus for an hour or more without becoming mixed with gastric juice. During this time salivary digestion continues. As digestion proceeds in the stomach, more vigorous mixing waves begin at the body of the stomach and intensify as they reach the pylorus. The pyloric sphincter normally remains almost but not completely closed. As food reaches the pylorus, each mixing wave forces a small amount of the gastric contents into the duodenum through the pyloric sphincter. Most of the food is forced back into the body of the stomach where it is subjected to further mixing. The next wave pushes it forward again and forces a little more into the duodenum. The forward and backward movement of the gastric contents are responsible for almost all of the mixing in the stomach. 2. Chemical - The principal chemical activity of the stomach is to begin the digestion of proteins. In the adult, digestion is achieved primarily through the enzyme pepsin. Pepsin breaks certain peptide bonds between the amino acids making up proteins. Thus a protein chain of many amino acids is broken down into smaller fragments called peptides. Pepsin is most effective in the very acidic environment of the stomach (pH - 2.0). It becomes inactive in an alkaline environment. What keeps pepsin from digesting the protein in stomach cells along with the food? First, pepsin is secreted in an inactive form called pepsinogen, so it cannot digest the proteins in the zymogenic cells that produce it. It is not converted into active pepsin until it comes in contact with the hydrochloric acid secreted by the parietal cells. Second, the stomach cells are protected by mucus, especially after pepsin has been activated. The mucus coats the mucosa to form a barrier between it and the gastric juices. Another enzyme of the stomach is gastric lipase. Gastric lipase splits the butterfat molecules found in milk. This enzyme operates best at a pH of 5.0 to 6.0 and has a limited role in the adult stomach. Adults rely almost exclusively on an enzyme secreted by the pancreas into the small intestine to digest fats. THE DIGESTIVE SYSTEM Page 110 The infant stomach also secretes rennin, which is important in the digestion of milk. Rennin and calcium act on the casein of milk to produce a curd. The coagulation prevents too rapid a passage of milk from the stomach. Rennin is absent in the gastric secretions of adults. EXHIBIT 24-3 SUMMARY OF GASTRIC D I G E S T I O N STRUCTURE ACTIVITY Mucosa Zymogenic (peptic) cells Parietal (oxyntic) cells RESULT Secrete pepsinogen. Precursor of pepsin is produced. Secrete hydrochloric acid. Secrete intrinsic factor. Converts pepsinogen into pepsin, which digests proteins into peptides. Required for absorption of vitamin B 12 and erythrocyte formation. Mucous cells Secrete mucus. Enteroendocrine cells Secrete stomach gastrin. Stimulates gastric secretion, contracts lower esophageal sphincter, increases motility of the stomach, and relaxes pyloric sphincter. Mixing waves. Macerate food, mix it with gastric juice, reduce food to chyme, and force chyme through pyloric sphincter. Muscularis Pyloric sphincter (valve) Prevents digestion of stomach wall. Opens to permit passage of chyme into duodenum. Prevents backflow of food from duodenum to stomach. Regulation of Gastric Secretion: Stimulation: The secretion of gastric juice is related by both nervous and hormonal mechanisms. Parasympathetic impulses from nuclei in the medulla are transmitted via the vagus cranial nerves (X) and stimulate the gastric glands to secrete pepsinogen, hydrochloric acid, mucus, and stomach gastrin. Stomach gastrin is also secreted by gastric glands in response to certain foods that enter the stomach. Ceohalic _ (Reflex)Phase: The cephalic (reflex) phase of gastric secretions occurs before food enters the stomach and prepares the stomach for digestion. The sight, smell, taste, or thought of food initiates this reflex. Nerve impulses from the cerebral cortex or feeding center in the hypothalamus send impulses to the medulla. The medulla relays impulses over the parasympathetic fibers in the vagus (X) nerve to stimulate the gastric glands to secrete. THE DIGESTIVE SYSTEM Gastric Phase: Page 111 Once the food reaches the stomach, both nervous and hormonal mechanisms ensure that gastric secretion continues. This is the gastric phase of secretion. Food of any kind causes distention and stimulates receptors in the wall of the stomach. These receptors send impulses to the medulla and back to the gastric glands, and they may send messages to the glands as well. The impulses stimulate the flow of gastric juice. Emotions such as anger, fear, and anxiety may slow down digestion in the stomach because they stimulate the sympathetic nervous system, which inhibits the impulses of the parasympathetic fibers. Protein foods and alcohol stimulate the pyloric mucosa to secrete the hormone stomach gastrin. It is absorbed into the bloodstream, circulated through the body, and finally reaches its target cells, the gastric glands, where it stimulates secretion of large amounts of gastric juice. It also contracts the lower esophageal sphincter, increases motility of the GI tract, and relaxes the pyloric sphincter and ileocecal sphincter. Intestinal Phase: Some investigators believe that when partially digested proteins leave the stomach and enter the duodenum, they stimulate the duodenal mucosa to release enteric gastrin, a hormone that stimulates the gastric glands to continue their secretion. This constitutes the intestinal phase of secretion. However, this mechanism produces relatively small amounts of gastric juice. Inhibition Even though chyme stimulates gastric secretion during the gastric phase, it can inhibit secretion during the intestinal phase. For example, the presence of food in the small intestine during the intestinal phase initiates an enterogastric reflex in which nerve impulses carried to the medulla from the duodenum return to the stomach and inhibit parasympathetic gastric stimulation and secretion. stimulate These impulses sympathetic ultimately activity. inhibit Stimuli that initiate this reflex are distention of the duodenum, the presence of acid or partially digested duodenal mucosa. proteins in food in the duodenum, or irritation of the Page 112 THE DIGESTIVE SYSTEM Several intestinal hormones also inhibit gastric secretion. In the presence of acid, partially irritating digested substances proteins, in chyme, fats, the hypertonic intestinal or hypotonic mucosa fluids, releases or secretin, cholecystokinin (CCK), and gastric inhibiting peptide (GIP). All three hormones inhibit gastric secretion and decrease motility of the GI tract. Secretin and cholecystokinin are also important in the control of pancreatic and intestinal secretion, and cholecystokinin also helps regulate secretion of bile from the gallbladder. Regulation of Gastric Emptying: Gastric emptying is stimulated by tow principal factors: nerve impulses in response to distension, and stomach gastrin released in the presence of certain types of foods. During the gastric phase of secretion, distension and-the presence of partially digested proteins and alcohol stimulate secretion of gastric juice and stomach gastrin. In the presence of stomach gastrin, the lower esophageal sphincter contracts, the motility of the stomach increases, and the pyloric sphincter relaxes. The net effect of these actions is stomach emptying. The stomach empties all of its contents into the duodenum within 2 to 6 hours after ingestion. Foods rich in carbohydrate spend the least time in the stomach. Protein focds are somewhat slower, and emptying is slowest after a meal containing large amounts of fat. Stomach emptying is inhibited by the enterogastric reflex and hormones released in response to inhibits gastric secretin, inhibit certain constituents secretion, cholecystokinin gastric secretion it chyme. also (CCK), and in and inhibit The inhibits enterogastric gastric reflex motility. gastric inhibiting gastric motility. The peptide The rate not hormones (GIP) of only also stomach emptying is limited to the amount of chyme that the small intestine can process. Excessive gastric emptying in the wrong direction sometimes occurs. Vomiting is the forcible expulsion of the contents of the upper GI tract (stomach sometimes duodenum) through the mouth. The strongest stimuli for vomiting are and Page 113 THE DIGESTIVE SYSTEM irritation and distension of the stomach. Basically vomiting involves squeezing the stomach between the diaphragm and abdominal muscles and expelling of the contents through open esophageal sphincters. Absorption: The stomach wall is permeable to the passage of most materials into the blood, so most substances are not absorbed until they reach the small intestine. However, the stomach does participate in the absorption of some water, electrolytes, certain drugs (especially aspirin), and alcohol. PANCREAS: The next organ of the GI tract involved in the breakdown of food is the small intestine. Chemical digestion in the small intestine depends not only on its own secretions but also on activities of three accessory structures of digestion outside the alimentary