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Questions and Answers
What is the primary source of arterial supply to the stomach?
What is the primary source of arterial supply to the stomach?
Which vein drains the left gastric vein?
Which vein drains the left gastric vein?
Which part of the nervous system supplies the stomach parasympathetically?
Which part of the nervous system supplies the stomach parasympathetically?
Which layers are part of the muscularis mucosae in the stomach?
Which layers are part of the muscularis mucosae in the stomach?
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From which segments of the sympathetic trunk does the stomach receive its sympathetic supply?
From which segments of the sympathetic trunk does the stomach receive its sympathetic supply?
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What is the primary function of the lower esophageal sphincter?
What is the primary function of the lower esophageal sphincter?
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What triggers the wave of relaxation that allows food to enter the stomach?
What triggers the wave of relaxation that allows food to enter the stomach?
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What is the term for the process of the stomach wall accommodating larger quantities of food?
What is the term for the process of the stomach wall accommodating larger quantities of food?
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How much volume can a completely relaxed stomach hold approximately?
How much volume can a completely relaxed stomach hold approximately?
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What effect does the presence of food have on the muscular wall of the stomach?
What effect does the presence of food have on the muscular wall of the stomach?
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What is the shortest segment of the small intestine?
What is the shortest segment of the small intestine?
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Which part of the small intestine is primarily responsible for nutrient absorption?
Which part of the small intestine is primarily responsible for nutrient absorption?
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Which arteries supply blood to the first two-thirds of the duodenum?
Which arteries supply blood to the first two-thirds of the duodenum?
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What is a key feature of the ileum that distinguishes it from other parts of the small intestine?
What is a key feature of the ileum that distinguishes it from other parts of the small intestine?
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How long is the jejunum compared to the ileum?
How long is the jejunum compared to the ileum?
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What is the primary blood supply to the pancreas and duodenum?
What is the primary blood supply to the pancreas and duodenum?
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Which cells are primarily involved in secreting hormones that regulate gastric emptying?
Which cells are primarily involved in secreting hormones that regulate gastric emptying?
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What primarily enhances peristaltic movements in the small intestine?
What primarily enhances peristaltic movements in the small intestine?
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Which anatomical structure primarily regulates the release of chyme into the cecum?
Which anatomical structure primarily regulates the release of chyme into the cecum?
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What is the main function of the plicae circulares in the small intestine?
What is the main function of the plicae circulares in the small intestine?
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Which T-helper cell type primarily secretes IL-4 and IL-5?
Which T-helper cell type primarily secretes IL-4 and IL-5?
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What is the predominant form of IgA found in the gastrointestinal tract?
What is the predominant form of IgA found in the gastrointestinal tract?
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Which innate lymphoid cell type is characterized by the secretion of IL-4 and helps promote Th2 responses?
Which innate lymphoid cell type is characterized by the secretion of IL-4 and helps promote Th2 responses?
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What is the primary function of Goblet cells in the intestine?
What is the primary function of Goblet cells in the intestine?
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Which protein is primarily important in the formation of tight junctions between epithelial cells?
Which protein is primarily important in the formation of tight junctions between epithelial cells?
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Which molecule is primarily responsible for enhancing regulatory T cell (Treg) production and inhibiting inflammation in the gut?
Which molecule is primarily responsible for enhancing regulatory T cell (Treg) production and inhibiting inflammation in the gut?
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What type of cytokines are present in low levels in the gut to maintain immune tolerance?
What type of cytokines are present in low levels in the gut to maintain immune tolerance?
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Which factors are considered tolerogenic features in the gastrointestinal tract?
Which factors are considered tolerogenic features in the gastrointestinal tract?
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APRIL and BAFF are important for promoting which specific type of immune response in the gut?
APRIL and BAFF are important for promoting which specific type of immune response in the gut?
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Which process is enhanced by low levels of Th17-type cytokines in the gut?
Which process is enhanced by low levels of Th17-type cytokines in the gut?
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What role do T-dependent pathways play in IgA class switching?
What role do T-dependent pathways play in IgA class switching?
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Which of the following accurately describes the role of ILC3 cells in the gut?
Which of the following accurately describes the role of ILC3 cells in the gut?
