ANATOMY AND PHYSIOLOGY OF GASTROINTESTINAL TRACT

Introduction to the gastrointestinal system

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from
the oral cavity, where food enters the mouth, continuing through the pharynx,
esophagus, stomach and intestines to the rectum and anus, where food is expelled.
There are various accessory organs that assist the tract by secreting enzymes to
help break down food into its component nutrients. Thus the salivary glands, liver,
pancreas and gall bladder have important functions in the digestive system. Food is
propelled along the length of the GIT by peristaltic movements of the muscular
walls.

The primary purpose of the gastrointestinal tract is to break food down into
nutrients, which can be absorbed into the body to provide energy. First food must
be ingested into the mouth to be mechanically processed and moistened. Secondly,
digestion occurs mainly in the stomach and small intestine where proteins, fats and
carbohydrates are chemically broken down into their basic building blocks.
Smaller molecules are then absorbed across the epithelium of the small intestine
and subsequently enter the circulation. The large intestine plays a key role in
reabsorbing excess water. Finally, undigested material and secreted waste products
are excreted from the body via defecation (passing of faeces).

In the case of gastrointestinal disease or disorders, these functions of the

gastrointestinal tract are not achieved successfully. Patients may develop
symptoms of nausea, vomiting, diarrhea, malabsorption, constipation or
obstruction. Gastrointestinal problems are very common and most people will have
experienced some of the above symptoms several times throughout their lives.
Basic structure

The gastrointestinal tract is a muscular tube lined by a special layer of cells, called
epithelium. The contents of the tube are considered external to the body and are in
continuity with the outside world at the mouth and the anus. Although each section
of the tract has specialized functions, the entire tract has a similar basic structure
with regional variations.
Mucosa
The innermost layer of the digestive tract has specialized epithelial cells supported
by an underlying connective tissue layer called the lamina propria. The lamina
propria contains blood vessels, nerves, lymphoid tissue and glands that support the
mucosa. Depending on its function, the epithelium may be simple (a single layer)
or stratified (multiple layers).

Areas such as the mouth and esophagus are covered by a stratified squamous (flat)
epithelium so they can survive the wear and tear of passing food. Simple columnar
(tall) or glandular epithelium lines the stomach and intestines to aid secretion and
absorption. The inner lining is constantly shed and replaced, making it one of the
most rapidly dividing areas of the body! Beneath the lamina propria is the
muscular is mucosa. This comprises layers of smooth muscle which can contract to
change the shape of the lumen.

Submucosa
The submucosa surrounds the muscular is mucosa and consists of fat, fibrous
connective tissue and larger vessels and nerves. At its outer margin there is a
specialized nerve plexus called the submucosal plexus or Meissner plexus. This
supplies the mucosa and submucosa.

Muscular is externa

This smooth muscle layer has inner circular and outer longitudinal layers of muscle
fibers separated by the myenteric plexus or Auer Bach plexus. Neural innervations
control the contraction of these muscles and hence the mechanical breakdown and
peristalsis of the food within the lumen.
Serosa/mesentery

The outer layer of the GIT is formed by fat and another layer of epithelial cells
called mesothelium.

Individual components of the gastrointestinal system

Oral cavity

The oral cavity or mouth is responsible for the intake of food. It is lined by a
stratified squamous oral mucosa with keratin covering those areas subject to
significant abrasion, such as the tongue, hard palate and roof of the mouth.
Mastication refers to the mechanical breakdown of food by chewing and chopping
actions of the teeth. The tongue, a strong muscular organ, manipulates the food
bolus to come in contact with the teeth. It is also the sensing organ of the mouth for
touch, temperature and taste using its specialized sensors known as papillae.

Insalivation refers to the mixing of the oral cavity contents with salivary gland
secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity
also plays a limited role in the digestion of carbohydrates. The enzyme serum
amylase, a component of saliva, starts the process of digestion of complex
carbohydrates. The final function of the oral cavity is absorption of small
molecules such as glucose and water, across the mucosa. From the mouth, food
passes through the pharynx and esophagus via the action of swallowing.