canal: the pancreas, liver, and gallbladder. Anatomy: The pancreas is a soft, oblong tubuloacinar gland about 12.5 cm (6 inches) long and 2.5 cm (1 inch) thick. It lies posterior to the greater curvature of the stomach and is connected by a duct (usually two) to the duodenum. The pancreas is divided into a head, body, and tail. The head is the expanded portion near the C-shaped curve of the duodenum. Moving superiorly and to the left of the head are the centrally located body and the terminal tapering tail. The pancreas is linked to the small intestine usually by two ducts. Pancreatic secretions pass from the secreting cells in the pancreas to small ducts that unite to form the two ducts that convey the secretions into the small intestine. The large of the two ducts is called the pancreatic duct (duct of Wirsung). In most people the pancreatic duct unites with the common bile duct from the liver and gallbladder and enters the duodenum in a common duct, called the hepatopancreatic ampulla (ampulla of Vater). The ampulla opens on an elevation of the duodenal mucosa known as the duodenal papilla, about 10 cm (4 inches) THE DIGESTIVE SYSTEM Page 114 below the pylorus of the stomach. The smaller of the two ducts is the accessory duct (duct of Santorini), which leads from the pancreas and empties into the duodenum about 2.5 cm. (1 inch) above the ampulla of Vater. Histology: The pancreas is made up of small clusters of glandular epithelial cells. About 1% of the cells, the pancreatic islets _ (islets of Langherhans), form the endocrine portion of the pancreas and consist of alpha, beta, and delta cells that secrete hormones (glucagon, insulin, and somatostatin, respectively). The remaining 99% of the cells called acini are the exocrine portions of the pancreas. Secreting cells of the acini release a mixture of digestive enzymes called pancreatic juice. Pancreatic Juice: Each day the pancreas produces 1,200 to 1,500 ml (about 1.2 to 1.5 qt) of pancreatic juice, a clear, colorless liquid. It consists mostly of water, some salts, sodium bicarbonate, and enzymes. The sodium bicarbonate gives pancreatic juice a slightly alkaline pH (7.1 to 8.2) that stops the action of pepsin from the stomach and creates the proper environment for the enzymes in the small intestine. enzyme trypsin, The called enzymes in pancreatic chymotrypsin, pancreatic amylase; and juice several include a carbohydrate-digesting protein-digesting carboxypolypeptidase; the enzymes principal called fat-digesting enzyme in the adult body called pancreatic lipase; and nucleic acid-digesting enzymes called ribonuclease and deoxyribonuclease. Just as pepsin pepsinogen, so is too produced are the in the stomach protein-digesting in an enzymes inactive of the form known pancreas. as This prevents the enzymes from digesting cells of the pancreas. The active enzyme trypsin is secreted in an inactive form called trypsinogen. Its activation to trypsin is accomplished in the small intestine by an enzyme secreted by the intestinal mucosa when the chyme comes in contact with the mucosa. The Page 115 THE DIGESTIVE SYSTEM a c t i v a t i n g enzyme is called enterokinase. Chymotrypsin is activated in the small intestine chymotrypsinogen. small intestine by trypsin from its is also Carboxypolypeptidase by trypsin. Its inactive form, activated inactive form in is t he called procarboxypolypeptidase. Regulation of Pancreatic Secretions: Pancreatic secretion, like gastric secretion, is regulated by both nervous and hormonal mechanisms. When the cephalic and gastric phases of gastric secretion occur, parasympathetic impulses are simultaneously transmitted along the vagus (X) nerves to the pancreas that result in the secretion of pancreatic enzymes. In response to chyme contains partially fluids, or in the digested irritating small intestine, proteins, fats, substances, the especially hypertonic small chyme or that hypotonic intestinal mucosa secretes secretin and cholecystokinin (CCK), two hormones that a f f e c t pancreatic secretion. pancreatic juice Cholecystokinin Secretin that (CCK) is stimulates rich stimulates in a the pancreas sodium to secrete bicarbonate pancreatic secretion ions. rich in d i g e s t i v e enzymes. LIVER: The l i v e r weights about 1.4 kg (about 3 lb) in the average adult. I t is located under the diaphragm and occupies most of the right and completely hypochondrium and part of the epigastrium of the abdomen . Anatomy: The liver covered is by a peritoneum. I t the left the right almost completely covered dense connective tissue peritoneum layer that lies beneath the is divided into to principal lobes --the right lobe and lobe--separated lobe by are the by the inferior falciform quadrate ligament. lobe and lobe. The falciform ligament is a r e f l e c t i o n of the Associated posterior with caudate THE DIGESTIVE SYSTEM Page 116 parietal peritoneum, which extends from the undersurface of the diaphragm to the superior surface of the l i v e r , between the two principal lobes of the liver. In the free border of the falciform ligament is the ligamentum teres also known as the (round ligament). It extends from the liver to the umbilicus. The ligamentum teres is a fibrous cord derived from the umbilical vein of the fetus. Bile, one of the liver's products, enters bile capillaries or c a n a l i c u l i that empty into small ducts. These small ducts eventually merge to form the larger right and l e f t hepatic ducts, which unite to leave the liver to become the common hepatic duct. Further on, the common hepatic duct joins the cystic duct from the gallbladder. The two tubes become the common bile duct. The common b i l e duct and pancreatic duct enter the duodenum i n a common duct c a l l e d the hepatopancreatic ampulla (ampulla of Vater). Histology: The lobes of the liver are made up of numerous functional units called lobules, which may be seen under a microscope. A lobule consists of cords of hepatic (liver) cells arranged in a radial pattern around a c e n t r a l v e i n . Between the cords are endothelial-lined spaces called sinusoids, through which blood passes, The sinusoids are also partly lined with phagocytic c e l l s , termed s t e l l a t e reticuloendothelial or (Kupffer's) cells, blood cells and bacteria. The liver that destroy wornout white and red contains sinusoids instead of typical capillaries. Blood Supply: The liver receives a double supply of blood. From the hepatic artery it obtains oxygenated blood, and from the hepatic portal vein it receives deoxygenated blood containing newly absorbed nutrients. Branches of both the hepatic artery and the hepatic portal vein carry the blood into the sinusoids of the lobules, where o x y g e n , m o s t o f t h e nutrients and certain poisons are extracted by the hepatic cells. Nutrients are stored are used to ;Hake new materials. The poisons THE DIGESTIVE SYSTEM Page 117 are stored or detoxified. Products manufactured by the hepatic cells and nutrients needed by other cells are secreted back into the blood. The blood then drains into the central vein and eventually passes into a hepatic vein. Unlike the other products of the liver, bile normally is not secreted into the bloodstream. Bile: Each day the hepatic cells secrete 800 to 1,000 ml (about 1 qt) of bile, a yellow, brownish, or olive-green liquid. It has a pH of 7.6 to 8.6. Bile consists mostly of water and bile salts, cholesterol, a phospholipid called lecithin, bile pigments, and several ions. Bile is partially an excretory product and partially a digestive secretion. Bile salts assume a role in emulsification, the breakdown of fat globules into a suspension of very tiny fat droplets and absorption of fats following their digestion. Cholesterol is made soluble in bile by bile salts and lecithin. The principal bile pigment is bilirubin. When red blood cells are broken down, iron, globin, and bilirubin are released. The iron and globin are recycled, but some of the bilirubin is excreted into the bile ducts. Bilirubin is eventually broken down in the intestine, and one of its breakdown products, known as urobilinogen, gives feces their color. If insufficient bile salts or lecithin are present in bile, or if there is excessive cholesterol, the cholesterol precipitates out of solution and crystalizes to form gallstones (biliary calculi). If the liver is unable to remove bilirubin from the blood because of increased destruction of red blood cells or obstruction of bile ducts, large amounts of bilirubin circulate through the bloodstream and collect in other tissues, giving the skin and eyes a yellow color. This condition is called jaundice. If the jaundice is due to damaged red blood cells, it is called hemolytic Jaundice; if it is due to obstruction in the biliary system, it is known as obstructive jaundice. Since the liver of the newborn functions poorly for the first week or so, large amounts of bilirubin are excreted into blood instead of being incorporated into bile in the liver. The result is a type of jaundice called neonatal (physiological) jaundice. THE DIGESTIVE SYSTEM Page 118 Regulation of Bile Secretion: The rate at which bile is secreted is determined by several factors. Va t-,al stimulation can increase the production of bile to more than twice the normal rate. Secretin, the hormone that stimulates the synthesis of pancreatic juice rich in sodium bicarbonate, also stimulates the secretion of bile. Within limits, as blood flow through the liver increases, so does the secretion of bile. Finally, the presence of large amounts of bile sales in the blood also increases the rate of bile production. Functions of the Liver: The liver performs many vital functions. Among these are the following: 1. The liver manufactures bile salts which are used in the small intestine for the emulsification and absorption of fats, cholesterol, phospholipids, and lipoproteins. 