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- •The Digestive System
- •SERIES EDITOR FOREWORD
- •PREFACE
- •ACKNOWLEDGEMENTS
- •CONTENTS
- •Oral mucosa
- •Innervation
- •Anatomy and histology of the tongue
- •Taste
- •Taste buds
- •Taste sensation
- •Causes, diagnosis and treatment
- •Causes
- •Sjögren’s syndrome
- •Symptomatic xerostomia
- •Diagnosis
- •Treatment and side- effects
- •Smell
- •Teeth
- •Mastication (chewing)
- •Control of mastication
- •Generation of movements
- •Regulation of the bite
- •Role of tongue movements in mastication
- •Clinical outlook
- •Introduction
- •The mouth
- •Anatomical features of the mouth
- •Saliva
- •Composition of saliva
- •Salivary glands
- •Structure and histology
- •Functions of saliva
- •Taste
- •Lubrication
- •Digestion
- •Protective functions of saliva
- •Control of water intake
- •Absorption in the mouth
- •Mechanisms of secretion
- •Control of secretion
- •Cellular mechanisms of control
- •Blood flow
- •Control of secretion by food
- •Oesophagus
- •Anatomical arrangements of the oesophagus
- •Oesophageal varices
- •Swallowing (deglutition)
- •Phases of swallowing
- •Control of swallowing
- •Control of motility in the oesophagus
- •Gastro- oesophageal reflux disease
- •Risk factors of GORD
- •Diagnosis of GORD
- •Treatment of GORD
- •Barrett’s metaplasia
- •Symptoms of Barrett’s metaplasia
- •Risk factors
- •Diagnosis
- •Treatment
- •Surveillance
- •Oesophageal cancer
- •Symptoms
- •Risk factors of oesophageal cancers
- •Socioeconomic status
- •Tobacco smoking
- •Alcohol overconsumption
- •GORD and Barrett’s metaplasia
- •Obesity
- •Tobacco smoking
- •Helicobacter pylori
- •Management of oesophageal cancer
- •Surgical resection
- •Achalasia
- •Symptoms
- •Causes
- •Diagnosis
- •Management of achalasia
- •Clinical outlook
- •Introduction
- •Anatomy and morphology of the stomach
- •Important cell types within the stomach
- •Composition of gastric juice
- •Parietal cells
- •Hormonal control
- •Gastrin
- •G cells and gastrin secretion
- •Gastrin receptors
- •Triggers of parietal cell acid secretion
- •Helicobacter pylori
- •The role of the stomach in nutrient absorption
- •Pernicious anaemia
- •Iron
- •Control of pepsinogen secretion
- •Iron-deficiencyanaemia
- •Drug therapy
- •Triple therapy
- •Surgery
- •Gastric cancer
- •Stomach motility
- •Mixing and emptying
- •Acetylcholine and gastrin-releasingpeptide
- •Inhibitory control of parietal cell acid secretion
- •Feedback control via acid concentration
- •Other inhibitory factors
- •The mucosal barrier
- •Acid reduction therapy
- •Antacids
- •Proton-pumpinhibitors
- •H2 receptor antagonists
- •Muscarinic receptor antagonists
- •Control of motility in the stomach
- •Control of gastric function by food
- •Control of the pyloric sphincter
- •Gastroparesis
- •Clinical outlook
- •Introduction
- •Anatomy and morphology
- •Exocrine tissue
- •Histology of the exocrine tissue
- •Pancreatic juice
- •Alkaline secretion
- •Composition
- •Functions
- •Cellular mechanisms of secretion
- •Variation in composition with flow rate
- •Pancreatic enzymes
- •Secretion of enzymes and precursors
- •Activation of enzyme precursors
- •Control of secretion
- •Bicarbonate secretion
- •Hormonal control
- •Neuronal control
- •Zymogen secretion
- •Hormonal control
- •Nervous control
- •Control of secretion during a meal
- •Cephalic phase
- •Gastric phase
- •Intestinal phase
- •Acute pancreatitis
- •Impairment of functions
- •Pancreatic cancer
- •Risk factors
- •Surgical resection