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What is a key difference between the small and large intestines in terms of immune cell population?
What is a key difference between the small and large intestines in terms of immune cell population?
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Which statement correctly outlines the impact of Th17 cells in the gut?
Which statement correctly outlines the impact of Th17 cells in the gut?
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What is the significance of somatic hypermutation in IgA production?
What is the significance of somatic hypermutation in IgA production?
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Study Notes
Stomach Vasculature: Arteries
- Main arterial supply originates from the celiac trunk of the aorta.
- Four primary arteries supply the stomach:
- Hepatic artery branches into the right gastric and right gastro-omental arteries.
- Celiac trunk branches into the left gastric artery.
- Splenic artery branches into the left gastro-omental artery.
Stomach Vasculature: Veins
- Veins parallel their respective arteries and drain into the hepatic portal vein or superior mesenteric vein.
- Key veins include:
- Left gastric vein drains into the hepatic portal vein.
- Right gastric vein drains into the hepatic portal vein.
- Left gastro-omental vein drains into the superior mesenteric vein.
- Right gastro-omental vein drains into the superior mesenteric vein.
Stomach Innervation
- Parasympathetic innervation from the anterior and posterior vagal trunks (vagus nerve).
- Sympathetic innervation originates from the T5-T9 segments of the sympathetic trunk, reaching the celiac plexus via the greater splanchnic nerve.
Stomach Histology
- Mucosa consists of:
- Epithelium and lamina propria (loose connective tissue, smooth muscle, and lymphoid cells).
- Muscularis mucosae arranged in three layers: inner circular, outer longitudinal.
- Lower esophageal sphincter controls food entry, prevents reflux, and maintains resting tone via myogenic properties and cholinergic regulation.
Stomach Physiology: Motility
- Food entry facilitated by a wave of relaxation along the esophagus and lower esophageal sphincter, triggered by swallowing.
- Peristaltic waves propel food into the stomach.
- Storage occurs in the fundus, accommodating up to 0.8-1.5L due to gastric accommodation, which stretches the stomach walls.
Stomach Physiology: Secretions
- Gastric acid secretion involves:
- Dissociation of water into H+ and OH- in cell cytoplasm.
- CO2 combines with OH- to form bicarbonate ions.
- H+ is pumped into the lumen via H+/K+ ATPase.
- Cl- is passively transported into the lumen.
Secretions: Regulation
- Parietal cells stimulated by multiple sources:
- Acetylcholine (parasympathetic stimulation on muscarinic receptors).
- Gastrin (acting on CCK2 receptors).
- Histamine (acting on H2 receptors).
- Proton pump inhibitors block H+/K+ ATPase.
Secretions: Histamine
- Histamine is released from enterochromaffin-like (ECL) cells stimulating gastric acid production.
- ECL cells also induce vasodilation.
Chronic H. pylori Gastritis: Pathogenesis
- H. pylori infections primarily affect the stomach antrum, leading to increased acid production and ulcer risk.
- Long-term infection can involve the gastric body and fundus, causing gastric atrophy.
Chronic H. pylori Gastritis: Pathology
- Features erythematous antral mucosa with increased plasma cells and inflammatory cells.
- Potential for gastric epithelium atrophy increases the risk of gastric adenocarcinoma and MALT lymphoma.
Chronic H. pylori Gastritis: Clinical Features & Diagnosis
- May present asymptomatically or cause epigastric pain, nausea, vomiting, anorexia, early satiety, and weight loss.
- Diagnosed via serum antibodies, fecal detection, or urea breath test.
Chronic H. pylori Gastritis: Treatment and Complications
- Complications include peptic ulcer disease (PUD), gastric adenocarcinoma, and MALT lymphoma.
- Treatment typically involves triple therapy (two antibiotics plus a proton pump inhibitor) for bacterial eradication.
Comparison of Acute & Chronic Gastritis
- Acute Gastritis: Features neutrophilic infiltration with possible erosion and bleeding.
- Chronic Gastritis: Characterized by plasma cells, lymphocytes, and potential for epithelium atrophy and MALT overgrowth.
Peptic Ulcer Disease (PUD)
- Common complication of chronic gastritis, with two main types:
- Duodenal ulcers (more common, lower malignancy risk).