Salivary glands
Three pairs of salivary glands communicate with the oral cavity. Each is a complex
gland with numerous acini lined by secretory epithelium. The acini secrete their
contents into specialized ducts. Each gland is divided into smaller segments called
lobes. Salivation occurs in response to the taste, smell or even appearance of food.
This occurs due to nerve signals that tell the salivary glands to secrete saliva to
prepare and moisten the mouth. Each pair of salivary glands secretes saliva with
slightly different compositions.

Parotids

The parotid glands are large, irregular shaped glands located under the skin on the
side of the face. They secrete 25% of saliva. They are situated below the zygomatic
arch (cheekbone) and cover part of the mandible (lower jaw bone). An enlarged
parotid gland can be easier felt when one clenches their teeth. The parotids produce
a watery secretion which is also rich in proteins. Immunoglobins are secreted help
to fight microorganisms and a-amylase proteins start to break down complex
carbohydrates.

Submandibular

The submandibular glands secrete 70% of the saliva in the mouth. They are found
in the floor of the mouth, in a groove along the inner surface of the mandible.
These glands produce a more viscid (thick) secretion, rich in mucin and with a
smaller amount of protein. Mucin is a glycoprotein that acts as a lubricant.

Sublingual

The sublingual’s are the smallest salivary glands, covered by a thin layer of tissue
at the floor of the mouth. They produce approximately 5% of the saliva and their
secretions are very sticky due to the large concentration of mucin. The main
functions are to provide buffers and lubrication.

Esophagus

The esophagus is a muscular tube of approximately 25cm in length and 2cm in

diameter. It extends from the pharynx to the stomach after passing through an
opening in the diaphragm. The wall of the esophagus is made up of inner circular
and outer longitudinal layers of muscle that are supplied by the esophageal nerve
plexus. This nerve plexus surrounds the lower portion of the esophagus. The
esophagus functions primarily as a transport medium between compartments.

Stomach

The stomach is a J shaped expanded bag, located just left of the midline between
the esophagus and small intestine. It is divided into four main regions and has two
borders called the greater and lesser curvatures. The first section is the cardia
which surrounds the cardial orifice where the esophagus enters the stomach. The
fundus is the superior, dilated portion of the stomach that has contact with the left
dome of the diaphragm. The body is the largest section between the fundus and the
curved portion of the J.
This is where most gastric glands are located and where most mixing of the food
occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are
expelled into the proximal duodenum via the pyloric sphincter. The inner surface
of the stomach is contracted into numerous longitudinal folds called rugae. These
allow the stomach to stretch and expand when food enters. The stomach can hold
up to 1.5 liters of material. The functions of the stomach include:

1. The short-term storage of ingested food.

2. Mechanical breakdown of food by churning and mixing motions.

3. Chemical digestion of proteins by acids and enzymes.

4. Stomach acid kills bugs and germs.

5. Some absorption of substances such as alcohol.

Most of these functions are achieved by the secretion of stomach juices by gastric
glands in the body and fundus. Some cells are responsible for secreting acid and
others secrete enzymes to break down proteins.

Small intestine

The small intestine is composed of the duodenum, jejunum, and ileum. It averages
approximately 6m in length, extending from the pyloric sphincter of the stomach to
the ileocecal valve separating the ileum from the caecum. The small intestine is
compressed into numerous folds and occupies a large proportion of the abdominal
cavity.
The duodenum is the proximal C-shaped section that curves around the head of the
pancreas. The duodenum serves a mixing function as it combines digestive
secretions from the pancreas and liver with the contents expelled from the stomach.
The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It
is in the jejunum where the majority of digestion and absorption occurs. The final
portion, the ileum, is the longest segment and empties into the caecum at the
ileocecal junction.
The small intestine performs the majority of digestion and absorption of nutrients.
Partly digested food from the stomach is further broken down by enzymes from the
pancreas and bile salts from the liver and gallbladder. These secretions enter the
duodenum at the Ampulla of Vater. After further digestion, food constituents such
as proteins, fats, and carbohydrates are broken down to small building blocks and
absorbed into the body’s blood stream.

The lining of the small intestine is made up of numerous permanent folds called
plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is
covered by epithelium with projecting microvilli (brush border). This increases the
surface area for absorption by a factor of several hundred. The mucosa of the small
intestine contains several specialized cells. Some are responsible for absorption,
whilst others secrete digestive enzymes and mucous to protect the intestinal lining
from digestive actions.

Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like
a frame. It consists of the appendix, caecum, ascending, transverse, descending and
sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width
of 7.5cm.

The caecum is the expanded pouch that receives material from the ileum and starts
to compress food products into faecal material. Food then travels along the colon.
The wall of the colon is made up of several pouches (haustra) that are held under
tension by three thick bands of muscle (tenia coli).

The rectum is the final 15cm of the large intestine. It expands to hold faecal matter
before it passes through the anorectal canal to the anus. Thick bands of muscle,
known as sphincters, control the passage of faeces.

The mucosa of the large intestine lacks villi seen in the small intestine. The
mucosal surface is flat with several deep intestinal glands. Numerous goblet cells
line the glands that secrete mucous to lubricate faecal matter as it solidifies.

The functions of the large intestine can be summarized as:

1. The accumulation of unabsorbed material to form faeces.

 2. Some digestion by bacteria. The bacteria are responsible for the formation of
intestinal gas.

3. Reabsorption of water, salts, sugar and vitamins.

Liver

The liver is a large, reddish-brown organ situated in the right upper quadrant of the
abdomen. It is surrounded by a strong capsule and divided into four lobes namely
the right, left, caudate and quadrate lobes. The liver has several important
functions. It acts as a mechanical filter by filtering blood that travels from the
intestinal system. It detoxifies several metabolites including the breakdown of
bilirubin and estrogen. In addition, the liver has synthetic functions, producing
albumin and blood clotting factors. However, its main roles in digestion are in the
production of bile and metabolism of nutrients. All nutrients absorbed by the
intestines pass through the liver and are processed before traveling to the rest of the
body. The bile produced by cells of the liver, enters the intestines at the duodenum.
Here, bile salts break down lipids into smaller particles so there is a greater surface
area for digestive enzymes to act.

Gall bladder

The gallbladder is a hollow, pear shaped organ that sits in a depression on the
posterior surface of the liver’s right lobe. It consists of a fundus, body and neck. It
empties via the cystic duct into the biliary duct system. The main functions of the
gall bladder are storage and concentration of bile. Bile is a thick fluid that contains
enzymes to help dissolve fat in the intestines. Bile is produced by the liver but
stored in the gallbladder until it is needed. Bile is released from the gall bladder by
contraction of its muscular walls in response to hormone signals from the
duodenum in the presence of food.
Pancreas

Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach.
Its head communicates with the duodenum and its tail extends to the spleen. The
organ is approximately 15cm in length with a long, slender body connecting the
head and tail segments. The pancreas has both exocrine and endocrine functions.
Endocrine refers to production of hormones which occurs in the Islets of
Langerhans. The Islets produce insulin, glucagon and other substances and these
are the areas damaged in diabetes mellitus. The exocrine (secretory) portion makes
up 80-85% of the pancreas and is the area relevant to the gastrointestinal tract.

It is made up of numerous acini (small glands) that secrete contents into ducts
which eventually lead to the duodenum. The pancreas secretes fluid rich in
carbohydrates and inactive enzymes. Secretion is triggered by the hormones
released by the duodenum in the presence of food. Pancreatic enzymes include
carbohydrates, lipases, nucleases and proteolytic enzymes that can break down
different components of food. These are secreted in an inactive form to prevent
digestion of the pancreas itself. The enzymes become active once they reach the
duodenum.

Pediatric Differences in Anatomy and Physiology

Oral cavity

Oral cavity in a child of the 1st year of life is relatively small, the tongue is rather
large, the chin is flattened, fatty bodies of the cheeks are well developed, the gums
are thickened, and transverse folds on mucous membranes of the lips are well
expressed. Peculiarities of masticatory apparatus in newborns are connected with
the act of mastication.

