Disorders of the Abdomen

Julie Mann, ACNP

HSCI 302

• Structure of the Digestive System

○ One big hollow tube from mouth to rectum.

• Alimentary Tract Functions
○ Ingestion of food
○ Propulsion of food and wastes
○ Secretion of mucus, water, & enzymes to break down food
○ Mechanical digestion of food particles
○ Chemical digestion of food particles
○ Absorption of digested food
○ Elimination of waste products by defecation
• Mouth
○ Tongue surface has chemoreceptors (taste buds)
 • Chemical messengers, relay to brain - salty, sweet, sour,
etc.
○ 32 permanent teeth (adult mouth)
• Starts breakdown of food, mastication.
○ Salivary Glands
 Lubricate food, break down food (particularly CHO)
• Submandibular Glands - floor of mouth
• Sublingual Glands - under tongue
• Parotid Glands - upper part of mandible, secrete through
stenson ducts.
• Esophagus
○ Conducts food from oropharnyx to stomach
○ Peristalsis
• Sequential relaxation and contraction.
○ Upper and
• Keeps air from entering stomach during inspiration.
○ Lower Esophageal Sphincter (cardiac sphincter)
• Prevents food from regurgitating back up from stomach
into esophagus.
• Swallowing
○ Oropharyngeal Phase (take 1 second)
i. Food made into bolus by tongue, pushed to back of
pharnyx
i. Superior constrictor muscle of pharnyx contracts
i. Respiration is inhibited, epiglottis slides down
○ Esophageal Phase (5-10sec)
i. Bolus enters the esophagus
i. Wave of relaxation travels over esophagus
i. Peristalsis to the lower esophageal sphincter
i. Bolus enters the stomach, sphincter returns to resting tone
• GI wall Structure (4 layers) inner to out
1. Mucosa
i. Lining of epithelial tissues and underlying tissue, and
smooth muscles.
i. Secrete mucus to protect from acid.
i. Enzymes released to break down food products.
i. Helps protect body against foreign antigens/pathogens.
1. Submucosa
i. Dense CT
i. Contains blood vessels and nervous tissue.
i. Layer that secretes digestive enzymes.
 1. Muscularis
i. Longitudinal muscles, circular muscles, help propel food
through digestive tract.
1. Adventitia (serosal layer)
 Squamous epithelium and some CT.
• Peritoneum
 Double layered tissue with space in middle (potential
space) with fluid (peritoneal fluid)
• Stomach

