fisiologia digestiva (bcm ii)

FISIOLOGIA DIGESTIVA (BCM II)FISIOLOGIA DIGESTIVA (BCM II)

Clase 10: Fisiología del colonClase 10: Fisiología del colon

Dr. Michel Baró A.

The anatomy of the colon is shown

Circular and longitudinal muscle layers in colon

The layers of the colonic wall are shown

Normal colonic mucosa in biopsy specimen

Maturation process of colonic epithelial cells

(3 a 5 días)

A human rectal columnar epithelial cell

Arterial blood supply to the colon is shown

The venous system that drains the colon is shown

The extrinsic innervation of the colon

Intrinsic innervation of the colonic wall

Ganglia in submucosal and myenteric plexuses

Lymph nodal drainage of the colon and anus (a)

Lymph nodal drainage of the colon and anus (b)

Scintigraphic pattern of colonic transit

Time a substance spends in each region of colon

Distinct motor patterns as measured by manometry

Contracciones de corta duración: estacionarias, de mezclaContracciones de larga duración: estacionarias o migratorias brevesContracciones de gran amplitud: movimientos de masa

Patterns of migration of contractions

Presence and intensity of short-duration contractions

Colonic electrical control or slow-wave activity

Borde submucoso Borde mientérico

Electrical activity from the human colon

SSB: Short spike burst. LSB: Long spike burst. MLSB: Migrating long spike burst

Patterns of motor and myoelectric activity (perros)

Development of high-amplitude propagating contractions

Colonic contents and motor activity in colon

Motility of colon over 24-hour period

Colonic motilityindex

Gastrocolonic motor response to meal ingestion

Fecal bolus in the colon has been postulated

Mediation of both limbs of colonic peristaltic reflex

Motor activity of colon modulated by vagal activity (ferret)

Actividad fásica espontánea del colon proximal

Colonic motor function can be significantly altered

Am J Med 1951

Summary of small intestinal and colonic fluid balance

Major electrolyte transport mechanisms

TABLE 1 - 32. MAJOR ELECTROLYTE TRANSPORT MECHANISMS

Pumps Carriers Channels

Electrogenic Na+ absorption Na+, K+ - ATPase Na+

Electroneural Na+ absorption Na+, K+ - ATPase Na+/H+ Exchange Cl - /HCO3 - Exchange

K+ Secretion Na+, K+ - ATPase Na+, K+, Cl - Cotransport K+

Cl - Secretion Na+, K+ - ATPase Na+, K+, Cl - Cotransport Cl -

HCO3 - Secretion Na+, K+ - ATPase Cl - /HCO3 - Exchange

Proposed pathways of active sodium transport in colon (a)

Proposed pathways of active sodium transport in colon (b)

The colon exhibits a net secretion of potassium

Sodium absorption and potassium secretion

The colonic lumen possesses a luxuriant flora

Fecal flora organisms

TABLE 1 - 37. THE FECAL FLORA ORGANISMS FOUND IN HEALTHY HUMANS

Flora, %

Genus Moore and Holdeman [27]GIC01-02-01rfref27

Finegold et al.[28]GIC01-02-01rfref28

Bacteroides 30 56

Eubacterium 26 14

Bifidobacterium 11 4

Peptostreptococcus 9 4

Fusobacterium 8 0.1

Ruminococcus 4 9

Clostridium 2 2

Lactobacillus 2 1

Unclassifiable 2 -

Streptococcus 2 6

Facultative gram - negatives 0.5 0.1

Propionibacterium and Actinomyces

0.3 0.6

Staphylococcus 0.1 0.01

Coprococcus 0.1 0.1

Acidaminococcus - 0.2

Organisms found to make up 0.1% or more of the flora

The anatomy of the rectum and anus

The muscular arrangement of the levator ani muscles

The histology of the rectal and anal mucosae

The arterial blood supply specific for the anus

Factors necessary for maintenance of fecal continence

The pressure profile of the anal canal

Triple loop mechanism of external anal sphincter

Epithelial nerve endings provide a specialized system

Fecal continence aided by highly compliant rectum (a)

Fecal continence aided by highly compliant rectum (b)