- Gastric ulcers (higher malignancy risk, tend to occur in the antrum).
- Primary causes include H. pylori infection, NSAIDs, and smoking.
PUD Pathogenesis
- Results from an imbalance between protective mechanisms and damaging factors, associated with chronic gastritis.
- Duodenal and antral gastric ulcers are linked to H. pylori infection but lack complete understanding of pathogenesis.
Small Intestine Anatomy
- Divided into three regions: duodenum, jejunum, and ileum.
- Duodenum: Shortest (25 cm), widest portion starting at the pyloric sphincter; C-shaped and mostly retroperitoneal, closely associated with the pancreas.
- Jejunum: About 1 meter long, follows the duodenum, enters the ileum.
- Ileum: Longest section at approximately 2 meters, connects to the large intestine at the ileocecal sphincter.
Duodenal Anatomy
- Major vessels interfacing with the liver, gall bladder, stomach, and pancreas are critical in duodenal structure.
- Predominantly retroperitoneal with limited intraperitoneal components.
Jejunal and Ileal Anatomy
- Jejunum features larger plicae circulares, enhancing absorption.
- Ileum is characterized by the presence of Peyer’s patches, large lymphoid nodules.
Arterial Supply
- First two-thirds of the duodenum supplied by the hepatic artery via the celiac trunk.
- Pancreaticoduodenal arteries complement blood supply to the pancreas and duodenum.
- Remaining small intestine (duodenum to ileum) and part of the large intestine receive blood from the superior mesenteric artery (SMA).
Venous Drainage
- Superior mesenteric vein collects blood from the small intestine and aspects of the large intestine, stomach, and pancreas.
- Splenic vein gathers blood from the stomach, spleen, pancreas, and distal large intestine.
- Formation of the hepatic portal vein from the joining of the splenic and superior mesenteric veins, draining into the liver.
Small Intestine Histology
- Mucosa: Simple columnar epithelium with villi; lamina propria containing vessels and nerves; crypts of Lieberkuhn found throughout the small intestine.
- Submucosa: Notable for plicae circulares, especially in jejunum and ileum.
- Muscularis Layer: Contains inner circular and outer longitudinal layers.
- Serosa/Adventitia: Composed of serosa and adventitia.
Key Structures
- Plicae Circulares: Permanent folds of mucosa and submucosa enhancing surface area for absorption and promoting chyme movement.
- Villi: Finger-like projections significantly increasing surface area; contain core of lamina propria with vascular structures.
- Microvilli: Tiny projections of epithelial cells, forming a brush border, further amplifying surface area.
Cell Types in Small Intestine
- Enterocytes: Absorptive cells with microvilli; short lifespan of a few days.
- Goblet Cells: Mucus-secreting cells facilitating material passage.
- Paneth Cells: Secrete enzymes like lysozyme, contributing to intestinal immunity.
- Enteroendocrine Cells: Secrete hormones influencing digestive processes, including CCK, secretin, and others.
Hormonal Regulation
- Major hormones include somatostatin, CCK (promotes enzyme secretion), secretin (regulates bicarbonate), and peptide YY (slows gastric emptying).
- Hormones respond to various stimuli, mainly from food composition and digestive requirements.
Small Intestine Movements
- Mixing/Segmentation: Local contractions driven by chyme presence to mix digestive contents.
- Peristalsis: Propulsive movements moving chyme through the small intestine at 0.5 to 2.0 cm/sec; intense contractions known as peristaltic rush.
Gastric Emptying Control
- Small intestine regulates gastric emptying based on chyme consistency and volume.
- Nervous Control: Initiated via both sympathetic and enteric systems responding to conditions like pH and distension in the duodenum.
- Hormonal Control: CCK and secretin participate in the feedback mechanism for slowing gastric emptying, ensuring optimal digestion and absorption.
Secretions in the Small Intestine
- Intestinal digestive juices from enterocytes facilitate the absorption of nutrients; consist of water and electrolytes akin to extracellular fluid.
- Brunner’s Glands: Secrete alkaline mucus to protect the duodenum and are activated by tactile, irritating stimuli, or via vagal stimulation.