Peculiarities of the structure of oral cavity

Mucous membrane of oral cavity is dryish, rich of blood vessels, very gentle.
Secretion of mucus is achieved by sublingual, parotid, maxillary and very many
small glands. In the first 3 months secretion of saliva is little, but under its
influence in oral cavity starts digestion of carbohydrates and clotting of milk
casein. At the age of 3-6 months increased secretion of saliva is observed, caused
by the exertion of tricuspid nerve by the teeth which start to erupt and also by
introduction of extra feed. Also is observed physiological hyper salivation
connected with inability of a child to swallow saliva

The teeth in children •

In the first months after birth the teeth are situated under the mucous membrane of
gums. Eruption of teeth starts at 6 months age. This process may go on with
deviations depending on the condition of a child. The child becomes very
excitable, sleep is disturbed, hyper salivation takes place, and the body temperature
rises. After eruption of the teeth all negative phenomena disappear, the child calms
down. On each half of the jaw simultaneously erupt the teeth of the left and right
sides of the oral cavity. More frequently at first erupt the lower teeth, then the
upper one

The teeth in children • Milk teeth in the number of 20 appear in the period from 6
to 24 months (their number is counted with a formula “age of a child -4”). Central
incisors appear in the 6th, 8th month (at first the lower, then the upper ones).
Lateral incisors erupt in the 8-12thth months, premolars – in the 16-20th months,
molars – in the 20-30 months. Milk teeth are lost beginning with 6-7 years.
Permanent teeth in the number of 32 start to erupt from 6-7 years. The process is
finished up to 17-20 years or later.

Peculiarities of the structure of esophagus

Mucous membrane is very gentle, there is insufficient development of elastic

muscular fibers, and there is almost full absence of glands. The upper border of
esophagus is situated higher than in adults (in newborns- on the level of 3-4
cervical vertebra, in adults – on the level of 6 cervical vertebra). In children there
are highly expressed physiological narrowing’s: the 1st – on the site of transition of
the throat into esophagus, the 2nd –on the site of attaching of esophagus to the
aorta, the 3rd- on crossing of the esophagus through diaphragm opening.

Peculiarities of the structure of the stomach

In newborn children the cardial portion, the bottom of the stomach, the Gyss angle
are poorly developed. The Gubarev’s valve is not well expressed, muscular fibers
of the inner oblique layer of the stomach are weak, and this promotes throwing its
contents into the esophagus, causes regurgitation, vomiting, development of peptic
disturbances of mucous membrane of esophagus in children of the 1st year of life.
In babies of the 1st year of life the stomach has a shape of ‘turned upside bottle’
(poorly developed cardial portion and well developed pyloric part)

Functional peculiarities of the stomach

In newborns and babies of the breast feeding age the majority of gastric functions
are decreased. But resorptive function in them is increased, enzyme activity is
decreased, pH is high. Up to 2 months the source of carbon ions is milk acid. The
duration of staying food in the stomach depends on the type of feeding: in natural
feeding – 2-2.5h, in artificial – 3,5-4h. Evacuation of food from the stomach in
children of breast feeding age is hindered by proteins (in the adults – by fats)

Peculiarities of the structure of the intestine

Duodenum has ring like shape, the border of division of mesenteric portion of
small intestine into the jejunum and blind gut is not well manifested. Bauhin’s
valve is underdeveloped, causing invaginations, it also promotes throwing the
microbial contents of blind gut into jejunum with the development of inflammatory
processes in its terminal portion. Mucous membrane of the small intestine has very
many villi, which considerably increase its surface. Mesentery in children is rather
long, promoting development of invaginations, volvuli, hernias.

Peculiarities of the structure of the intestine

In large intestine the descending portion is longer than the ascending portion.
Mesentery of sigmoid colon is relatively long. This may be the reason of frequent
constipations in children. The blind gut is situated lower than in adults. In the
mucous membrane there are no circularly folds. Appendix often is situated
atypically (retrocecally, retrocecally, retroperitoneal, subhepatically), it has the
shape of funnel and wide opening. Rectum has underdeveloped muscular layer and
weak fixation of submucosa layer, producing conditions for its falling out.

Functional peculiarities of the intestine

The duration of movement of food along the GIT comprises on an average 15h.:
along small intestine 7-8h., along the large intestine - 4-12h. • In newborns the rate
of defecations comprises 5- 7 times a day, up to 6 months – 2-3 times, in a year –
1-2 times; in older children – from 1 time in 2 days to 2 times in 1 day. In the first
2 days in newborns is released meconium – thick, viscous mass of dark olive color
without smell (contents of the intestine of fetus). After 3 days – transition stool,
from the 5thth day – usual defecations.