The reflex responsiveness of the anal region

Reflejo inhibitorio rectoanal

Defecation involves a coordinated interaction

Summary of muscular actions required for defecation

Manometric and electromyographic responses to defecation

Alteraciones motoras del colon

Sagittal view of anorectal anatomy

Incontinencia fecal

Anorectal continence mechanisms

TABLE 5 - 2. ANORECTAL CONTINENCE MECHANISMS

Reservoir elements

Rectal compliance/accomodation

Colonic compliance/accomodation

Sensorimotor elements

Anorectal angle

Rectal sensation

Anal sensory nerves

Internal anal sphincter

External anal sphincter

Diagnostic studies for fecal incontinence

TABLE 5 - 3. DIAGNOSTIC STUDIES FOR FECAL INCONTINENCE

Tests Information Obtained

Sigmoidoscopy Inflammation, strictures, tumors

Anorectal manometry Sphincter pressures

Rectal sensation, compliance

External sphincter responses

Pelvic floor neurophysiology External sphincter electromyography

Puborectalis electromyography

Pudendal nerve conduction

Proctography Rectal capacity

Anorectal angle

Perineal descent

Retention of contrast

Anal ultrasonography Anal sphincter integrity

Diagnostic studies for fecal incontinence

Anorectal function in neurogenic disorders

Fecal incontinence associated with spinal cord injury

Anorectal findings in spinal cord injuries

TABLE 5 - 7. ANORECTAL FINDINGS IN SPINAL CORD INJURIES

Parameters Sacral Suprasacral

Rectal sensation Usually absent Absent

Basal anal pressure Normal or low Normal

Anal squeeze pressure

Probably absent Absent

Reflex defecation Usually absent Present

Impending defecation

No warning, but occasionally abdominal pain is present

Often no warning; autonomic signs present

Fecal incontinence associated with pudendal neuropathy (A)

Fecal incontinence associated with pudendal neuropathy (B)

Fecal incontinence associated with pudendal neuropathy (C)

Fecal incontinence associated with pudendal neuropathy (D)

External sphincter electromyographic patterns (A)

External sphincter electromyographic patterns (B)

External sphincter electromyographic patterns (C)

Pudendal nerve latencies

Anal endosonography

Normal anatomy as viewed by anal endosonography (A)

Normal anatomy as viewed by anal endosonography (B)

Esfinterotomía(interno)

Normal anatomy as viewed by anal endosonography (C)

Desgarro obstétrico

Anorectal manometry in fecal incontinence (A)

Anorectal manometry in fecal incontinence (B)

normal

Biofeedback (A)

Biofeedback (B)

Constipación

Colonic scintigraphy (A)

Colonic scintigraphy (B)

Colonic transit of markers

Colonic transit patters in chronic constipation (A)

TABLE 5 - 17A. NORMAL TRANSIT CONSTIPATION–WILLFUL DECEPTION

Complaint: 32 - year - old female; infrequent defecation for several years; all tests normal

Colon transit study:

Day R L RS Total

1 10 9 1 20

2 0 2 7 9

3 0 0 0 0

Bowel diary: one stool in 14 days

Colonic transit patters in chronic constipation (B)

TABLE 5 - 17B. SLOW TRANSIT CONSTIPATION–COLONIC INERTIA

Complaint: 22 - year - old female; infrequent defecation for 4 years; increasingly disabled

Colon transit study:

Day R L RS Total

1 12 8 0 20

3 6 9 5 20

5 2 9 4 15

7 0 10 5 15

Bowel diary: two stools in 14 days

Colonic motor activity can be studied (A)

Colonic motor activity can be studied (B)

Propagating contractions in healthy control subjects vs constipated

Colonic motility within 30 mins after breakfast

Distal bowel in Hirschsprung's disease (A)

Distal bowel in Hirschsprung's disease (B)

Balloon manometry

Idiopathic megacolon

Rectal compliance in idiopathic megarectum

Using the Schuster-type balloon manometer

y puborectal

Pressure changes and electromyographic recordings

Rectocele (A)

Rectocele (B)

Subtotal colectomy with ileorectal anastomosis

Diagnostic or Rome criteria

TABLE 5 - 29. DIAGNOSTIC OR ROME CRITERIA FOR IRRITABLE BOW EL SYNDROME

At least 3 months of continuous or recurrent symptoms of:

Abdominal pain or discomfort

Relieved with defecation and/or

Associated with change in stool frequency

Associated with change in stool consistency

Two or more of the following symptoms at least 1/4 of the time

Altered stool frequency (< 3/wk or > 3/day)

Altered stool form (hard or loose)

Altered stool passage (staining, urgency, incomplete evacuation)

Passage of mucus

Bloating/abdominal distension

Barium enema in irritable bowel syndrome patient

Emotions and colon motility

Emotions and colonic motility (A)

Delay stressor

Pneumograma

Emotions and colonic motility (B)

Emotions and colonic motility (C)

Visceral sensations

A 73-year-old woman with constipation

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