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  <head>
    <title>021-02 Gut transport, portal integration, and failure of digestive reserve</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Gut transport, portal flow, and digestive reserve">
      <outline text="Motility as coordinated propulsion">
        <outline text="Slow waves set contraction windows"/>
        <outline text="Neural and chemical signals reach threshold"/>
        <outline text="Uncoordinated force worsens pain or obstruction"/>
        <outline text="Peristalsis: contract behind, relax ahead"/>
        <outline text="Segmentation improves mucosal contact"/>
        <outline text="Migrating complex clears between meals">
          <outline text="Loss favours bacterial overgrowth"/>
        </outline>
        <outline text="Emptying depends on particle size and feedback">
          <outline text="Symptoms track measured delay imperfectly"/>
        </outline>
        <outline text="Obstruction versus ileus">
          <outline text="Obstruction: transition point, proximal distension"/>
          <outline text="Ileus: diffuse propulsion failure"/>
          <outline text="Shared complications, different treatment"/>
        </outline>
      </outline>
      <outline text="Secretion and mucosal defence">
        <outline text="Proton pump is the final step">
          <outline text="Blocking it overcomes upstream signals"/>
          <outline text="Review long-term indication and duration"/>
        </outline>
        <outline text="Barrier: mucus, bicarbonate, prostaglandins, flow"/>
        <outline text="Anti-inflammatory drugs remove prostaglandin support"/>
        <outline text="Helicobacter pylori adds inflammation and ulcers"/>
        <outline text="Premature enzyme activation in pancreatitis">
          <outline text="Severe: capillary leak, necrosis, organ failure"/>
        </outline>
      </outline>
      <outline text="Absorption needs digestion and surface">
        <outline text="Digestion, bile, surface, transport, lymph, transit"/>
        <outline text="Coeliac disease damages proximal surface"/>
        <outline text="Bile-acid loss in two phases">
          <outline text="Modest: colonic secretion and diarrhoea"/>
          <outline text="Extensive: pool depletion and steatorrhoea"/>
          <outline text="Fatty acids bind calcium, oxalate stones"/>
        </outline>
        <outline text="Short bowel depends on remaining segments">
          <outline text="Colon in continuity salvages water and energy"/>
          <outline text="Parenteral support if autonomy insufficient"/>
        </outline>
        <outline text="Carbohydrate: osmoles, gas, acidic stool"/>
        <outline text="Protein loss through inflamed mucosa"/>
      </outline>
      <outline text="Diarrhoea as transport phenotype">
        <outline text="Osmotic improves with fasting"/>
        <outline text="Secretory persists during fasting"/>
        <outline text="Inflammatory adds blood and lost surface"/>
        <outline text="Rapid transit coexists with each"/>
        <outline text="Stool osmotic gap">
          <outline text="Low gap supports secretion"/>
          <outline text="High gap suggests unmeasured osmoles"/>
        </outline>
        <outline text="High volume: normal-gap acidosis, weakness"/>
        <outline text="Rehydration via sodium-glucose cotransport"/>
      </outline>
      <outline text="Portal circulation and zonation">
        <outline text="Portal blood brings nutrients, microbes, drugs"/>
        <outline text="Periportal: oxidation, gluconeogenesis, urea"/>
        <outline text="Centrilobular: drug enzymes, low-flow injury"/>
        <outline text="Portal hypertension from raised resistance">
          <outline text="Splanchnic vasodilation drives sodium retention"/>
          <outline text="Varices shunt ammonia and drugs"/>
          <outline text="Splenic congestion lowers platelets"/>
        </outline>
        <outline text="Ascites is more than low albumin">
          <outline text="Infection without perforation, sample urgently"/>
        </outline>
      </outline>
      <outline text="Liver tests as compartment signals">
        <outline text="Aminotransferases: membrane injury, not synthesis"/>
        <outline text="Alkaline phosphatase and others: ductal pattern"/>
        <outline text="Albumin and clotting reflect synthesis"/>
        <outline text="Falling enzymes: recovery or hepatocyte loss"/>
        <outline text="Failure: bilirubin, clotting, glucose, encephalopathy"/>
        <outline text="Encephalopathy from ammonia and inflammation">
          <outline text="Triggers: bleeding, infection, constipation, sedatives"/>
          <outline text="Reduce gut nitrogen, protect airway"/>
        </outline>
      </outline>
      <outline text="Nutrition as functional physiology">
        <outline text="Oedema and ascites conceal weight"/>
        <outline text="Strength and trajectory beat serum proteins"/>
        <outline text="Enteral feeding does not end aspiration">
          <outline text="Post-pyloric feeding misses oral secretions"/>
        </outline>
        <outline text="Parenteral nutrition needs precise composition">
          <outline text="Excess: hyperglycaemia, carbon dioxide, fatty liver"/>
          <outline text="Underfeeding perpetuates catabolism"/>
        </outline>
        <outline text="Monitor tolerance, not only delivered intake"/>
        <outline text="Microbiome ferments fibre to short-chain acids">
          <outline text="Composition rarely proves causation"/>
        </outline>
      </outline>
      <outline text="Integrated synthesis and red flags">
        <outline text="Name the failing process"/>
        <outline text="Then cause, consequence, trigger, recovery measure"/>
        <outline text="Ischaemia: symptoms exceed examination">
          <outline text="Normal lactate does not exclude it"/>
          <outline text="Do not delay imaging and surgical review"/>
        </outline>
        <outline text="Jaundice matched to bilirubin pathway">
          <outline text="Haemolysis raises unconjugated load"/>
          <outline text="Obstruction raises conjugated fraction"/>
          <outline text="Urinary bilirubin is the conjugated form"/>
        </outline>
      </outline>
    </outline>
  </body>
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