2. The liver, together with mast cells, manufactures the anticoagulant heparin and most of the other plasma proteins, such as prothrombin, fibrinogen, and albumin. 3. The stellate reticuloendothelial (Kupffer's) cells of the liver phagocytize worn-out red and white blood cells and some bacteria. 4. Liver cells contain enzymes that either break down poisons or transform them into less harmful compounds. When amino acids are burned for energy, for example, they leave behind toxic nitrogenous wastes (such as ammonia) that are converted to urea by the liver cells. Moderate amounts of urea are harmless to the body and are easily excreted by the kidneys and sweat glands. 5. Newly absorbed nutrients are collected in the liver. Depending on the body's needs, it can change any excess monosaccharides into glycogen or fat, both of which can be store, or it can transform glycogen, fat, and protein into glucose. 6. The liver stores glycogen, copper, iron, and vitamins A, B12, D, E, and K. It also stores some poisons that cannot be broken down and excreted. High levels of DDT are found in the livers of animals, including humans, who eat sprayed fruits and vegetables.) 7. The liver and kidneys participate in the activation of vitamin D. The hepatic triad or portal triad refers to the hepatic portal vein, hepatic artery, and bile duct. Page 119 THE DIGESTIVE SYSTEM GALLBLADDER: The gallbladder is a pear-shaped sac about 7 to 10 cm (3 to 4 inches) long. It is located in a fossa of the visceral surface of the liver. Histology: The inner wall of the gallbladder consists of a mucous membrane arranged in rugaa resembling those of the stomach. The middle, muscular coat of the wall consists of smooth muscle fibers. Contraction of these fibers by hormonal stimulation ejects the contents of the gallbladder into the cystic duct. The outer coat is the visceral peritoneum. Function: The function of the gallbladder is to store and concentrate bile (up to 10-fold) until it is needed in the small intestine. In the concentration process, water and many ions are absorbed by the gallbladder mucosa. Bile from the liver enters the small intestine through the common bile duct. When the small intestine is empty, a valve around the hepatopancreatic ampulla (ampulla of Vater) called the sphincter of the hepatopancreatic ampulla or sphincter of Oddi, closes, and the backed-up bile overflows into the cystic duct to the gallbladder for storage. Emptying of the Gallbladder: In order for the gallbladder to eject bile into the small intestine to participate in the digestive process, the muscularis must contract to force bile into the common bile duct and the sphincter of the hepatopancreatic ampulla must relax. Chyme entering the duodenum that contains particularly high concentrations of fats or partially digested proteins stimulates the intestinal mucosa to secrete cholecystokinin (CCK). This hormone brings about contraction of the muscularis coupled with relaxation of the sphincter hepatopancreatic ampulla, resulting in emptying of the gallbladder. of the THE DIGESTIVE SYSTEM Page 120 SMALL INTESTINE: The major portions of digestion and absorption occur in a long tube called the small intestine. The small intestine begins at the pyloric sphincter of the stomach, coils through the central and lower part of the abdominal cavity, and eventually opens into the large intestine. It averages 2.5 cm (1 inch) in diameter and about 6.35 m (21 feet) in length. Anatomy: The small intestine is divided into three segments. The duodenum, the shortest part, originates at the pyloric sphincter of the stomach and extends about 25 cm (10 inches) until it merges with the jejunum. The jeiunum is about 2.5 m (8 ft) long and extends to ileum. The final portion of the small intestine, the ileum, measures about 3.6 m (12 ft) and joins the large intestine at the ileocecal sphincter or ileocecal valve. Histology: The wall of the small intestine is composed of the same four tunics that make up most of the GI tract. However, both the mucosa and the submucosa are modified to allow the small intestine to complete the process of digestion and absorption. The mucosa of the small intestines epithelium. These pits known as the contains many pits lined with glandular intestinal glands (crypts of Lieberkuhn) secrete intestinal juice. The submucosa of the duodenum contains duodenal glands known as Brunner's glands, which secrete an alkaline mucus to protect the wall of the small intestine from the action of the enzymes and to aid in neutralizing acid in the chyme. Some of the epithelial cells in the mucosa and submucosa have been transformed to goblet cells, which secrete additional mucus. Since almost all the absorption of nutrients occurs in the small intestine, its structure is specially adapted for this function. Its length alone provides a THE DIGESTIVE SYSTEM large surface area for absorption and that Page 121 area is further increased by modification in the structure of its wall. The epithelium covering and lining the mucosa consists of simple columnar epithelium. These epithelial cells, except those transformed into goblet cells, contain microvilli, fingerlike projections of the plasma membrane. Larger amounts of digested nutrients diffuse into the intestinal wall because the microvilli increase the surface are of the plasma membrane. They also increase the surface area for digestion. The mucosa lies in a series of villi, projections 0.5 to 1 mm high, giving the intestinal mucosa its velvety appearance. The enormous number of villi (10-40 per square millimeter) vastly increases the surface area of the epithelium available for absorption and digestion. Each villus has a core of lamina propria, the connective tissue layer of the mucosa. Embedded in this connective tissue are an arteriole, a venule, a capillary network, and a lacteal, or lymphatic vessel. Nutrients that diffuse through the epithelial cells that cover the villus are able to pass through the capillary walls and the lacteal and enter the cardiovascular and lymphatic systems. In addition to the microvilli and villi, a third set of projections called plicae circulares or circular folds, further increases the surface area for absorption and digestion of nutrients. The plicae are permanent ridges, about 10 mm (0.4 inch) high, in the mucosa. The plicae circulares enhance absorption by causing the chyme to spiral rather than to move in a straight line as it passes through the small intestine. Since the plicae circulares and villi decrease in size in the distal ileum, most absorption occurs in the duodenum and jejunum. The muscularis of the small intestine consists of two layers of smooth muscle. There is an abundance of lymphatic tissue in the form of lymphatic nodules, masses of lymphatic tissue not covered by a capsule wall. Solitary lymphatic nodules are most numerous in the lower part of the ileum. Groups of lymphatic nodules, referred to as aggregated lymphatic follicles or Peyer's patches, are numerous in the ileum of the small intestine. THE DIGESTIVE SYSTEM Page 122 Intestinal Juice: Intestinal juice is a clear yellow fluid secreted in amounts of about 2 to 3 liters (about 2 to 3 qt) a day. It has a pH of 7.6, which is slightly alkaline, and contains water and mucus. The juice is rapidly reabsorbed by the villi and provides a vehicle for the absorption of substances from chyme as they come in contact with the villi. Most digestion by enzymes of the small intestine occurs within the cells on the surfaces of their microvilli. Most digestion by enzymes of the small intestine occurs in or on the epithelial cells that line the villi, rather than in the lumen, as in other parts of the gastrointestinal tract. Among the enzymes produced by small intestinal cells are three carbohydrate-digesting enzymes called maltase, sucrase, and lactase; several protein-digesting enzymes called peptidases; and two nucleic acid-digesting enzymes, ribonuclease and deoxyribonuclease. Digestion in the Small Intestine: 1. Mechanical Digestion: The movements of the small intestine are arbitrarily divided into two types: segmentation and peristalsis. Segmentation is the major movement of the small intestine. It is strictly a localized contraction in areas containing food. It mixes chyme with the digestive juices and brings the particles of food into contact with the mucosa for absorption. It does not push the intestinal contents along the GI tract. The segmentation sequence of events is repeated 12 to 16 times a minute sloshing the chyme back and forth. Segmentation depends mainly on intestinal distension which initiates impulses to the central nervous system. Returning parasympathetic impulses increase motility. Sympathetic impulses decrease intestinal motility as distension decreases. Peristalsis propels the chyme onward through the intestinal tract. Peristaltic contractions in the small intestine are normally very weak THE DIGESTIVE SYSTEM Page 123 compared to those in the esophagus or stomach. Chyme moves through the small intestine at a rate of about 1 cm/min. Thus, chyme remains in the small intestine for 3 to 5 hours. Peristalsis, like segmentation, is initiated by distension and controlled by the autonomic nervous system. 