○ Food enters through lower esophageal sphincter, enzymes

secreted, food moved down through pylorus into duodenum.
○ Blood supply is abundant, therefore problematic when ulcers
occur.
• Gastric Motility
○ Peristaltic contractions influenced by neural and hormonal
activity
• Neural - vegas nerve
 • Hormonal - Gastrin, modolin, etc. help control peristaltic
contractions.
○ Mixing and emptying of food (chyme) from stomach takes
several hours
○ Rate of Gastric emptying depends on:
• Volume
 Larger volume increases rate of gastric emptying.
• Osmotic Pressure
 Non-isotonic food decreases rate of emptying.
• Chemical Composition of Gastric Contents
 Fat takes longer to empty.
• Gastric Secretion
○ Mucus
• protects gastric mucosa from acid
○ Acid-formed in the parietal cells, secretion is stimulated by
acetylcholine, gastrin, and histamine and inhibited by
somatostatin
• Decrease rate when exposed to unpleasant odors.
• Dissolves food fibers
• Acts as bacteriocide against swallowed organisms
• Chronic situation increases acid secretion
○ Pepsin- secreted from chief cells proteolytic enzyme.
• Breaks down protein (all in stomach, so if pushed out too
rapidly it won't digest properly in small intestine)
• Inactivated in duodenum (alkaline environment).
• G.I. Hormones
○ Stomach
• Gastrin
 Secreted from G-cells, located in antum of stomach
 Increase gastric acid secretion into stomach.
• Ghrelin
 Polypeptide hormone, produced by endocrine cells
inside of fundus of stomach.
 Stimulates body to intake food and reduces energy
expenditure at time of ingestion of food.
○ Intestine
• Secretin
 Secreted by S-Cells
 Inhibits secretion of gastrin --> less acids.
• Cholecystokinin (CCK)
  Secreted by I-Cells in mucosa of small intestine
 Downregulates action of secretin. Increase gastric
secretion.
○ GLP-1 (not covered)
○ GIP (not covered)
• Small Intestine
○ Duodenum, jejunum, & ileumIleocecal valve
○ Microvilli & brush border
• Microvilli - folds that create a huge surface area where
electrolytes and fluids can be absorbed during digestive
process.
• Length gives time for food to digest (CHO further broken
down, protein, fats)
○ Digestion aided by pancreatic enzymes, intestinal enzymes,
and bile salts
• Intestinal Motility (Small Intestine)
○ Enteric Nervous System Innervation
• myenteric (Auerbach) plexus
 Nervous tissue sits between longitudinal and circular
muscles in small intestine.
 Controls movement of bolus.
• submucosal (Meissner) plexus
 Sits between mucosal layer and circular layer
 Controls mixing movement.
 Controls local blood flow.
○ ANS Innervation
• Mainly Parasympathetic- vagus nerve
 Stimulate both plexuses to increase intestinal motility
• Sympathetic
 Inhibits intestinal motility.
○ Intestinal Smooth Muscle
• slow wave activity
 Muscle cells within small intestinal wall with generate
rhythmic waves, 12 waves/min.
• How own intrinsic rate for firing.
• Large Intestine
○ Cecum, appendix (no function, possibly immune), colon,
rectum, and anal canal
○ Colon
• Ascending, Transverse, Descending, & Sigmoid
 ○ Ileocecal valve to cecum, O’Briene sphincter (from descending
to sigmoid), Internal (unconscious control) and External
(conscious control) anal sphincters (defecation)
• Colonic Motility
○ Two types of movement
• Haustrations
 Water absorbed from chyme by mixing it around.
• propulsive mass movements
 Move forward to anal canal.
○ Defecation
• initiated by mass movements
• controlled by internal and external sphincters (poop!)
• Anorexia: loss of appetite
○ Any loss of appetite, forerunner to nausea.
• Nausea: subjective sensation
• Retching: rhythmic spasmodic movements
○ but not expelling, vs. vomiting.
• Vomiting: sudden forceful oral expulsion of the contents of the
stomach
○ Activation of vomiting center of brain.
○ Chemoreceptors that send the message.
• Dysphasia
○ Difficulty of swallowing.
○ Problems with Cranial nerves 5,9,10.
○ Narrowing of esophagus.
○ Stroke
• Hiatal Hernia
○ Herniation of stomach up through diaphragm (see pics in book)
○ Sliding
• Bell shaped protrusion through stomach.
• Pouch slides up and back down
• Gastric acid can come back up through esophagus
○ Paraesophageal
• Whole separate portion of stomach comes up through
diaphragm opening.
• Gastroesophageal Reflux
○ LES relaxes 1-2 hours after eating
○ Can cause inflammatory response called reflux esophagitis
• GERD
○ Persistant reflux of gastric contents
 ○ Assoc. with weak LES and delayed gastric emptying (chyme
and acids)
○ Tell pt. to sit up so that chyme doesn't flow back up over LES.
○ Symptoms: heartburn
○ Reflux esophagitis: mucosal injury, hyperemia (increase of
blood to area), inflammation.
• More of a problem when chronic
○ Complications:
• Strictures
 Narrowing within esophagus
• Barrett esophagus
 Form of metaplasia, cells change over esophagus,
when untreated --> increased risk towards esophageal
cancer.
• Peptic Ulcer Disease
○ Any break, or ulceration, in the protective mucosal lining of the
lower esophagus, stomach, or duodenum
○ Acute/Chronic, Superficial/Deep
• Chronic - Decrease mucosal secretion, ie smokers.
• Superficial inner lining, vs deep through to the muscles.
• Acid kills/desolves cells in stomach
○ Risk Factors?
• Smoking, advance age, habitual use of anti-inflammatories
(aspirin), chronic alcohol, emphysema, RA, exposure to h.
pylori.
○ Clinical Manifestations
• Discomfort/pain in between meals, eat - pain goes away
• Muscle guarding - tense stomach muscles when try to
touch abd.
• Can have exacerbations then remissions.
○ Complications: hemorrhage, perforation (hole through tissue),
and penetration (into surrounding tissues)
• Irritable Bowel Syndrome
○ persistent or recurrent sympt. of abd pain, altered bowel
function, and flatulence, bloating, nausea, anorexia,
constipation, diarrhea, anxiety, and depression to varying
degrees.
○ Dysfunction in regulation of the intestinal motor and sensory
fuctions
○ Stress exacerbates issue, physiological and psychological.
 ○ More common in women than men, usually during
premenstrual time period (hormonal trigger?).
○ diagnosis made by signs and symptoms
○ Treatment
• Treat stress (trigger).
• Inflammatory Bowel Disease
○ Ulcerative Colitis
• Chronic inflammatory disease causes ulceration (erosion of
tissue) of the mucosa of the colon
 Bleed into colon, cramping pain, strong urge to
defecate.
• Age 20 – 40 years
• Risk Factors
 Family history, Jewish descent, Caucasian.
• Cause is unknown, start with inflammatory process
primarily in rectum and sigmoid colon.
• Frequent exacerbations and remissions, watery diarrhea, a
lot of blood (will be redder cause lower in GI tract).
 When GI bleed Higher up in GI tract will be blacker.
• Clinical Manifestations
 Lesion begins with inflammation, usually in rectum
and sigmoid colon causing mucosal destruction
• Complications
 Anal fissures, hemorrhoids, abcesses form around
rectal area, increased risk for colon cancer.
• Treatment - surgically fix colon/rectum. Anti-inflammatory.
○ Crohn’s Disease
• Inflammatory disorder of the small and large intestines
(not as often in Sigmoid or rectum), cause fissures in the
colon
• Nonspecific irritable bowel symptoms for many years,
bloody diarrhea, weight loss.
• Problems depend on area which is destroyed, which
nutrients are no longer absorbed.
• Rectum is rarely involved
• Risk Factors/causes
 Jewish descent, caucasian, family history.
• Ascending and transverse colon most affected
 Skipped lesions, areas of inflammation, then ok, then
inflamed, etc.
 • Clinical Manifestations
• Complications
 Intestinal obstructions (narrowing), fistulas (opening
between 2 areas of body where there shouldn't be.
• Treatments - surgically remove damaged sections, Anti-
inflammatory.
• Diverticular Disease
○ Saclike outpouchings of mucosa through the muscle layer-
usually sigmoid colon
○ Diverticulosis
• Having the pouch
○ Diverticulitis
• Pouch gets infected/inflamed
○ Common in elderly, or if diet high in refined foods (the
American diet) because bolus does not require a lot of muscle
to push through, therefore fiber eaters triumph again!
○ Symptoms
• When eat something with little parts that get stuck in
outpouchings, diverticulitis can set in --> cramping of abd,
distension, flatulant, diarrhea or constipation, obstruction,
infection (fever, inc WBCs, pain)
• When severe, can rupture, get peritonitis (inflammation of
peritoneal area)