Pancreatic and Hepatic Role
- Involves the secretion of digestive enzymes and hormones necessary for digestion in the small intestine, emphasizing the interconnected nature of gastrointestinal organs.### Digestion in the Duodenum
- Chyme enters the duodenum via the pyloric sphincter.
- Nutrients and low pH levels activate enteroendocrine cells and mucosal receptors.
- Cholecystokinin (CCK) promotes gallbladder contraction, pancreatic enzyme release, and relaxes the sphincter of Oddi.
- Secretin stimulates bicarbonate-rich secretions from the pancreas and small intestine enterocytes.
- Bile emulsifies lipids, while pancreatic enzymes hydrolyze fats, proteins, and carbohydrates into smaller molecules.
Biliary Apparatus
- Liver secretes bile into right and left hepatic ducts, forming the common hepatic duct.
- The common bile duct is created where the cystic duct joins the common hepatic duct.
- The sphincter of Oddi, located at the ampulla of Vater (major duodenal papilla), regulates bile entry into the duodenum.
- Bile is stored in the gallbladder when the sphincter of Oddi is closed.
Pancreatic Secretions
- Digestive enzymes from the pancreas include:
- Trypsinogen (activated by Enterokinase) cleaves peptide bonds near arginine or lysine.
- Chymotrypsinogen (activated by trypsin) targets peptide bonds next to various amino acids.
- Elastase (activated by trypsin) cleaves elastin.
- Procarboxypeptidase (activated by trypsin) cleaves carboxy-terminal ends of peptides.
- Pancreatic amylase digests starch.
- Pancreatic lipase requires co-lipase and breaks triglycerides into free fatty acids and 2-monoacyl glycerol.
Chemical Digestion Overview
- Chemical digestion involves breaking down macromolecules into smaller units for absorption.
- Enzymatic digestion through hydrolysis is key, utilizing pancreatic, gastric, and brush-border enzymes.
Carbohydrate Digestion and Absorption
- Salivary amylase (ptyalin) begins starch digestion in the mouth, producing maltose and small glucose polymers, but is inactivated by gastric acid.
- Pancreatic amylase, more potent than salivary amylase, continues starch digestion in the small intestine, resulting in maltose and small glucose polymers.
- Disaccharides are converted to monosaccharides by brush-border enzymes (lactase, maltase, sucrase).
- Monosaccharides are absorbed through facilitated diffusion or co-transport (SGLT-1, GLUT5, GLUT2) into the enterocytes and then into capillaries.
Protein Digestion
- Mechanical digestion occurs in the mouth; no enzymatic action.
- Stomach acids (HCL) denature proteins and activate pepsin, initiating protein digestion (10-20%).
- In the small intestine, pancreatic proteolytic enzymes break down proteins into polypeptides and free amino acids.
- Key enzymes:
- Trypsin activates other zymogens and cleaves peptide bonds next to lysine or arginine.
- Chymotrypsin targets hydrophobic and aromatic amino acids.
- Carboxypeptidase cleaves amino acids from the carboxy-terminal ends.
- Brush-border peptidases further digest peptides into amino acids and dipeptides.
Fat Digestion and Emulsification
- Fats are poorly soluble in water and form large droplets, complicating digestion.
- Emulsification into smaller droplets increases surface area for effective digestion.
- Bile salts and lecithins form micelles, aiding lipid emulsification and providing hydrophilic and hydrophobic environments.
- Pancreatic lipase acts on triglycerides within micelles, breaking them down into free fatty acids and 2-monoacyl glycerol.
- Lipids are reassembled into triglycerides in enterocytes and packaged into chylomicrons for transport into the lymphatic system.
Absorption Mechanisms
- Carbohydrates and amino acids diffuse into the capillary networks within villi.
- Small free fatty acids can enter the bloodstream directly, while larger lipids utilize chylomicrons.
- Chylomicrons are secreted into the lymphatic system and are crucial for transporting lipids in circulation.
Malabsorption Overview
- Malabsorption results in undigested nutrients in the intestine, leading to diarrhea, nutrient deficiencies, and gas production by bacteria.
- Key disturbances include:
- Intraluminal digestion issues (enzyme/bile insufficiency).
- Terminal digestion issues (brush-border enzyme deficit).
- Transepithelial transport disruptions.
- Impaired lymphatic transport of lipids.