2. Chemical Digestion: In the mouth salivary amylase converts starch, or polysaccharide, to maltose (a disaccharide). In the stomach, pepsin converts proteins to peptides (small proteins). Thus, chyme entering the small intestine contains partially digested carbohydrates, partially completion the of proteins, digestion of and essentially carbohydrates, undigested proteins, and lipids. lipids The is a collective effort of pancreatic juice, bile, and intestinal juice in the small intestine. Carbohydrates: E v e n though the action of salivary amylase may continue in the stomach for some time, its activity is blocked by the acidic pH of the stomach. Thus, few starches are reduced to maltose by the time chyme leaves the stomach. Any starches not already broken down into the disaccharide are converted by pancreatic amylase, an enzyme in pancreatic juice that acts in the small intestine. Sucrose and lactose, two disaccharides, are ingested as such and are not acted upon until they reach the small intestine. Three enzymes in the intestinal juice digest the disaccharides into monosaccharides. Maltase splits maltose into two molecules of glucose. Sucrase breaks sucrose into a molecule of glucose and a molecule of fructose. Lactase digests lactose into a molecule of glucose and a molecule of galactose. This completes the digestion of carbohydrates. In some individuals the mucosal cells of the small intestine fail to produce lactase, which is essential for the digestion of lactose. This condition is called lactose _ intolerance. Its symptoms include diarrhea, gas, bloating, and abdominal cramps following consumption of milk and other dairy products. THE DIGESTIVE SYSTEM Proteins: Protein digestion starts in Page 124 the stomach, where proteins are fragmented by the action of pepsin into peptides. Enzymes found in pancreatic juice continue the digestion. Trypsin and chymotrypsin continue to break down proteins into peptides. Although pepsin, trypsin, and chymotrypsin all convert whole proteins into peptides, their actions differ somewhat since each splits peptide bonds between different amino acids. carboxypolypeptidase acts on peptides and breaks the peptide bond that attaches the terminal amino acid to the carboxyl or acid end of the peptide. Protein digestion is completed by the peptidases. Aminopeptidase acts on peptides and breaks the peptide bonds that attach amino acids to the amino end of the peptide. Dipeptidase splits dipeptides, which are two amino acids joined by a peptide bond, into amino acids that can be absorbed. Lipids: In an adult, almost lipid digestion occurs in the small intestine. The first step in the process involves the preparation of neutral fats (triglycerides) by bile salts. Neutral fats, or just simply fats, are the most abundant lipids in the diet. They are called triglycerides because they consist of a molecule of glycerol and three molecules of fatty acid. Bile salts break the globules of fat into very small droplets. This process is called emulsification. It is necessary so that the fat-splitting enzyme can get at the lipid molecules. In the second step, pancreatic lipase, an enzyme found in pancreatic juice, hydrolyzes each fat molecule into fatty acids and monoglycerides, end products of fat digestion. Lipase removes two of the three fatty acids from glycerol; the third remains attached to the glycerol, thus forming monoglycerides. Nucleic Acids: Both intestinal juice and pancreatic juice contain nucleases, that digest nucleotides into their constituent pentoses and nitrogen bases. ribonuclease acts on ribonucleic acid nucleotides, and deoxyribonuclease acts on deoxyribonucleic acid nucleotides. Regulation of Intestinal Secretion: The most important means for regulating small intestinal secretion is local reflexes in response to the presence of chyme. Also, secretin and cholecystokinin (CCK) stimulate the production of intestinal juice. THE DIGESTIVE SYSTEM Page 125 Absorption: All the chemical and mechanical phases of digestion from the mouth down through the small intestine are directed toward changing food into forms that can pass through the epithelial cells lining the mucosa into the underlying blood and lymph vessels. These forms are monosaccharides (glucose, fructose, and galactose), amino acids, fatty acids, glycerol, and glycerides. Passage of these digestive nutrients from the alimentary canal into the blood or lymph is called absorption. About 90% of all absorption of nutrients takes place throughout the length of the small intestine. The other 10% occurs in the stomach and large intestine. Any undigested or unabsorbed material left in the small intestine is passed on to the large intestine. Absorption of materials in the small intestine occurs specifically through the villi and depends on diffusion, facilitated diffusion, osmosis, and active transport. Carbohydrates: Essentially all carbohydrates are absorbed as monosaccharides. Glucose and galactose are transported into epithelial cells of the villi by an active process that is coupled with the active transport of sodium. Fructose is transported by facilitated diffusion. Transported monosaccharides then move out of the epithelial cells by diffusion and enter the capillaries of the villi. From here they are transported in the bloodstream to the liver via the hepatic portal system. After their passage through the liver, they move through the heart and then enter the general circulation. Proteins: Most proteins are absorbed as amino acids, and the process occurs mostly in the duodenum and jejunum. Amino acid transport into epithelial cells of the villi is an active transport process also coupled with active sodium transport. Amino acids move out of the epithelial cells by diffusion to enter the bloodstream. The follow the same route as that taken by monosaccharides. THE DIGESTIVE SYSTEM Page 126 Lipids: As a result of emulsification and fat digestion, neutral fats, or triglycerides) are broken down into monoglycerides and fatty acids. Lipase removes two of three fatty acids from glycerol during fat digestion. The other fatty acid remains attached to glycerol thus forming monoglycerides. Short-chain fatty acids, those with less than 10 to 12 carbon atoms, pass into the epithelia cells by diffusion and follow the same route taken by monosaccharides and amino acids. Most fatty acids are long-chain fatty acids. They and the monoglycerides are transported differently. Bile salts form spherical aggregates called micelles. They are are about 2.5 namometers in diameter and consist of 20 to 50 molecules of bile salt. Despite their relatively large size, micelles have the ability to dissolve in water in the intestinal fluid. During fat digestion, fatty acids and monoglycerides dissolve in the center of the micelles, and it is in this form that they reach the epithelial cells of the villi. On coming into contact with the surfaces of the epithelial cells, fatty acids and monoglycerides diffuse into the cells, leaving the micelles behind in chyme. The micelles continually repeat this ferrying function. The majority of bile salts in the small intestine are ultimately reabsorbed in the ileum to be returned by the blood to the liver for resecretion. This cycle is called enterohepatic circulation. Insufficient bile salts, due to obstruction of the biliary ducts or removal of the gallbladder, can result in the loss of up to 40% of lipids in feces due to improper lipid absorption. Also, when lipids are not absorbed properly, the fat-soluble vitamins (A, D, E, K) are not adequately absorbed. Within the epithelial cells, many monoglycerides are further digested by lipase in the cells to glycerol and fatty acids. Then the fatty acids and glycerol are recombined to form triglycerides in the smooth endoplasmic reticulum of the epithelial cell. aggregate into The globules triglycerides, along still in with phospholipids the endoplasmic and cholesterol reticulum, and become coated with proteins. These masses are called chylomicrons. The protein coat keeps the chylomicrons suspended and from sticking to each other. The THE DIGESTIVE SYSTEM Page 127 chylomicrons leave the epithelial cells and enter the lacteal of a villus. From here, they are transported by way of lymphatic vessels to the thoracic duct and enter the cardiovascular system at the left subciavian vein. Finally they arrive at the liver through the hepatic artery. Water: The total