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    Fundamentals of Medical Physiology Harminder - Unlocked - Split - 76

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    Fundamentals of Medical Physiology Harminder - Unlocked - Split - 76

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    Fundamentals of Medical Physiology Harminder - Unlocked - Split - 76

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    of 5

    CHAPTER 46 — Stomach and Gastric Secretion 357

    gastric contents are squeezed in oesophagus motor activity. Pacemaker cells of BER are interstitial cells
    of Cajal. MMC (interdigestive housekeepers) are peristal-
    because of reflex relaxation of cardiac end tic waves during interdigestive period showing migrating
    of oesophagus. motor activity, starting from oesophagus and travelling
    c. Antiperistalsis in oesophagus propels the through whole GIT in regular cycle. In relation to meals,
    vomitus in mouth. Antiperistalsis or reverse gastric motility consists of receptive relaxation (vagally me-
    diated), mixing movements (peristalsis and reteropulsion)
    peristalsis is 2–3 cm/s from ileum to up- and gastric emptying. Enterogastric reflex slows down gas-
    wards and leads to distension of duodenum tric emptying and occurs due to stimulation of receptors in
    in 3–5 min. duodenal mucosa due to stretching.
    Gastric function tests include—Fractional meal test,
    d. Soft palate rises and shuts off nasal cavity pentagastrin test, histamine test, augmented histamine
    from throat. test, insulin test, barium meal, endoscopy and biopsy.
    e. Diaphragm ascends (or relaxes). Damage or disruption of mucosa of pyloric region of
    stomach and duodenum leads to peptic ulcer. Main causa-
    f. Muscles of expiration and abdominal wall tive organism is H. pylori which liquefies the protective gas-
    contract. tric mucosal barrier by releasing digestive enzymes which
    cause ulceration in mucosal wall and by releasing vacudat-
    Treatment ing cytotoxin (Vac A).
    Vomiting is expulsion of gastric or intestinal contents
    Following drugs are used in the treatment of from stomach or intestine. Vomiting centre is CTZ.
    vomiting
    • 5HT3 antagonists—Ondansetron
    • D2 antagonists—Chlorpromazine, haloperidol
    • Corticosteroids, benzodiazepines, cannabinoids RECENTLY ASKED QUESTIONS
    (chemotherapy induced vomiting)—Alone or IN EXAMINATION
    in combination with above drugs. • Functions of gastric juice
    • Mechanism of HCl secretion
    • Regulation of gastric juice secretion along with
    CHAPTER RECAPITULATION applied aspect
    Gastric juice (2–2.5 L/day) consists of water, HCl (secret- • Phases of gastric juice secretion
    ed by parietal cells), solids, enzymes like pepsin (precur- • BER
    sor pepsinogen is secreted by chief cells of gastric glands), • MMC
    gastric lipase, gastric amylase, gastric gelatinase, lysozymes, • Gastric emptying
    urease, carbonic anhydrase, mucus (secreted by pyloric • Gastric function tests
    and antral glands) and intrinsic factor (secreted by pari- • Pathophysiology and management of peptic ulcer
    etal cells).
    • Pathophysiology of vomiting and the events
    Membrane potential of smooth muscle of GIT is fluctu-
    ating between −65 and −45 mV (BER), which maintains
    occurring during vomiting

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    Liver, Gall Bladder and 47
    Pancreas

    KNOWLEDGE GOALS
    • Functional unit of liver • Liver function tests
    • Functions of liver • Cholelithiasis
    • Bile and bile salts • Pancreatic secretion and pancreatic
    • Enterohepatic circulation function tests
    • Choleretics

    2. Zone II—Middle zone.


    LIVER AND GALL BLADDER
    3. Zone III—This zone is also known as centrilobu-
    FUNCTIONAL UNIT OF LIVER lar zone. Zone III is maximally prone to hypoxia
    and ischemic damage because of least blood
    Liver consists of lobes which are further divided into supply and oxygenation.
    hepatic lobules. Previously, hepatic lobule was sup-
    posed to be the functional unit of liver, but hepatic Hepatocytes are arranged in hepatic cords,
    lobule is the anatomical unit. Each hepatic lobule is a each of which contains two rows of hepatocytes
    hexagonal lobule consisting of hepatocytes arranged (arranged back to back). The blood spaces
    in single celled thick plate pattern. In between the around the hepatocytes on each side are lined by
    hepatocytes communicating lacunae are present, sinusoids (Fig. 47-2 B).
    known as sinusoids. Sinusoids are lined by the epi­
    thelial cells. At regular intervals, Kupffer cells at- DUAL BLOOD SUPPLY OF LIVER
    tached to the endothelium of sinusoids are present
    Blood supply of liver (1500 mL/min) is from
    which have macrophagic function (Fig. 47-1 A).
    two sources—hepatic artery and porto-hepatic
    Sinusoids are connected with portal vein and
    venous system.
    drain in central vein. In this way the substances
    produced by hepatocytes, carbon dioxide and • Hepatic artery—Hepatic artery is a branch of
    other waste products are dumped in the sinusoids. celiac trunk and contributes 20%–25% of blood
    supply to liver. Hepatic artery provides oxygen-
    • Portal triad—Branch of hepatic artery, portal
    ated blood to liver. Hepatic artery is 95% satu-
    vein and interlobular bile duct (Fig. 47-2 A).
    rated with oxygen.
    • Portal lobule is the area of portal triad between
    • Porto-hepatic system collects blood from GIT
    three adjacent hepatic lobules.
    and spleen and contributes to 75% of blood
    Now, acinus is known as the functional unit of supply to liver. Both hepatic and portal veins
    liver. Acinus is a line joining the two portal triads join the sinusoids. Sinusoids drain in the central
    extending towards the two adjoining central veins vein of lobule. Central vein of the lobules coa-
    in outwardly direction (Fig. 47-1 B). Each acinus lesce to form bigger vein. Big veins open in
    has three zones: right and left hepatic veins which drain in IVC.
    Portal vein is 85% saturated with oxygen.
    1. Zone I—Well oxygenated zone of acinus. This
    zone is least prone to ischaemic injury, but sus- Portal system is the venous system carrying
    ceptible towards infections like viral hepatitis. blood from one capillary bed to another capillary