- •Clinical outlook
- •Introduction
- •Overview of the functioning of the hepatobiliary system
- •Anatomy and morphology of the liver
- •Histology
- •Hepatocytes
- •The canaliculus
- •Extrahepatic ducts
- •Liver cirrhosis
- •Causes of liver cirrhosis
- •Clinical management
- •Bile
- •Composition and functions
- •Secretion of the duct cells
- •Secretion from the hepatocytes
- •Biliary lipids
- •Micelle formation
- •Conjugation of metabolites and drugs
- •Determinants of preferential excretion into bile
- •Transport of organic ions
- •Transport into the hepatocyte
- •Transport into bile
- •Metabolism of bilirubin
- •Fate of bile pigments in the gastrointestinal tract
- •Jaundice
- •Prehepatic (or haemolytic) jaundice
- •Intrahepatic (or hepatocellular) jaundice
- •Post- hepatic (or obstructive) jaundice
- •Proteins in bile
- •The gallbladder
- •Anatomy and histology
- •Functions
- •Gallbladder contraction
- •Surgical resection
- •Liver cancer
- •Risk factors
- •Surgical resection
- •The sphincter of Oddi
- •The enterohepatic circulation of bile acids
- •Control of the hepatobiliary system during a meal
- •Cephalic phase
- •Gastric phase
- •Intestinal phase
- •Clinical outlook
- •Introduction
- •Anatomy and structure
- •Duodenum
- •Jejunum and ileum
- •Blood supply
- •Ischaemia
- •Circulation in the villi
- •Surgical resection
- •Structure of the intestinal wall
- •The brush border/unstirred layer
- •The villus and crypts
- •Cell histology of the villus and the crypt
- •Columnar absorptive cells/enterocytes
- •Goblet cells
- •Paneth cells
- •Endocrine cells
- •Stem cells
- •Oligomucous cells
- •Tuft cells
- •M cells
- •Intestinal secretions
- •Electrolyte secretion from crypt cells
- •Control of secretion in the small intestine
- •Hormonal regulation of secretion
- •Neuronal regulation of secretion
- •Absorption
- •Surface area of the small intestine
- •Barriers to absorption
- •Potential difference across the small intestine
- •Absorption of drugs
- •Lipid- soluble drugs
- •Weak electrolyte drugs
- •Strong electrolyte drugs
- •Mechanisms of absorption into the blood or lymph
- •Absorption into the blood
- •Absorption into the lymph
- •Transport of water and electrolytes in different regions of the small intestine
- •Absorption of water
- •Absorption of sodium and chloride
- •Sodium
- •Chloride
- •Diarrhoea
- •Secretory diarrhoea
- •Osmotic diarrhoea
- •Invasive diarrhoea
- •Hypermotility of the intestines
- •Treatment of diarrhoea
- •Antibiotics
- •Antimotility drugs
- •Absorbents
- •Motility in the small intestine
- •Types of motility
- •Spontaneous contractions
- •Migrating motor complex (MMC)
- •Mixing and propulsion during a meal
- •Segmentation
- •Peristalsis
- •Contraction of the muscularis mucosae
- •Control of motility
- •Nervous control
- •Hormonal control
- •Reflex control
- •Gastro- ileal reflex
- •Ileocaecal sphincter
- •Drugs that affect intestinal motility
- •Secretory laxatives
- •Osmotic laxatives
- •Emollients
- •Bulk- forming agents
- •Drugs that increase motility
- •Clinical outlook
- •Introduction
- •Absorption
- •Absorption of important nutrients
- •Carbohydrates
- •Structure of starch and glycogen
- •Digestion of carbohydrate
- •Role of brush-border enzymes
- •Brush- border diseases
- •Monosaccharide absorption
- •Hexose transporters
- •Hexose transport
- •Protein
- •Digestion
- •Digestion in the stomach
- •Digestion in the small intestine
- •Absorption of amino acids
- •Amino- acid malabsorption diseases