volume of fluid that enters the small intestine each day is about 9 liters (±9 qt). This fluid is derived from ingestion of liquids (about 1.5 liters) and from various gastrointestinal secretions (about 7.5 liters). Roughly 8 to 8.5 liters of the fluid in the small intestine is absorbed; the remainder, about 0.5 to 1.0 liter, passes into the large intestine. There most of it is also absorbed. The absorption of water by the small intestine occurs by osmosis from the lumen of the small intestine through epithelial cells and into the blood capillaries in the villi. The normal rate of absorption is about 200 to 400 ml/hour. Water can move across the intestinal mucosa in both directions. The absorption of water from the small intestine is associated with the absorption of electrolytes and digested foods in order to maintain an osmotic balance with the blood. Electrolytes: The electrolytes absorbed by gastrointestinal secretions. the small Some are intestine are mostly constituents also components of ingested foods of and liquids. Sodium is able to move in and out of epithelial cells by diffusion. It can also move into mucosal cells by active transport for removal from the small intestine. Chloride, iodide, and nitrate ions can passively follow sodium ions or be actively transported. Calcium ions are also actively transported, and their movement depends on parathyroid hormone, also known as parathormone and vitamin D. Other electrolytes such as iron, potassium, magnesium, and phosphate can also move by active transport. THE DIGESTIVE SYSTEM Page 128 Vitamins: Fat-soluble vitamins, such as A , D, E, and K are absorbed along with ingested dietary fats in micelles. In fact, they cannot be absorbed unless they are ingested with some fat. Most water-soluble vitamins, such as the B vitamins and C are absorbed by diffusion. Vitamin B12 requires combination with intrinsic factor produced by the stomPch for its absorption. EXHIBIT 24-6 ` SUMMARY OF DIGESTION AND ABSORPTION IN THE SMALL INTESTINE STRUCTURE ACTIVITY Pancreas Liver Delivers pancreatic juice into the duodenum via the pancreatic duct (see Exhibit 24-5 for pancreatic enzymes and their functions). Produces bile which is necessary for emulsification of fats. Gall Bladder Stores, concentrates, and delivers bile into the duodenum via the common bile duct. Secrete Small Intestines Mucosa and submucosa Intestinal Glands . Secrete intestinal juice (see Exhibit 24 5 for intestinal enzymes and their functions). Duodenal (Brunner’s glands) Secrete mucus for protection and lubrication. Microvilli Fingerlike projections of epithelial cells that increase surface area for absorption and digestion. Villi Projections of mucosa that are the sites of absorption of digested food and also increase the surface area for absorption and digestion. Plicae circulars Muscularis Segmentation Peristalsis Circular folds of mucosa and submucosa that increase surface area for absorption and digestion. Consists of alternating contractions of circular fibers that produce segmentation and resegmentation of portions of the small intestine; mixes chyme with digestive juices and brings food into contact with the mucosa for absorption. Consists of mild waves of contraction and relaxation of circular and longitudinal muscle passing the length of the small intestine; moves chyme toward ileocecal valve. LARGE INTESTINE: The overall functions of the large intestine are the completion of absorption, the manufacture of certain vitamins, the formation of feces, and the expulsion of feces from the body. T H E D IG E S T I V E SYSTEM Page 129 Anatomy: The la r g e intestine is about 1.5 m (5 ft) in length and averages 6.5 cm (2.5 inches) in diameter. It extends from the ileum to the anus and is attached to the posterior abdominal wall by its mesocolon of visceral peritoneum. Structurally, the large intestine is divided into four principal regions: cecum, colon, rectum, and anal canal. The opening from the ileum into the large intestine is guarded by a fold of mucous membrane called the ileocecal sphincter or ileocecal valve. This structure allows materials from the small intestine to pass into the large intestine. Hanging below the ileocecal valve is the cecum, a blind pouch about 6 cm (2.5 inches) long. Attached to the cecum is a twisted, coiled tube, measuring about 8 cm (3 inches) in length, called the vermiform appendix. The visceral peritoneum of the appendix, called the mesoappendix, attaches the appendix to the inferior part of the ileum and adjacent part of the posterior abdominal wall. The open end of the cecum merges with a long tube called the colon. The colon is divided ascending into ascending, colon ascends transverse, on the descending, right side of and the sigmoid abdomen, portions. The reaches the undersurface of the liver, and turns abruptly to the left. Here it forms the right colic flexure, also known as the hepatic flexure. The colon continues across the abdomen to the left side as the transverse colon. It curves beneath the lower end of the spleen on the left side as the left colic flexure or splenic flexure and passes downward to the level of the iliac crest as the descending colon. The sigmoid colon begins at the left iliac crest, projects inward to the midline, and terminates as the rectum at about the level of the third sacral vetebra. The rectum, the last 20 cm (8 inches) of the GI tract, lies anterior to the sacrum and coccyx. The terminal 2 to 3 cm (1 inch) of the rectum is called the anal canal. The mucous membrane of the anal canal is arranged in longitudinal THE DIGESTIVE SYSTEM folds called anal columns, or columns of Morgagni Page 130 that contain a network of artaries and veins. The opening of the anal canal to the exterior is called the anus. It is guarded by an internal sphincter of smooth muscle which is involuntary and an external sphincter of skeletal muscle which is voluntary. Normally the anus is closed except during the elimination of the wastes of digestion. The medical specialty that deals with the diagnosis and treatment of disorders of the rectum and anus is called proctologv. Varacosities in any veins involve inflammation and enlargement. Varacosities of the rectal veins are known as hemorrhoids or piles. Histology: The wall of the large intestine differs from that of the small intestine in several respects. No villi or permanent circular folds are found in the mucosa, which does, however, contain simple columnar epithelium with numerous goblet cells. The columnar cells function primarily in water absorption. The goblet cells secrete mucus that lubricates the colonic contents as they pass through the colon. Both columnar and mucous cells are located in long, straight, tubular intestinal glands that extend the full thickness of the mucosa. Solitary lymphatic nodules also are found in the mucosa. The submucosa of the large intestine is similar to that found in the rest of the alimentary canal. The muscularis consists of an external layer of longitudinal muscles and an internal layer of circular muscles. Unlike other parts of the digestive tract tract, portions of the longitudinal muscles are thickened, forming three conspicuous longitudinal bands referred to as taeniae coli. Each band runs the length of most of the large intestine. Tonic contractions of the bands bather the colon into a series of pouches called haustra, which give the colon its puckered appearance. The serosa of the large intestine is part of the visceral peritoneum. Small pouches of visceral peritoneum filled with fat are attached to taeniae cols and are called epiploic appendages (folds). T H E D IG E S T I V E S Y S T E M Page 131 Digestion in the Large Intestine: 1. Mechanical Digestion: The passage of chyme from the ileum into the cecum is regulated by the action of the ileocecal valve. The value normally remains mildly contracted so that the passage of chyme into the cecum is usually a slow process. Immediately following a meal, there is a gastroileal reflex in which ileal peristalsis is intensified and any chyme in the ileum is forced into the cecum. The hormone stomach gastrin also relaxes the valve. Whenever the cecum is distended, the degree of contraction of the ileocecal valve is intensified. Movements of the colon begin when substances enter through the ileocecal valve. Since chyme moves through the small intestine at a fairly constant rate, the time required for a meal to pass into the colon is determined by gastric evacuation time. As food passes through the ileocecal valve, it fills the cecum and accumulates in the ascending colon. One movement characteristic of the large intestine is haustral churning. In this process, the haustra remain relaxed and distended while they fill up. When the distension reaches a certain point, the walls contract and squeeze the contents into the next haustrum. Peristalsis also occurs, although at a slower rate than in other portions of the tract (3 to 12 contractions per minute). A final type of movement is mass peristalsis, a strong peristaltic wave that begins in about the middle of the transverse colon and drives the colonic contents into the rectum. Food in the stomach initiates this reflex action in the colon. Thus mass peristalsis usually takes place three to four times a day, during a meal or immediately after. 