    359

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    360 SECTION VI — GASTROINTESTINAL TRACT

    Figure 47-1 Hepatic acinus. [Source: Pathologic Basis of Veterinary Disease. 2007. Figure 8-1, Schematic views of the
    microscopic and functional organization of the liver. A, Microscopic organization of the liver. A central vein is located in the
    center of the lobule with plates of hepatocytes arranged radially. Branches of the portal vein and hepatic artery are located on
    the periphery of the lobule, and blood from both perfuses the sinusoids. Peripherally located bile ducts drain the bile canaliculi
    that run between hepatocytes. B, Functional organization of the liver. Both the lobule and the acinus are represented. The
    lobule is a hexagonal unit with portal areas at the margin and a terminal hepatic vein (central vein) at the center. The lobule is
    divided into the periportal, midzonal, and centrilobular areas. The acinus is a diamond-shaped structure with the distributing
    branches of the vessels from the portal areas as the center of the structure. Zone 1 of the acinus is closest to the afferent
    blood supply, and zone 3 is at the tip of the diamond-shaped structure, close to the terminal hepatic vein. Zone 2 is between
    zones 1 and 3.]

    bed, bypassing the heart. Blood from GIT which


    is rich in nutrients enters the liver before enter-
    ing in heart. In liver, carbohydrates and amino POINTS TO REMEMBER
    acids are stored which can be used for new car- Other organs with dual blood supply
    bohydrate and protein synthesis. Some cofactors • Lungs—Pulmonary and bronchial arteries
    and vitamins are extracted from blood for stor- • Brain—Carotid and vertebral arteries
    age. Certain toxins which get absorbed along with • Heart—Systemic and coronary circulation
    food are also filtered by liver.

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    CHAPTER 47 — Liver, Gall Bladder and Pancreas 361

    Figure 47-2 Structure of hepatic cord. [Source: Textbook of Clinical Embryology. Elsevier; 2012. Figure 14.3, Histologi-
    cal components of developing liver. A. Arrangement of hepatic cords. Note, they radiate from central vein towards periphery.
    B. Location of bile canaliculi and bile ductule (derivatives of hepatic bud), liver sinusoids (derivatives of vitelline and umbilical
    veins), and hemopoietic tissue (derivative of septum transversum);158-167.]

    – Synthesis of amino acids, clotting factors


    Applied aspect (II,VI, IX,X), anti thrombin, protein C,
    Regeneration capacity of liver—Liver pos- protein S, thrombopoietin, albumin,
    sesses high regenerative ability. Even 25% of globulins
    the liver mass has the ability to regenerate to – Deamination and transamination
    its original full size, but the shape of the liver – Urea cycle
    is not replaced in mammals. Regeneration oc- c. Lipid metabolism—Hydrolysis of cholester-
    curs due to mitosis of hepatocytes followed by ol, triglycerides and phospholipids to fatty
    biliary epithelial cells and sinusoidal cells. An- acids is done by lipoprotein lipase.
    giogenesis and reconstruction of the extracel- – Cholesterol homeostasis—Cholesterol syn-
    lular matrix occurs. Removal of 75% of liver thesis and conversion to bile acids.
    mass is restored in 40–60 days. This forms the – β-oxidation of fatty acids
    basis for liver donation. – Site for lipogenesis and fat emulsifica-
    tion
    3. Synthetic function
    FUNCTIONS OF LIVER Synthesis of clotting factors (II, VII, IX, X),
    1. Exocrine function—Liver is the largest exo- albumin, angiotensinogen, urea, cholesterol,
    crine gland of body (1.5 kg). Bile is synthe- enzymes like SGOT, SGPT, ALP, insulin-like
    sised by liver which is required for the diges- growth factor
    tion and absorption of fat. 4. Detoxifying function—Physiological degra-
    Bile pigments are taken from sinusoids and dation and removal of toxic agents by liver is
    are released in the canaliculi. Bile salts in- known as detoxification.
    clude sodium and potassium salts of tauro- Kupffer cells are exposed to gut derived bac-
    cholate and glycocholate. teria and endotoxins, so get activated to re-
    2. Metabolic function lease cytokines, NO, prostanoides etc.
    a. Carbohydrate metabolism—Liver performs Liver as a site of xenobiotic metabo-
    ‘glucose buffer action’, that is liver regulates lism—Xenobiotic metabolism refers to
    postprandial blood glucose levels. enzymatic modification of xenobiotics.
    – Glycogenolysis and gluconeogenesis Xenobiotics are the foreign agents pre-
    b. Protein metabolism—Site for both protein sent in an individual, for example drugs,
    synthesis and protein degradation. poisons etc.

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