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The Digestive System

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SYSTEMS OF THE BODY
The Digestive System
BASIC SCIENCE AND CLINICAL CONDITIONS
third edition
Richard Horniblow MSci, PhD,
PGCHE, FHEA Lecturer of Biomedical Science School of Biomedical Sciences College of Medical and Dental Sciences University of Birmingham Birmingham, UK
Mohammed Nabil Quraishi
PhD, MRCP, FEBGH
Consultant Gastroenterologist Honorary Senior Clinical Lecturer University Hospitals Birmingham NHS Foundation Trust University of Birmingham Birmingham, UK
1st and 2nd edition authors:
Margaret Smith Dion Morton
Chris Tselepis BSc, PhD, FRSB, PFHEA
Professor of Biomedical Science School of Biomedical Sciences College of Medical and Dental Sciences University of Birmingham Birmingham, UK
Series Editor Stephen Hughes BSc, MSc, MBBS,
FRCSEd, FRCEM, FHEA Consultant in Emergency Medicine, Broomfield Hospital Senior Lecturer in Medicine, School of Medicine, Anglia Ruskin University Chelmsford, UK
For additional online content visit ExpertConsult.com
© 2023, Elsevier Limited. All rights reserved.
First edition 2003 Second edition 2010
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verication of diagnoses and drug dos­ages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-7020-8376-1
Publisher: Jeremy Bowes Content Project Manager: Fariha Nadeem Design: Margaret Reid Illustration Manager: Anitha Rajarathnam Marketing Manager: Deborah Watkins
Copyedited by Editage, a unit of Cactus Communications Services Pte. Ltd. Typeset by TNQ Technologies Pvt. Ltd. Printed in Poland
Last digit is the print number: 9 8 7 6 5 4 3 2 1

SERIES EDITOR FOREWORD

Most students now study medicine through a form of inte grated curriculum. These courses blend basic science with exposure to clinical medicine from an early stage. These students have the good fortune to be left in no doubt, from the outset, why they are studying medicine. I teach in a medical school that delivers a fully integrated curriculum and I can compare it with the traditional model according to which I received my early medical education. That com parison is very favourable.
Unlike many other texts, the Systems of the Body series
has been designed very specifically to sup port an inte­grated approach to learning medicine. Our carefully selected panel of authors drawn from across the English­speaking world have combined basic sci ence with clinical application. Links to clinical skills, clinical inves­tigation and therapeutics are made clear throughout.
The aim is to offer highly accessible guidance for all student types and stages. It will be invaluable to those who are approaching the subject for the first time or who may have found a topic challenging when using other more traditionally configured resources – as well as greatly assist all students wishing to excel as their course progresses. The clear layout and writing style, together
with detail that informs without overwhelming, go a long way to supporting students. It may also provide welcome reminders to postgraduates facing their own examinations.
Whatever curriculum you follow, wherever you are in the world, and whichever stage you are at, we know that the Systems of the Body volumes will serve as great places to start when learning something new and enable you to effectively piece together the essential compo­nents of each major body system, in a modern clinical context.
Good luck!
Stephen Hughes, MSc MBBS FRCSEd FRCEM FHEA
Senior Lecturer in Medicine
Anglia Ruskin University
Chelmsford, UK
and
Consultant, Emergency Medicine
Broomfield Hospital
Chelmsford, UK

PREFACE

The field of gastroenterology is a dynamic and exciting area of clinical medicine and biomedical science. The evolution of this system, enabling us to extract nutrients from our diet, has allowed us to thrive. What appears to the uninformed to be a simple hollow tract traversing our body is, in reality, a complex, multi- compartmental system, vital for human life. However, students studying the subject can often feel somewhat overwhelmed with this complexity, particularly as the gastrointestinal tract is commonly dissected into many individual function­ing parts. Consequently, this third edition of The Digestive System has focussed the subject content in addition to streamlining the learning outcomes. Furthermore, there is now an opportunity for self- assessment at the end of each chapter which allows for reflection and assess­ing understanding of the subject. Similarly, many years
teaching both preclinical and biomedical scientists on the subject has highlighted a continued disconnect between the descriptive physiology of the gastrointestinal tract and clinical manifestations. Thus, in this edition, there is increased integration between the basic science and clini­cal cases of common diseases presenting in healthcare settings, enabling the reader to easily grasp the under­pinning physiological changes associated with disease. Furthermore, gastrointestinal pathologies and treatment pathways are now described within their respective chapters to better compartmentalise information. Finally, this edition now includes a chapter on the intestinal microbiome, a subject which has come to the fore in the last decade, becoming incredibly important to gastroin­testinal biology and is now implicated in many intestinal and extra- intestinal diseases and processes.