2. Chemical Digestion: The last stage of digestion is chemical and occurs through bacterial, not enzymatic, action in the large intestine. Mucus is secreted by the glands of the large intestine, but no enzymes are secreted. Chyme is prepared for elimination by the action of bacteria. These bacteria ferment any remaining carbohydrates and release hydrogen, carbon dioxide, and methane gas. These gases THE DIGESTIVE SYSTEM Page 132 contribute to flatus (gas) in the colon. They also convert remaining to amino acids and break down the amino acids into simpler p roteins substances: indole, skatole, hydrogen sulfide, and fatty acids. Some of the indole and skatole is carried off in the feces and contributes to their odor. The rest are absorbed and transported to the liver, where they are converted to less toxic compounds and excreted in the urine. Bacteria also decompose bilirubin to simpler pigments (urobilinogen), which give feces their brown color. Several vitamins needed for normal metabolism, including some B vitamins and vitamin K, are synthesized by bacterial action and absorbed. Absorption and Feces Formation: By the time the chyme has remained in the large intestine 3 to 10 hours, it has become solid or semisolid as a result of absorption and is now known as feces. Chemically, feces consist of water, inorganic salts, sloughed off epithelial cells from the mucosa of the alimentary canal, bacteria, products of bacterial decomposition, and undigested parts of food. Although most water absorption occurs in the small intestine, the large intestine absorbs enough to make it an important organ in maintaining the body's water balance. Of the 0.5 to 1.0 liter that enters the large intestine, all but about 100 ml is absorbed. The absorption is greatest in the cecum and ascending colon. The large intestine also absorbs sodium and chloride. Defecation: Mass peristaltic movements push fecal material from the sigmoid colon into the rectum. The resulting distension of the rectal wall stimulates pressure- sensitive receptors, initiating a reflex for defecation, the emptying of the rectum. Diarrhea refers to frequent frequent defecation of liquid feces caused by increased motility of the intestines. THE DIGESTIVE SYSTEM Page 133 Constipation refers to infrequent or difficult defecation. DISORDERS: HOMEOSTATIC IMBALANCES 1. Dental Caries, softening of initiated when enamel. sticky or tooth the decay , enamel bacteria Microbes such polysaccharide bacteria causing dextran, and them other and act as on involve dentin. to to debris stick adhering to off mutans sucrose the demineralization process giving Streptococcus from gradual The sugars produced a teeth dental acids causes forms teeth. of a Masses are or caries demineralize is the caries. Dextran, capsule around of bacterial collectively a the cells, called dents plaque. 2. Periodontal Disease characterized alveolar called bone, by is a inflammation periodontal pyorrhea. collective and term for degeneration ligament, and The initial symptoms are a of cementum. variety the One enlargement of conditions gingivae such (gums), condition is and inflammation of the soft tissue and bleeding gums. 3. Peritonitis is an acute inflammation of the serous membrane lining the abdominal cavity and covering the abdominal viscera . 4. Peptic Ulcers: An ulcer is a craterlike lesion in a membrane. Ulcers that develop in areas of the a limentary canal exposed to acid gastric juice are called peptic ulcers. Peptic ulcers occasionally develop in the lower end of the esophagus, but most occur on the lesser curvature of the stomach, where they are called gastric ulcers, or in the first part of the duodenum where they are called duodenal ulcers. Most peptic ulcers are duodenal. Hypersecretion of acid gastric juice seems to be the immediate cause of duodenal ulcers. Among the factors believed to stimulate an increase in acid secretion are emot ions, certain foods, or medications, and also alcohol, coffee, and aspirin, as well as overstimulation of the vagus nerve. The most common complication of peptic ulcers is bleeding. THE DIGESTIVE SYSTEM 5. Page 134 Appendicitis: An inflammation of the vermiform appendix. It is preceded by obstruction of the lumen of the appendix by fecal material, inflammation, a foreign body, carcinoma of the cecum, stenosis, or kinking of the organ. The infection that follows may result in edema, ischemia, gangrene, and perforation. Rupture of the appendix develops into peritonitis. 6. Tumors: Both benign and malignant tumors can occur in all parts of the gastrointestinal tract. The benign growths are much more common. Carcinoma of the colon and rectum is one of the most common malignant diseases ranking second to that of the lungs in males and lungs and breasts in females. Over 50% of colorectal cancers occur in the rectum and sigmoid colon. Malignant tumors of the rectum may be detected by digital rectal examination. The easiest method for detecting cancer of the colon is fecal occult blood testing, in which a sample of stool is tested for the presence of occult (hidden) blood, a sign that a malignant tumor might be present. Another test in a routine examination for intestinal disorders is the filling of the gastrointestinal tract with barium, which is either swallowed or given in an enema. Barium, a mineral, shows up on x rays the same way that calcium appears in bones. Tumors as well as ulcers can be diagnosed this way. 7. Diverticulitis: Diverticula are saclike outpouchings of the wall of the colon in places where the muscularis has become weak. The development of diverticula is called diverticulosis. Many people who develop diverticulosis are asymptomatic and experience no complications. About 15% of people with diverticulosis will eventually develop an inflammation within diverticula, a condition known as diverticulitis. 8. Cirrhosis: Cirrhosis refers to a distorted or scarred liver as a result of chronic inflammation. Cirrhosis may be caused by hepatitis which is inflammation of the liver. Certain chemicals that destroy liver cells, parasites that infect the liver, and alcoholism. THE DIGESTIVE SYSTEM 9. Page 135 Hepatitis: Refers to inflammation of the liver and can be caused by viruses, drugs, and chemicals, including alcohol. Clinically several types of hepatitis are recognized. Hepatitis A (least serious form) also known as infectious hepatitis is caused by hepatitis A virus and is spread by fecal contamination of food, clothing, toys, eating utensils, and so forth. This is known as the fecal-oral route. It is generally a mild disease of children and young adults characterized by anorexia, malaise, nausea, diarrhea, fever, and chills. Eventually jaundice appears. It does not cause lasting liver damage. Most people recover in four to six weeks. Hepatitis B also known as serum hepatitis is caused by hepatitis B virus and is spread primarily by contaminated syringes and transfusion equipment. It can also be spread by an secretion of fluid by the body (tears, saliva, semen). Hepatitis B can produce chronic liver inflammation and can persist for years or even a lifetime. Persons who harbor the active hepatitis B virus are at risk for cirrhosis and also become carriers. Non-A, Non-B (NANB) Hepatitis: A form of hepatitis that cannot be traced to either hepatitis A or hepatitis B viruses. It is clinically similar to hepatitis B and is often spread by blood transfusions. It is believed to account for considerably more posttransfusion hepatitis than that related to hepatitis B. 10. Gallstones: The cholesterol in bile may crystallize at any point between bile canaliculi, where it is first apparent, and the hepatopancreatic ampulla, where the bile enters the duodenum. The fusion of single crystals is the beginning of 95% of all gallstones, also known as biliary calculi. Following their formation, gallstones gradually grow in size and number and may cause minimal, intermittent, or complete obstruction to the flow of bile from the gallbladder into the duct system. If obstruction of the outlet occurs and the gallbladder cannot empty as it normally does after eating, THE DIGESTIVE SYSTEM Page 136 the pressure within it increases and the individual may have intense pain or discomfort (binary colic). Complete obstruction of the flow of bile into the duodenum may result in death. 11. Anorexia Nervosa: Anorexia Nervosa is a disorder characterized by loss of appetite and starvation bizarre appears patterns to be a of eating. response to The subconsciously emotional self-imposed conflicts about self- identification and acceptance of a normal adult sex role. The disorder is found predominantly in young, single females. The physical consequence of the disorder is menstruation) severe and a and progressive lowered basal starvation. metabolic rate Amenorrhea reflect (absence the of depressant effects of the starvation. 