GIN5 - Overview of Neurogastroenterology

GIN 14: Overview of Neurogastroenterology Proscribe: Tara Kinra
19 September 2007 Reviewer: An Pham

Dr. Sushil Sarna, Ph. D. Chief Reviewer: Ramona Ataya
Overview of Neurogastroenterology
I. Objectives
a. To impart “basic information” about gut motility for clinical practice
b. To understand the current science and mechanisms of regulation of GI motility to help
understand the physiology and pathogenesis of motility disorders
* In the lecture objectives in the syllabus there are some that were not really covered in this lecture so
you may want to consult the reading assignment, Barrett’s GI Physiology Ch’s 7, 8, & 9.
II. Functions
a. Gut functions (review) = Absorption, Digestion, Secretion, and Motility
b. Motility functions
i. Mixing, agitation, stirring, turning over of “digesta”
1. rate is important for allowing efficient digestion and absorption
2. amount of time spent in each part increases to allow increased digestion and
absorption: remember its 15 sec in esophagus, 15 min in stomach, 2 hrs in
small intestine, and 26-48 hours in colon
ii. Propulsion
1. may be rapid and over long distances
2. special situations include vomiting, defecation, and mass movement
iii. Cleaning (in between meals) of debris, secretion, bacteria (stasis leads to
fermentation of bacteria which you want to avoid)
c. Three distinct types of gut contractions to accomplish the motility functions
i. Rhythmic phasic contractions
(C)- short in duration (3-10 sec)
and may or may not occlude the
lumen
ii. Ultra-propulsive contractions-
key words are large amplitude and
longer duration
1. GMC = Giant Migrating
Contractions (D)
2. RGC = Retrograde Giant
Contractions
iii. Tonic contractions (B) –
decreased diameter of the lumen
(may be combined with other
contractions, such as to make rhythmic phasic contractions more effective in
propagating)
d. Patterns of Contraction to accomplish the different motility functions
1. Propagating
a. Slow phasic propulsion (A) starts proximal and moves distal, away
from the mouth (aboral)
b. Rapid strong propulsion (B)
2. Mixing
a. Propulsion occurs (C) distally but also some food escapes
proximally because the lumen is not completely occluded (this
allows mixing)
b. Very little/no propulsion (D) occurs with random contractions at
different locations since there is occlusion of the lumen so
digesta moves back and forth to be exposed to the mucosa for
digestion/absorption
III. Esophagus
Page 1 of 7
a. Motility & Function
i. Rapid motility ~15 sec to go through this long tube to reach the stomach through the
lower esophageal sphincter
ii. No digestion or absorption
b. Swallowing mechanism = primary peristaltic wave = GMC (type of ultrapropulsive
contraction)
i. Note: the LES is closed at rest
ii. LES relaxes and stomach pressure
decreases to equal LES pressure
iii. Bolus of food passes through LES
iv. Afterwards the LES contracts
again… otherwise you get GERD
(dysfunction of LES allowing
gastric acid to reflux upwards)
v. The pressures can be measured
using manometry with transducers
throughout the length… showing
the peristaltic wave here 
IV. Motility disorders associated with Esophagus

a. Achalasia
i. Symptoms
1. Dysphagia – difficulty
swallowing
2. Regurgitation and
pulmonary aspiration
3. Chest pain
4. Heartburn
ii. Characteristics
1. Incomplete or absent relaxation of LES pressure in response to swallow
2. Progressive nature of disesae
3. Barium swallow shows a patient progressing from normal (1983) to some
blockage of distal esophagus (5 years later in 1988) and eventually to
significant dilation of the esophagus and still lack of connection to the
stomach (1990) *note characteristic “bird’s beak” obstruction of the
achalasic esophagus… here it one upside down for you to see better…
remarkable resemblance to happy feet?
2a
4. Manometry shows LES pressure becomes erratic and actually elevated

during the swallow rather than decrease/relax
5. Dry (just saliva) and wet (squirt liquid down throat) swallows fail to
induce peristaltic GMC’s in distal 2/3’s of esophagus
6. Swallow induces instead a low amplitude simultaneous contraction
Page 2 of 7
7. Elevated intra-esophageal pressure relative to gastric baseline (therefore
food bolus does not go into stomach)
b. Symptomatic Diffuse Esophageal Spasm
i. Symptoms
1. Dysphagia – difficulty swallowing
2. Chest pain – worsened by emotional stress and hot or cold liquids
ii. Characteristics
1. Simultaneous contractions in distal esophagus, mixed with peristaltic
contractions in response to swallow (sometime it is spastic and sometimes
not)
2. Multiple repetitive, small amplitude contractions in response to swallow,
although began as a GMC proximally
3. LES relaxation may or may not be normal
4. Manometry show the small amplitude multiple contractions and lack of
consistent GMC’s
V. Stomach
i. Not as rapid as esophagus, takes ~ 15 minutes to be mixed back and forth and go on
to the duodenum through the pyloric sphincter
ii. Digestion begins
b. Factors regulating gastric emptying
i. Fundic adaptive (receptive) relaxation followed by gradual contraction
1. Fundus relaxes proximally with distension to accommodate larger volume
of food in its reservoir
2. Keeps pressure in stomach under control
3. Eventually the fundus gradually increases its tone to transfer food to body
for mixing
ii. Antro-pyloro-duodenal coordination allows food to pass
through pylorus
1. Antrum and corpus contract by phasic
contractions
a. Mix food with gastric secretions
b. Breaks up food into liquid-like chyme
2. Pylorus is relaxed at rest
a. Small particles < 0.5 mm (Other sources say 1-2 mm) can pass
through at anytime and therefore spend less time before being
emptied (the pylorus closes with contractions)
b. Rate of gastric emptying is related to particle size
3. Duodenum is open/relaxed at rest