Common Malabsorption Conditions
- Celiac disease causes damage to villi, affecting nutrient absorption.
- Chronic pancreatitis leads to enzyme insufficiency, resulting in malabsorption.
- Disaccharidase deficiencies cause osmotic diarrhea due to undigested sugars.
- Gastroenteritis impairs gastrointestinal absorption due to brush-border damage.
T-helper Polarization
- IL-12, iCOS, and CD40 interactions play crucial roles in T-helper cell polarization.
- TH1 cells primarily secrete IFN-y, influencing class switching to IgG subtypes.
- TGF-beta and Retinoic Acid promote class switching to IgA, along with IL-21.
- TH2 cells release IL-4 and IL-5, resulting in class switching to IgE and IgM production.
Antibody Classes
-
IgE:
- Secreted as a monomer in small amounts.
- Binds to Fc receptors on eosinophils, basophils, and mast cells, triggering degranulation.
-
IgA:
- Predominately exists as a dimer, found in GI and respiratory tracts, as well as in tears, saliva, and breastmilk.
- Critical for neutralizing pathogens and is produced in the highest quantity in the body (up to 5 grams/day).
- Contributes to developing tolerance in mucosal immunity.
Innate Lymphoid Cells (ILCs)
- NK Cells: Cytotoxic cells monitoring and responding to abnormal cells.
-
Resident ILCs: Live in barrier tissues, with three main types:
- Type 1 ILCs (ILC1): Secrete IFN-γ and TNF-α, promoting TH1 cell development.
- Type 2 ILCs (ILC2): Release IL-4, IL-5, IL-9, and IL-13, favoring TH2 responses.
- Type 3 ILCs (ILC3): Produce IL-17 and IFN-γ, effective against extracellular bacteria and support lymphoid tissue development.
Tight Junctions
-
Key Proteins:
- Claudins: Transmembrane proteins serving as channels for small molecules.
- Occludin: Transmembrane protein with an unclear function.
- Junctional Adhesion Molecules (JAM): Potentially mediate permeability for larger molecules.
- ZO-proteins: Essential for tight junction formation, interact with the cytoskeleton.
Immune Structures in the Gut
-
Peyer’s Patches:
- Large lymphoid collections in the ileum, about 100 patches per individual, lined with M (microfold) cells.
-
Isolated Lymphoid Follicles (ILFs):
- Smaller, found throughout the gut, may also contain M cells.
Gut Cells with Immune Functions
-
Enterocytes:
- Express PRRs that detect intracellular bacteria and breaches in the tight junction barrier.
- Translocate IgA from plasma cells to mucus.
-
Goblet Cells:
- Densely populated in the colon, they secrete mucus and antimicrobial peptides (AMPs).
- Offer a barrier to bacterial invasion and transport antigens to APCs.
-
Paneth Cells:
- Located in crypts, they secrete large amounts of AMPs.
-
Microfold Cells (M-cells):
- Specialized for antigen capture, present in Peyer’s patches and ILFs, facilitating transport of lymphocytes and dendritic cells.
Challenges of the Gut
- The GI tract must balance maintaining beneficial bacteria and nutrients while combating pathogens.
- Avoids inflammatory responses to non-harmful antigens and commensals, highlighting its complex immune barrier.
Immune Tolerance in the Gut
-
Maintaining Distance:
- Mucous impedes bacterial movement; thick mucins produced by goblet cells are crucial.
- AMPs by enterocytes and Paneth cells degrade bacterial cell walls.
-
IgA Functions:
- Unshuffled IgA shows broad specificity, while shuffled IgA, due to affinity maturation, is effective against pathogens.
-
Antigen Presentation:
- Potentially tolerogenic or inflammatory, depending on the APC activation state.
-
A "happy" gut environment is characterized by low inflammation and balanced immune signals, supported by IL-10, retinoic acid, and TGF-beta.
-
Signals associated with gut tolerance include:
- APRIL and BAFF, promoting B cell production of IgA with low inflammation signals from Th17-type cytokines.
Conclusion
- The gut's immunological landscape is subject to ongoing research with emerging non-traditional mechanisms and continues to adapt as new discoveries are made in the field of immunity.