12. Bulimia,: A disorder that typically affects single, middle-class, young, white females. It is also known as binge-purge syndrome. It is characterized by uncontrollable overeating followed by forced vomiting or overdoses of laxatives. overweight, This binge-purge stress, cycle depression, occurs and in response physiological to fears disorders of being such as hypothalamic tumors. Bulimia can upset the body's electrolyte balance and increase susceptibility to flu, salivary gland infections, dry skin, acne, muscle spasms, loss of hair, kidney and liver diseases, tooth decay, ulcers, hernias, constipation, and hormone imbalances. 13. Dietary Fiber (Roughage) and GI Disorders: A deficiency in our diet that has received recent attention is lack of dietary fiber or roughage. Dietary fiber consists of indigestible substances, such as cellulose, lignin, and pectin, found in fruits, vegetables, grains, and beans. The bulk of our intake consists of extensively purified carbohydrates--mainly starches and sugars--as well as substantial amounts of fats and oils. People who chose a fiber-rich, unrefined diet will greatly reduce their chances of developing disease of overnutrition (such as obesity, diabetes, gallstones, and THE DIGESTIVE SYSTEM coronary heart disease), disease of the Page 137 underworked mouth (caries and peridontal disease), and diseases of underfed large bowel (constipation, varicose veins, hemorrhoids, colon spasm, diverticulitis, appendicitis, and large intestinal cancer). 14. Botulism: A type of food poisoning caused by a toxin produced by Clostridium botulinum. The bacterium is ingested in improperly cooked or preserved food. Symptoms include paralysis, nausea, vomiting, blurred or double vision, difficulty in speech, difficulty in swallowing, dryness of mouth, and general weakness. 15. Cholecystitis: Inflammation of the gallbladder that often leads to infection. Some cases are caused by obstruction of the cystic duct with bile stones. 16. Cholelithiasis: The presence of gallstones. 17. Colitis: Inflammation of the colon and rectum. This inflammation of the mucosa reduces feces, and, in absorption severe of cases, water and salts, dehydration and producing salt watery, depletion. bloody Irritated muscularis spasms produce cramps. 18. Colostomy: An incision of the colon to create an artificial opening or "stoma" to the exterior. This opening serves as a substitute anus through which feces are eliminated. 19. Dysphagia: Difficulty in swallowing. 20. Enteritis: An inflammation of the intestine, particularly the small intestine. 21. Flatus: Excessive amounts of air (gas) in the stomach or intestine, usually expelled through the anus. If the gas is expelled through the mouth, it is called eructation or belching (burping). THE DIGESTIVE SYSTEM Page 138 22. Gastrectomy: Removal of a portion of the entire stomach. 23. Hernia: Protrusion of an organ or part of an organ through a membrane or cavity wall wall, usually the abdominal cavity. Diaphragmatic (hiatal) hernia is the protrusion of the lower esophagus, stomach, or intestine in the thoracic cavity through the opening in the diaphragm (esophageal hiatus) that allows passage abdominal of organs the esophagus. through the navel Umbilical area of hernia the is the abdominal protrusion wall. of Inguinal hernia is a protrusion of the hernial sac containing the intestine into the inguinal opening. It may extend into the scrotal compartment, causing strangulation of the herniated part. 24. Inflammatory Bowel Disease (IBD): Disorder that exists in two forms: (1) Chron's disease (inflamed intestine) (2) Ulcerative colitis (inflammation of the colon consisting of ulcerations and usually accompanied by rectal bleeding). 25. Irritable Bowel Syndrome: Disease of the entire gastrointestinal tract characterized by abnormal muscular contractions, especially a spastic colon, excessive mucus in stools, and alternating diarrhea and constipation. 26. Nausea: Discomfort preceding vomiting. Possibly, it is caused by distention or irritation of the gastrointestinal tract, most commonly the stomach. 27. Pancreatitis: Inflammation of the pancreas. Page 139 Minerals Vital to the Body MINERAL COMMENTS Calcium Phosphorus Iron IMPORTANCE Most abundant cation in body. Appears In combination with of bones and teeth, blood clotting, normal muscle and nerve activity, Formation : phosphorus in ratio of 2 1.5. About 99 percent is stored in endocytosis and exocytosis, cellular motility, chromosome movement prior to cell divibone and teeth. Remainder stored in muscle, soft metabolism, and synthesis and release of neurotransmitters. sion,other glycogen tissues, and blood plasma. Blood calcium level controlled by calcitonin (CT) and parathyroid hormone (PTH). Absorption occurs only in the presence of vitamin D. Most is excreted in feces and small amount in urine. Sources are milk, egg yolk, shellfish, green leafy vegetables. Formation of bones and teeth. Constitutes a major buffer system of About 80 percent found in bones and teeth. Remainder blood. Plays important role in muscle contraction and nerve activity. distributed in muscle, brain cells, blood. More functions Component of many enzymes. Involved in transfer and storage of than any other mineral. Blood phosphorous level conenergy (ATP). Component of DNA and RNA. trolled by calcitonin (CT) and parathyroid hormone (PTH). Most excreted in urine, small amount eliminated in feces. Sources are dairy products, meat, fish, poultry, nuts. About 66 percent found in hemoglobin of blood. Remain-der distributed in skeletal muscles, liver, spleen, enzymes. Normal losses of iron occur by shedding of hair, epithelial cells, and mucosal cells, and in sweat, urine, feces, and bile. Sources are meat, liver, shellfish, egg yolk, beans, legumes, dried fruits, nuts, cereals. As component of hemoglobin, carries O2 to body cells. Component of cytochromes involved in formation of ATP from catabolism. Iodine Essential component of thyroid hormones. Excreted in urine. Sources are seafood, cod-liver oil, and vegetables grown in iodine-rich soils or iodized salt. Required by thyroid gland to synthesize thyroid hormones, hormones that regulate metabolic rate. Copper Some stored in liver and spleen. Most excreted in feces. Sources include eggs, whole-wheat flour, beans, beets, liver, fish, spinach, asparagus. Required with iron for synthesis of hemoglobin. Component of enzyme necessary for melanin pigment formation. Sodium Most found in extracellular fluids, some in bones. Excreted in urine and perspiration. Normal intake of NaCl (table salt) supplies required amounts. As most abundant cation in extracellular fluid, strongly affects distribution of water through osmosis. Part of bicarbonate buffer system. Functions in nerve impulses conduction. Principal cation in intracellular fluid. Most is excreted in urine. Normal food intake supplies required amounts. Found in extracellular and intracellular fluids. Principal anion of extracellular fluid. Most excreted in urine. Normal intake of NaCl supplies required amounts. Potassium Chlorine Magnesium Component of soft tissues and bone. Excreted in urine and feces. Widespread in various foods. Sulfur Constituent of many proteins (such as insulin) and some vitamins (thiamine and biotin). Excreted in urine. Sources include beef, liver, lamb, fish, poultry, eggs, cheese, beans. Zinc Important component of certain enzymes. many foods, especially meats. Widespread in Fluorine Component of bones, teeth, other tissues Manganese Some stored in liver and spleen. Most excreted in feces. Cobalt Constituent of vitamin B12 Functions in transmission of nerve impulses and muscle contraction. Assumes role in acid-base balance of blood, water balance, and formation of HCI in stomach. Required for normal functioning of muscle and nervous tissue. Participates in bone formation. Constituent of many coenzymes. As component of hormones and vitamins, regulates various body activities. As a component of carbonic anhydrase, important in carbon dioxide metabolism. Necessary for normal growth and wound healing, proper functioning of prostate gland, normal taste sensations and appetite, and normal sperm counts in males. As a component of peptidases, it is involved in protein digestion. Appears to improve tooth structure and inhibit carcinogenesis Activates several enzymes. Needed for hemoglobin synthesis, urea formation, growth, reproduction, and lactation. As part of B12, required for maturation of erythropoeisis. . Page 140 EXHIBIT 25-3 (Continued) MINERAL Chromium COMMENTS Found in high concentrations in brewer's yeast. Also found in wine and some brands of beer. IMPORTANCE Necessary for the proper utilization of dietary sugars and other carbohydrates by optimizing the production and effects of insulin. Helps increase blood levels of HDL, while decreasing levels of LDL. An antioxidant. Prevents chromosome breakage and may Selenium Found in seafood, meat, chicken, grain cereals, egg yolk, milk, mushrooms, and garlic. assume a role in preventing certain birth defects. EXHIBIT 25-4 THE PRINCIPAL VITAMINS VITAMIN FUNCTION COMMENT AND SOURCE DEFICIENCY SYMPTOMS AND DISORDERS FAT-SOLUBLE A Formed from provitamin carotene Maintains general health and vigor (and other provitamins) in intestinal of epithelial cells. tract. Requires bile salts and fat for