a. Food enters the duodenum when it is relaxed not while contracting
b. Contractions push food back from pylorus back into the stomach
for further breakdown/digestion
iii. Neurohormonal feedbacks from the small intestine
Page 3 of 7
1. Duodenal and Jejunal receptors control gastric emptying by feedback
2. Main proximal receptors have osmo-receptors, pH receptors, and fat-
receptors
3. Minor contributions to help modify gastric emptying include: temperature,
gravity, volume, composition, osmolality, viscosity
Page 4 of 7
VI. Small Intestine
i. Mixing but always moving (if it sits still it will obstruct) at a slow rate; 2 hours to
pass through
ii. Vigorous mixing with bile acid (secreted into here)
iii. Most of absorption take place in the upper (proximal) half of the small intestine
b. Organization of contractions spatially and temporally
i. Proximal small intestine has more rapid and farther spreading propagation
ii. Middle sections have both propagation and mixing
iii. Distal small intestine is slower in propagation and functions for more maximal
mixing (time for absorption)
iv.
However,
remember
that the
proximal
small
intestine (SI)
also has the
majority of
the
absorption,
although it
spends less
time there…interesting, huh? This allows gastric emptying without obstruction by
keeping things moving for larger quantities to be absorbed simultaneously throughout
the SI
c. Migrating Motor Complex (MMC)

i. A type of cyclic motor activity which repeats every 2 hours during interdigestive
states (start 6-8 hours after a meal when all the digesta has traveled to the colon)
ii. Function = to clean gut, squeezing everything out by complete occlusion of the
lumen
iii. MMC’s are strong/large persistent contractions that begin in the LES, antrum, and
duodenum simultaneously and spread throughout the SI ending at the ileocolonic
junction
iv. MMC’s continue in a cyclic pattern until food is re-introduced
Page 5 of 7
v. MMC is coordinated with secretions of bile acid from the gallbladder, trypsin from
the pancreas, acid secretion from parietal cells, and bicarbonate output from the
pancreas
1. peak in secretions occurs at the beginning of the MMC (proximal end)
2. these secretions help to digest/clean anything left over from eating
3. this happens during the fasting state
Page 6 of 7
VII. Giant Migrating Contractions in more exciting special motility functions
a. Diarrhea
i. GMC normally occur in distal SI (terminal ileum)
ii. Normal propagation is 2-4 cm and occurs at a low frequency (2-6x a day)
iii. Increased frequency and propagation (i.e. 95 cm) can result in  diarrhea
iv. GMC can be strong, rapidly repel over long distances in short time
b. Vomiting
i. 2 phases of vomiting
1. Regurgitation and retching
a. inspiration on partially closed glottis
b. hypopharyngeal sphincter is closed
c. low intrathoracic pressure
d. LES relaxed and body of the stomach relaxed
e. high intra-abdominal pressure
f. antrum & duodenum in spasm
2. Vomiting
a. glottis closed to prevent aspiration
b. hypopharyngeal sphincter opens
c. high intrathoracic pressure
d. esophagus, LES and body of stomach relaxed
e. high intra-abdominal pressure
ii. After retching a few times  may progress to vomiting (meal is expelled)
iii. Accomplished by strong contractions of abdominal muscles and diaphragmatic
muscle and therefore *not regulated by control of gut
iv. Gut can help bring contents of SI back to the stomach via retrograde giant
contractions
1. Capable of emptying all contents of proximal half of SI
2. Useful if there is any harmful substance
c. Abdominal cramping – also caused by GMC of increased amplitude or with decreased pain
threshold to cause pain (more on this in lecture #15)
VIII. Colon
i. Uses rhythmic contractions therefore runs at much slower rate, it takes between 36
(in males) to 48 (in females) hours to pass through from the cecum to the rectum
ii. Water and electrolytes are absorbed
iii. Tone increases after eating a meal and is sustained for long periods of tone (vs.
transient tone occurs when water is given but returns to normal within ½ hour )
iv. Feces are stored before being expelled in the distal colon
v. Motility disorders – may have increased propulsion
b. Defecation
i. capable to achieve in a short period of time (thankfully we are not turkeys)
ii. GMC’s in the distal colon rapidly
expel feces for defecation
iii. Anal sphincter relaxed
iv. BISACODYL stimulates GMC’s
and can be used to relieve
constipation
v. Other laxatives stimulate
secretions
Page 7 of 7

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GIN 14: Overview of Neurogastroenterology Proscribe: Tara Kinra

19 September 2007 Reviewer: An Pham

IV. Motility disorders associated with Esophagus

4. Manometry shows LES pressure becomes erratic and actually elevated

3. Duodenum is open/relaxed at rest

c. Migrating Motor Complex (MMC)

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