IgA and Intestinal Immunity
- IgA is primarily secreted by plasma cells located in intestinal lymphoid follicles (ILFs) and Peyer’s patches.
- Mesenteric lymph nodes also contribute to IgA secretion after B cells are activated and migrate to the mucosa.
- IgA class switching can occur through two pathways:
- T-dependent: Involves follicular T cells (Tfh) inducing IgA class switching in B cells using TGF-beta and CD40L interactions; this process may take over a week and produces few specific antibodies.
- T-independent: Driven by mucosal dendritic cells and enterocytes secreting BAFF and APRIL, resulting in a rapid production of diverse, low-affinity antibodies, typically in tolerogenic conditions.
ILC3 and Th17 in the Gut
- Th17 and ILC3 cells are crucial not only for inflammation but also for maintaining immune tolerance and proper intestinal immune development.
- ILC3 cells in humans can directly respond to microbes via TLRs, unlike in mice.
- Activated ILC3 cells secrete IL-22 and IL-17, enhancing antimicrobial peptide (AMP) production and aiding in the development of Peyer’s patches and IgA production.
- Th17 cells can differentiate into:
- Tfh cells: Assist in antibody production.
- Treg cells: Promote anti-inflammatory responses and downregulate antigen-presenting cells (APCs).
- Th17 and ILC3 cells are pivotal in autoimmunity and inflammatory diseases but also vital for maintaining tolerance.
Comparison – Large and Small Intestines
-
Small Intestine:
- Lower microbial diversity, with more Paneth cells and fewer goblet cells.
- Presence of M cells, Peyer’s patches, and fewer ILFs.
-
Large Intestine:
- Significantly larger microbial community (1,000 – 1,000,000 times).
- Higher numbers of goblet cells with a thicker mucous layer but no Paneth cells.
- More ILFs, fewer M cells.
- Distinct microbe populations in each intestine influence the development of autoimmune disorders differently.
Immune Tolerance and the Microbiome
- Commensal bacteria stimulate the growth of regulatory T cells (Tregs), particularly Firmicutes, Actinobacteria, and Bacteroidetes.
- Short-chain fatty acids (SCFAs) produced by commensals influence dendritic cells, leading to Treg induction.
- Human ILC3s recognize commensals through TLR signaling, producing IL-17, IL-22, and promoting mucosa-associated lymphoid tissue (MALT) development.
- Segmenting and filamentous bacteria enhance IgA production and Th17 development.
Failure of Tolerance – Celiac Disease
- Alpha-gliadin, resistant to digestive enzymes, initiates a cascade disrupting intestinal immunity.
- It binds to the CXCR3 receptor, causing increased zonulin secretion and disruption of tight junction integrity.
- Elevated IL-15 from enterocytes leads to activation of intra-epithelial lymphocytes.
- Gliadin leakage triggers antigen presentation by APCs, activating Th1 or Th17 cells, particularly in individuals expressing HLA-DQ2 or HLA-DQ8.
Celiac Disease – Pathogenesis
- Enterocyte destruction by intra-epithelial lymphocytes and loss of tight junction integrity contribute to ongoing inflammation, leading to:
- Production of tissue-transglutaminase antibodies.
- Villous atrophy and crypt hyperplasia.
- Immune cell infiltration in the lamina propria.
Celiac Disease – Clinical Presentation
- Adults: Present with anemia, chronic diarrhea, bloating, and vitamin deficiencies (B12, iron).
- Children: Symptoms include irritability, malabsorption, chronic diarrhea, and abdominal pain.
- Extra-intestinal symptoms affect all ages, including arthritis, dermatitis herpetiformis, and, in children, delayed growth and seizure disorders.
Celiac Disease – Diagnosis and Prognosis
- Diagnosis involves anti-tissue transglutaminase antibodies (over 95% specificity) and duodenal biopsy as the gold standard.
- Strict gluten avoidance leads to a good prognosis, while ongoing exposure can result in further intestinal damage and potential development of B-cell lymphoma.
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Description
This quiz focuses on the arterial and venous supply to the stomach as outlined in Moore's Clinically Oriented Anatomy. It covers the major arteries such as the celiac trunk and its branches, and how the veins correspond with these arteries. Test your understanding of the stomach's vascular structure!