absorption. Stored in liver. Sources of carotene and other provitamins include yellow and Deficiency results in atrophy and keratinization of epithelium, leading to dry skin and hair, increased incidence of ear, sinus, respiratory, urinary, and digestive infections, inability to gain weight, drying of cornea with ulceration (xerophthalmla), nervous disorders, and skin sores. green vegetables; sources of vita-min A Essential for formation of rhodopsin, light-sensitive chemical in rods of retina. Growth of bones and teeth by apparently helping to regulate activity of osteoblasts and osteoblasts Night blindness or decreased ability for dark adaptation. Slow and faulty development of bones and teeth. Page VITAMIN D E (tocopherols) K WATER-SOLUBLE B1 (thiamine) COMMENT AND SOURCE In presence of sunlight, dehydrocholesterot in the skin is converted t o chotecalcif erol (vitamin D,). In the liver, cholecalciferol is converted to 25-hydroxychotecalciferol. In the kidneys, 25-hydroxychotecalciferol i s converted to 1,25dihydroxycalciferot, the active form of vitamin D. Dietary vitamin 0 requires moderate amounts of bile salts and fat for absorption. Stored in tissues to slight extent. Most excreted via bile. Sources include fish-liver oils, egg yolk, fortified milk. Stored in liver, adipose tissue, and muscles. Requires bile salts and tat for absorption. Sources include fresh nuts and wheat germ, seed oils, green leafy vegetables. FUNCTION Essential for absorption and utilization of calcium and phosphorus from gastrointestinal tract. May work with parathyroid hormone (PTH) that controls calcium metabolism. Believed t o inhibit catabolism of certain fatty acids that help form call structures, especially membranes. Involved in formation o f DNA, RNA, and red blood cells. May promote wound heating, contribute to the normal structure and functioning of the nervous system, prevent scarring and reduce the severity of visual loss associated with retrolental fibroplasia (an eye disease in premature infants caused by too much oxygen in incubators) by functioning as an antioxidant. Believed to help protect liver from toxic chemicals like carbon tetrachloride. Produced in considerable quantities by intestinal bacteria. Re-quires bile salts and fat for absorption. Stored in liver and spleen. Other sources include spinach, cauliflower, cabbage, liver. Coenzyme believed essential for synthesis of prothrombin by liver and several clotting factors. Also known as antihemorrhagic vita-min. Rapidly destroyed by heat. Not stored in body. Excessive intake eliminated in urine. Sources include whole-grain products, eggs, pork, nuts, liver, yeast. Acts as coenzyme for many different enzymes involved in carbohydrate metabolism of pyruvic acid to CO, and H=O. Essential for synthesis of acetylcholine. 141 DEFICIENCY SYMPTOMS AND DISORDERS Defective utilization of calcium by bones leads to rickets in children and osteomalacla in adults. Possible toss of muscle lone. May cause the oxidation of unsaturated fats resulting in abnormal structure and function of mitochondria, lysosomes, and plasma membranes, a possible consequence being hemolytic anemia. Deficiency also causes muscular dystrophy in monkeys and sterility in rats. Delayed clotting time excessive bleeding. results in Improper carbohydrate metabolism leads to buildup of pyruvic and lactic acids and insufficient energy for muscle and nerve calls. Deficiency leads to two syndromes: (1) beriberi—partial paralysis of smooth muscle of GI tract causing digestive disturbances, skeletal muscle paraysis, atrophy of limbs; (2) polyneuritis—due to degeneration of myelin sheaths reflexes related to kinesthesia are impaired, impairment of sense of touch, de-creased intestinal motility, stunted growth in children, and poor appetite. EXHIBIT 25-4 (Continued) VITAMIN B2 (riboflavin) COMMENT AND SOURCE Not stored in large amounts in tissues. Most is excreted in urine. Small amounts supplied by bacteria of GI tract. Other sources include yeast, liver, beef, veal, Iamb, eggs, whole-grain products, asparagus, peas, beets, peanuts. FUNCTION Component of certain coenzymes (e g., FAD) concerned with carbohydrate and protein metabolism, especially in cells of eye, integument, mucosa of intestine, blood. Niacin (nicotinamide) Derived from amino acid tryptophan. Sources include yeast, meats, Essential component of coenzyme liver, fish, whole-grain products, (NAD) concerned with energyreleasing reactions. In lipid peas, beans, nuts. metabolism, inhibits production of cholesterol and assists in fat breakdown. May function as coenzyme in fat metabolism. Essential coenzyme B6 (pyridoxine) Formed by bacteria of GI tract. Stored in for normal amino acid metabolism. liver, muscle, brain. Other sources Assists production of circulating include salmon, yeast, tomatoes, antibodies. yellow corn, spinach, whole-grain products, liver, yogurt. Coenzyme necessary for red blood B12 (cyanocobalaOnly B vitamin not found in vegecell formation, formation of amino min) tables; only vitamin containing cobalt. acid methionine, entrance of some Absorption from GI tract deamino acids into Krebs cycle, and pendent on HCI and intrinsic manufacture of eholine (chemical factor secreted by gastric musimilar in function to acetylcholine). cosa. Sources include liver, kidney, milk, eggs, cheese, meat. Constituent of coenzyme A essential for transfer of pyruvic acid Pantothenic acid Stored primarily in liver and kidneys. into Krebs cycle, conversion of Some produced by bacteria of GI lipids and amino acids into glutract. Other sources include cose, and synthesis of cholesterol kidney, liver, yeast, green vegetaand steroid hormones. bles, cereal. Synthesized by bacteria of GI tract. Other sources include green leafy vegetables and liver. Component of enzyme systems synthesizing purines and pyrimidines built into DNA and RNA. Essential for normal production of red and white blood cells. Biotin Synthesized by bacteria of GI tract. Other sources include yeast, liver, egg yolk, kidneys. Essential coenzyme for conversion of pyruvic acid to oxaloacetic acid and synthesis of fatty acids and purines. Folic acid C (ascorbic acid) Rapidly destroyed by heat. Some stored in glandular tissue and plasma. Sources include cirtrus fruits, tomatoes, green vegetables. Exact role not understood. Promotes many metabolic reactions, particularly protein metabolism, including laying down of collagen in formation of connective tissue. As coenzyme may combine with poisons, rendering them harmless until excreted. Works with antibodies. Promotes wound healing. DEFICIENCY SYMPTOMS AND DISORDERS Deficiency may lead to improper utilization of oxygen resulting in blurred vision, cataracts, and corneal ulcerations. Also dermatitis and cracking of skin, lesions of intestinal mucosa, and development of one type of anemia. Principal deficiency is pellagra, characterized by dermatitis, diarrhea, and psychological disturbances. Most common deficiency symptom is dermatitis of eyes, nose, and mouth. Other symptoms are retarded growth and nausea. Pernicious anemia and malfunction of nervous system due to degeneration of axons of spinal cord. Experimental deficiency tests indicate fatigue, muscle spasms, neuromuscular degeneration, insufficient production of adrenal steroid hormones. Production of abnormally large red blood cells (macrocytic anemia). Mental depression, muscular pain, dermatitis, fatigue, nausea. Scurvy; anemia; many symptoms related to poor connective tissue growth and repair including tender swollen gums, loosening of teeth (alveolar processes also deteriorate), poor wound healing, bleeding (vessel walls fragile because of connective tissue degeneration), and retardation of growth. Page 143 EXHIBIT 25-5 ABNORMAL CONDITIONS ASSOCIATED WITH MEGADOSES OF SELECTED MINERALS AND VITAMINS SUBSTANCE ABNORMALITY MINERALS Calcium Depresses nerve function, causes drowsiness, extreme lethargy, calcium deposits, kidney stones. Iron Damage to liver, heart, and pancreas. Zinc Masklike fixed expression, difficulty in walking, slurred speech, hand tremor, involuntary laughter. Cobalt Goiter, polycythemia, and heart damage. Selenium Nausea, vomiting, fatigue, irritability, and loss of fingernails and toenails. VITAMINS A Blurred vision, dizziness, ringing in the ears, headache, skin rash, nausea, vomiting, diarrhea, hair loss, menstrual irregularities, fatigue, liver damage, abnormal bone growth, and damage to nervous system. D Calcium deposits, deafness, nausea, loss of appetite, kidney stones, weak bones, hypertension, high cholesterol. E Thrombophlebitis, pulmonary embolism, hypertension, severe fatigue, breast tenderness, and slow wound healing. Niacin Flushing, peptic ulcers, liver dysfunction, gout, arrhythmias, and hyperglycemia. B. Impaired sense of position and vibration, diminished tendon reflexes, numbness and loss of sensations in hands and feet, difficulty in walking. C Dependence on megadoses may lead to scurvy when withdrawn, kidney stones, diarrhea, hemolysis, and blood clotting. megadose is defined as taking 10 the National Research Council. A or more times the adult recommended daily allowances (RDA's) set by