FISIOLOGIA DIGESTIVA (BCM II)
Clase 10: Fisiología del colon
Dr. Michel Baró A.
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The anatomy of the colon is shown
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Circular and longitudinal muscle layers in colon
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The layers of the colonic wall are shown
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Normal colonic mucosa in biopsy specimen
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Maturation process of colonic epithelial cells
(3 a 5 días)
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A human rectal columnar epithelial cell
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Arterial blood supply to the colon is shown
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The venous system that drains the colon is shown
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The extrinsic innervation of the colon
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Intrinsic innervation of the colonic wall
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Ganglia in submucosal and myenteric plexuses
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Lymph nodal drainage of the colon and anus (a)
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Lymph nodal drainage of the colon and anus (b)
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Scintigraphic pattern of colonic transit
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Time a substance spends in each region of colon
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Distinct motor patterns as measured by manometry
Contracciones de corta duración: estacionarias, de mezcla
Contracciones de larga duración: estacionarias o migratorias breves
Contracciones de gran amplitud: movimientos de masa
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Patterns of migration of contractions
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Presence and intensity of short-duration contractions
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Colonic electrical control or slow-wave activity
Borde submucoso
Borde mientérico
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Electrical activity from the human colon
SSB: Short spike burst. LSB: Long spike burst. MLSB: Migrating long spike burst
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Patterns of motor and myoelectric activity (perros)
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Development of high-amplitude propagating contractions
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Colonic contents and motor activity in colon
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Motility of colon over 24-hour period
Colonic motility
index
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Gastrocolonic motor response to meal ingestion
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Fecal bolus in the colon has been postulated
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Mediation of both limbs of colonic peristaltic reflex
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Motor activity of colon modulated by vagal activity (ferret)
Actividad fásica espontánea
del colon proximal
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Colonic motor function can be significantly altered
Am J Med 1951
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Summary of small intestinal and colonic fluid balance
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Major electrolyte transport mechanisms
TABLE 1 - 32. MAJOR ELECTROLYTE TRANSPORT MECHANISMS
Pumps
Carriers
Electrogenic Na+ absorption Na+, K+ - ATPase
Channels
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
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Proposed pathways of active sodium transport in colon (a)
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Proposed pathways of active sodium transport in colon (b)
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The colon exhibits a net secretion of potassium
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Sodium absorption and potassium secretion
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The colonic lumen possesses a luxuriant flora
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Fecal flora organisms
TABLE 1 - 37. THE FECAL FLORA ORGANISMS FOUND IN HEALTHY
HUMANS
Flora, %
Genus
Moore and Holdeman [27]GIC01-0201rfref27
Finegold et al.[28]GIC01-0201rfref28
Bacteroides
30
56
Eub acterium
26
14
Bifidobacterium
11
4
Peptostreptococcus
9
4
Fusob acterium
8
0.1
Ruminococcus
4
9
Clostridium
2
2
Lactob acillus
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
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The anatomy of the rectum and anus
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The muscular arrangement of the levator ani muscles
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The histology of the rectal and anal mucosae
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The arterial blood supply specific for the anus
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Factors necessary for maintenance of fecal continence
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The pressure profile of the anal canal
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Triple loop mechanism of external anal sphincter
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Epithelial nerve endings provide a specialized system
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Fecal continence aided by highly compliant rectum (a)
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Fecal continence aided by highly compliant rectum (b)
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The reflex responsiveness of the anal region
Reflejo inhibitorio
rectoanal
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Defecation involves a coordinated interaction
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Summary of muscular actions required for defecation
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Manometric and electromyographic responses to defecation
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Alteraciones motoras del colon
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Sagittal view of anorectal anatomy
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Incontinencia fecal
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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
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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
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Diagnostic studies for fecal incontinence
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Anorectal function in neurogenic disorders
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Fecal incontinence associated with spinal cord injury
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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 Often no warning; autonomic signs
present
present
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Fecal incontinence associated with pudendal neuropathy (A)
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Fecal incontinence associated with pudendal neuropathy (B)
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Fecal incontinence associated with pudendal neuropathy (C)
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Fecal incontinence associated with pudendal neuropathy (D)
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External sphincter electromyographic patterns (A)
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External sphincter electromyographic patterns (B)
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External sphincter electromyographic patterns (C)
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Pudendal nerve latencies
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Anal endosonography
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Normal anatomy as viewed by anal endosonography (A)
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Normal anatomy as viewed by anal endosonography (B)
Esfinterotomía
(interno)
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Normal anatomy as viewed by anal endosonography (C)
Desgarro obstétrico
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Anorectal manometry in fecal incontinence (A)
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Anorectal manometry in fecal incontinence (B)
normal
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Biofeedback (A)
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Biofeedback (B)
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Constipación
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Colonic scintigraphy (A)
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Colonic scintigraphy (B)
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Colonic transit of markers
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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
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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
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Colonic motor activity can be studied (A)
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Colonic motor activity can be studied (B)
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Propagating contractions in healthy control subjects vs constipated
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Colonic motility within 30 mins after breakfast
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Distal bowel in Hirschsprung's disease (A)
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Distal bowel in Hirschsprung's disease (B)
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Balloon manometry
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Idiopathic megacolon
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Rectal compliance in idiopathic megarectum
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Using the Schuster-type balloon manometer
y puborectal
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Pressure changes and electromyographic recordings
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Rectocele (A)
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Rectocele (B)
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Subtotal colectomy with ileorectal anastomosis
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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
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Barium enema in irritable bowel syndrome patient
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Emotions and colon motility
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Emotions and colonic motility (A)
motor
EMG
Pneumograma
Delay stressor
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Emotions and colonic motility (B)
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Emotions and colonic motility (C)
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Visceral sensations
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A 73-year-old woman with constipation
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Fin
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