ACKNOWLEDGEMENTS

We are grateful for the help given by various academ­ics and clinicians in the preparation of this new edition of The Digestive System. This edit builds on the success­ful previous editions of the book and, as such, we wish to thank all contributing individuals acknowledged in the previous editions. Furthermore, we wish to thank Prof. Margaret Smith and Prof. Dion Morton who estab-
lished the basis of the previous editions and for provid­ing us with the opportunity to develop this new edition. Key individuals who provided guidance and support for this update include Dr Revers Donga and Dr Robert Stephenson for their contributions to anatomical sections and Dr Praveen Sharma from the School of Dentistry, University of Birmingham.

CONTENTS

1
DIGESTION FROM THE START: THE MOUTH, SALIVARY GLANDS AND OESOPHAGUS 1
Clinical outlook 2 Introduction 2 The mouth 2 Anatomy and histology of the tongue 3 Causes, diagnosis and treatment 4 Saliva 9 Salivary glands 10 Oesophagus 14 Gastro- oesophageal reflux disease 16 Barrett’s metaplasia 18 Oesophageal cancer 19 Achalasia 22  
2
THE STOMACH: BASIC FUNCTIONS AND CONTROL MECHANISMS 25
Clinical outlook 26 Introduction 26 Anatomy and morphology of the stomach 26 Important cell types within the stomach 27 Composition of gastric juice 27 Parietal cells 27 Triggers of parietal cell acid secretion 28 Inhibitory control of parietal cell acid secretion 29 The mucosal barrier 30 Acid reduction therapy 32 Helicobacter pylori 33 The role of the stomach in nutrient absorption 33 Secretions of the chief cell 34 Peptic ulcer disease 35 Gastric cancer 36 Stomach motility 37 Control of motility in the stomach 39 Control of the pyloric sphincter 40 Control of gastric function by food 40 Gastroparesis 44  
3
EXOCRINE FUNCTIONS OF THE PANCREAS 45
Clinical outlook 46 Introduction 46 Anatomy and morphology 46 Pancreatic juice 48 Pancreatic enzymes 50 Secretion of enzymes and precursors 50 Control of secretion 52 Control of secretion during a meal 53 Acute pancreatitis 54 Pancreatic cancer 57 Surgical resection 57  
4
LIVER AND BILIARY SYSTEM 59
Clinical outlook 60 Introduction 60 Overview of the functioning of the hepatobiliary system 60 Anatomy and morphology of the liver 60 Liver cirrhosis 63 Bile 63 Biliary lipids 65 Micelle formation 66 Conjugation of metabolites and drugs 66 Determinants of preferential excretion into bile 69 Transport of organic ions 69 Jaundice 71 Proteins in bile 72 The gallbladder 72 Surgical resection 74 Liver cancer 77 Surgical resection 77 The sphincter of Oddi 77 The enterohepatic circulation of bile acids 77 Control of the hepatobiliary system during a meal 78  
5
THE SMALL INTESTINE 79
Clinical outlook 80 Introduction 80 Anatomy and structure 80 Blood supply 81 Surgical resection 82 Structure of the intestinal wall 83 The villus and crypts 83 Cell histology of the villus and the crypt 83 Intestinal secretions 84 Absorption 85 Absorption of drugs 86 Mechanisms of absorption into the blood or lymph 87 Transport of water and electrolytes in different regions of the small intestine 88 Diarrhoea 90 Treatment of diarrhoea 92 Motility in the small intestine 93 Control of motility 94 Drugs that affect intestinal motility 96