- •Minerals and trace elements
- •Calcium
- •Rickets and osteomalacia
- •Iron
- •Regulation of iron absorption
- •Iron- deficiency anaemia
- •Hereditary haemochromatosis
- •Water- soluble vitamins
- •Biotin
- •Folate
- •Pernicious anaemia
- •Lipids
- •Dietary lipids
- •Fat- soluble vitamins and essential fatty acids
- •Lipid solubility
- •Digestion
- •Emulsification
- •Micelle formation
- •The unstirred layer
- •Fate of lipid in the epithelial cell
- •Defects in fat digestion and absorption
- •Bile acids
- •Modification of bile acids in the small intestine
- •Absorption
- •Bile pigments
- •Fat malabsorption
- •Introduction
- •The absorptive state
- •Fate of absorbed carbohydrate
- •Glycogen storage disorders
- •Defects in liver enzymes
- •Defects in muscle enzymes
- •Fate of blood triacylglycerol
- •Fate of absorbed amino acids
- •Insulin
- •Control of insulin secretion
- •Control by glucose
- •Control by amino acids
- •Control by other hormones
- •Control by nerves
- •Actions of insulin in the absorptive state
- •The insulin receptor
- •Glucose entry into cells
- •Glycolysis
- •Glycogen synthesis
- •Triacylglycerol synthesis
- •Amino acid transport and protein synthesis
- •Insulin sensitivity
- •Post- absorptive state
- •Non- insulin- dependent diabetes mellitus (NIDDM)
- •Defects
- •Treatment
- •Insulin- dependent diabetes mellitus (IDDM)
- •Treatment of type 1 diabetes
- •Metabolic state
- •Glucose tolerance test in types 1 and 2 diabetes
- •Comparison with post- absorptive state
- •Glucose- supplying reactions
- •Glucose- sparing reactions
- •Control of the post- absorptive state
- •Release of hormones in the post- absorptive state
- •Actions of hormones in the post- absorptive state
- •Effects on glucose- supplying reactions
- •Effects on glucose- sparing reactions
- •Clinical outlook
- •Introduction
- •Anatomy
- •Innervation
- •Histology
- •The appendix
- •The anal canal
- •Functions of the colon
- •Secretion
- •Absorption and digestion
- •Ions and water
- •Bacterial- derived nutrients
- •Absorption of drugs
- •Motility of the colon
- •Colonic rhythmic phasic contractions
- •Colonic giant migrating contractions
- •Effect of food and importance of fibre
- •Intestinal gas
- •Laxatives
- •Control of motility in the colon
- •Nervous control
- •Reflex control
- •Defecation
- •Control of defecation
- •Ulcerative colitis
- •Colon cancer
- •Risk factors
- •Familial adenomatous polyposis
- •Hereditary non- polyposis colorectal cancer
- •Surgical resection
- •Clinical outlook
- •Introduction
- •Composition of the microbiome
- •Factors altering composition throughout life
- •Diet
- •Antibiotics
- •Bile salts
- •Others
- •Enterotypes
- •Functions of the intestinal microbiome
- •Digestive functions
- •Host defence and colonisation resistance
- •Host immune development
- •The hygiene hypothesis
- •Dysbiosis of the intestinal microbiome
- •Dysbiosis in disease
- •Clostridioides difficile infection
- •Obesity
- •Extra- intestinal diseases
- •Examining the intestinal microbiome
- •16S rRNA sequencing
- •Metagenomics
- •Intestinal microbiome as a therapeutic target
- •Probiotics
- •Prebiotics
- •Faecal microbiota transplantation
- •Preparation of FMT material
- •FMT in disease
- •Self-assessment questions and answers
- •GLOSSARY
- •Index


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2020_ME

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 verication 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
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