GI Physiology

Regulation

Neural Hormonal

Neural Regulation Involuntary except oesophagus & rectum Rest Autonomic ENS

Extrinsic Innervation

Somatic / Autonomic Somatic Pharynx & prox. Oe. (Motor lower cranial nerves Anal canal pudendal nerve

Autonomic NS

PSNS Vagus Increases GI motility (A SNS Inhibit GI activity (Norad)

Intrinsic Innervation

By ENS Afferents from gut Response with or without ANS little brain of gut

Hormonal Regulation
1. Gastrin (Antrum) Increase of LES pressure, stim of small bowel and GB 2. CCK (Duo & Jej) - Stim of GB, slows motility of small bowel & stomach 3. Secretin (Duo & Jej) Increases pyloric pressure, inhibits small & large bowel 4. Motilin (Duo) increase of gastric emptying

Hormonal Regulation
5. Somatostatin (Islets) Increases gastric emptying, inhibits secretions 6. GIP (small intestine) Delays gastric emptying

Oesophagus
Sphincters prevent regurg. and keep oe. empty between swallows UES prevents regurg to pharynx LES - prevents regurg maintains HPZ

Stomach Functions
1. 2. 3. 4. 5.

Reservoir : 200 1500ml Mix and grind food Chemically breakdown food Kill microbes Control emptying into duodenum

Stomach Glands

Mucous cells mucous for protection Parietal cells HCl & IF Chief cells - Pepsinogen

Stomach Innervation

Vagus Increased motility & secretions Relax fundus on food intake

Sympathetics Decreased activity of smooth muscle

Small Bowel

Mucosal surface increased by plicae, villi and microvilli (500 fold) Motility influenzed by ANS,ENS and hormones

Functions of Colon

1. Absorption of water and electrolytes 2. Transportation of waste 3. Storage of waste

Anal Canal

Internal sphincter Involuntary, Responsible for resting pressure External sphincter Voluntary, Responsible for pressure on voluntary squeeze Innervated by somatic nerves

Gall bladder

Concentrates bile and works as reservoir Empties in relation to meals in response to hormones Sphincter of Oddi several parts HPZ

Pancreas

1. Exocrine function 2. Secretion of HCO3

3. Endocrine function Insulin, Glucagon, Somatostatin Hormonal mechanisms for regulation

Physiology of Swallowing

1. Oral stage tongue voluntary control 2. Pharyngeal stage Reflex Food stimulates swallow receptors Swallow centre inhibits respiration

3. Oesophageal stage
Peristalsis + Gravity 7-10 sec LES pressure 20mmHg over intra-gastric pressure at rest Pressures equal during swallowing LES opens until bolus and contraction have passed through

Factors affecting LES Pressure

Increase Gastrin, Motilin, Vasopressin Protein Prokinetics

Decrease Proges.,Secretin,CCK,Glucagon Fat, alcohol, chocolate Ca blockers, Benzodiazepines, Theophylline, Atropine

Disorders of Swallowing

1. Mechanical eg. Ca, FB 2. Neuromuscular incoordination eg. Achalasia, DES, Bulbar palsy

Achalasia

Autoimmune/ Genetic/ Infective Loss of ganglion cells in myenteric plexus Degenerative changes in vagus & DMN Chagas is aquired achalasia

Manometry in Achalasia

Absence of peristalsis Elevated LES pressure Incomplete relaxation of LES

GERD
Gastric acid pH 1.5 2 Oesophageal pH 6 7

Physiological reflux After meals, short duration, not during sleep Pathological reflux long duration, D/N, symptomatic

Aetiology of GERD

1. Incompetent LES 2. Deficient/delayed acid clearance 3. Gastric abnormalities 4. Transient LES relaxation

Incompetent LES

1. Hormonal factors eg. Progesterone in pregnancy 2. Length of LES exposed to higher intragastric pressure Hiatus hernia

Delayed acid clearance

1. Primary peristalsis D/N = 60/6 2. Secondary peristalsis absence of swallow 3. Salivation neutralises acid

Gastric abnormalities

1. GOO 2. Delayed emptying eg. DM, vagotomy

Basis of tests

Manometry LES pressure & length 24 hr oesophageal pH Quantify, frequency, timing

Physiology of defaecation
Distension of rectum registered in cortex RAIR IAS relaxes Faeces in contact with upper anal receptors Receptors determine quality and content (sampling reflex) Contraction of rectum, relaxation of EAS, pelvic floor & puborectalis sling

Anorectal Manometry

Resting pressure autonomic neuropathy, MDA Squeeze pressure Trauma, surgery RAIR absent in Hirshprungs