Functional peculiarities of the intestine

In feeding a baby with breast milk the stool is of golden yellow color with sour
smell, its consistency is like thick soured cream. While staying in an air the stool
becomes green (oxidation of bilirubin). With full assimilation of mother’s milk the
amount of stool becomes less. In artificial feeding: defecations increase (because
of less degree of assimilation), often alkaline. • For a baby of the 1st half year in
normal microbiocenosis dominating are Bifidobacterium and lacto bacteria. In the
2nd half a year increases almost in half the presence of intestinal bacilli, which
start to prevail after 1 year of life. Microflora of large intestine synthesizes
vitamins B1, K, stimulates immune mechanism, and fulfills barrier function.

Peculiarities of the structure of the liver

The liver in children is of considerably larger sizes. Up to 5-7 years it always

bulges out from under the right costal arc along the medial clavicular line: • Up to
3 years –for 2-3 cm; • Up to 4-5 years – for 1,0-1,5 cm; • Up to 7 years – for 0,5-
1,0 cm. • Up to 7 months the gall-bladder has spindle like shape and from 6 months
– pear like shape. Up to 5 years the gall-bladder is situated more laterally than in
adults, and has a bend curve. The bile in children contains considerably less bile
acids and this can be the reason of appearing steatorrhea (indigestion of fats in the
stool).

Functional peculiarities of the liver

• The liver of a newborn has relatively large size, it composes about 4-4,4% of the
body mass, is well vasculized, has not sufficiently developed connective tissue and
poorly distincted particles. The liver is functionally immature. The function of
glycogen formation is well manifested, but poorly expressed is the function of
dysintoxication. The liver takes part in the processes of digestion, blood formation,
blood circulation and metabolism. The bile in the first months of the baby’s life is
formed in little amount, contains little bile acids, much water, mucin, pigments; in
newborns also there is much urea. The bile also has more taurocholic acid than
glycocholic one, promoting its bactericidal properties, stimulating secretion of the
pancreas and increasing peristalsis of the large intestine.

Pancreas

• Pancreas is the main gland of the digestive tract. Its secretion especially quickly
increases after introduction of extra feed and reaches the level of an adult person at
the age of 5 years. • The main enzymes of pancreatic juice are: trypsin,
chymotrypsin, diastase, amylase, lipase, phospholipase, incretory insulin. •
Pancreas is morphologically underdeveloped (considerable development of
connective tissue, rich vasculation, and uncompleted differentiation of
parenchyma). • Lymphatic vessels are tightly connected with neighboring organs,
promoting generalization of inflammatory process. Methods of examination of
Summary: We have seen the anatomy and physiology of GI tract and the
difference between adult and child GI tract and functions. The primary purpose of
the gastrointestinal tract is to break food down into nutrients, which can be
absorbed into the body to provide energy. First food must be ingested into the
mouth to be mechanically processed and moistened. Secondly, digestion occurs
mainly in the stomach and small intestine where proteins, fats and carbohydrates
are chemically broken down into their basic building blocks.

Conclusion:

As a nurse we should have knowledge about the GI tract anatomy of the child
which helps us to understand the normal and abnormal differences, main
complaints which helps for early identification of the disturbance of digestive
organs and helps in early intervention.
Bibliography:

1. Marlow, Textbook of child health nursing.3rd edition, published by jaypee

brother’s medical publications.
2. Achara, textbook of child health nursing 5thedition published by
orientlongman publications
3. Padmaja textbook of child health nursing published by jaypee brothers medical
publications
4. https://healthengine.com.au/info/gastrointestinal-system#c0
5. Best Pediatrics Articles of 2019 Official Journal of American Academy of
Pediatrics
 PRESENTATION ON ANATOMY AND PHYSIOLOGY OF

GASTROINTESTINAL SYSTEM IN PEDIATRICS

Submitted To Submitted by
Mrs.A.Sunitha madam S.krupajyothirmai
Lecturer (Dept. of child Health) MSc N II year
GCON GCON