Intestinal Electrolyte Absorption and Secretion

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CHAPTER 99 Intestinal Electrolyte Absorption and Secretion

The gastrointestinal (GI) tract processes 8 to 9 L of fluid daily that is derived from oral intake and endogenous exocrine secretions. Intestinal fluid absorption is a process that functions with 98% efficiency, allowing only 100 to 200 mL to be excreted each day. The intestine also extracts nutrients, vitamins, and minerals; excludes destructive antigens and microbes; and excretes waste (Fig. 99-1). This multitasking is achieved by the unique tissue, cellular, and molecular architecture of the small and large intestine in combination with a complex array of intricate regulatory mechanisms (Fig. 99-2). Regulation is accomplished by cross-talk between endocrine and paracrine hormones, neurotransmitters, immunomodulators, and luminal factors. Remarkably, this orchestration proceeds smoothly on a daily basis; however, when the balance is perturbed, as occurs with an enteric infection, diarrhea ensues.


Figure 99-2. Architecture of intestinal epithelia. Intestinal epithelial cells are structurally and functionally geared for vectorial transport: The cell membrane is divided into distinct apical and basolateral domains by the tight junctions with an asymmetrical distribution of transporters; the Na+ pump on the basolateral membrane is integral to maintaining an electrochemical profile; this profile permits downhill entry of sodium from either the apical or basolateral side; water and solutes can cross the epithelium either between the cell (paracellular) or through the cell (transcellular).

Transcellular transport across the membrane can be passive or active. The paracellular pathway is characterized by a series of structures that are defined by specific molecular distributions. The tight junction, or zona occludens (ZO), is made up of a network of strands and grooves that consist of membrane proteins (e.g., occludins, claudins, and junctional adhesion molecules [JAMs]) that attach to a group of scaffolding proteins (zonula occludens proteins [ZO-1, ZO-2, ZO-3], multi-PDZ domain protein-1 [MUPP1]). These scaffolding proteins are then linked to the cytoskeleton, participate in vesicular transport (via monomeric guanosine triphosphatase [GTPase] of the Ras superfamily (Rab3b) and in the activation of signaling molecules that regulate junction assembly (partition-defective protein, PAR-3 and -6, and atypical protein kinase C, [aPKC]). Cadherins span the paracellular pathway across the zona adherens and are responsible for cell-to-cell attachment and maintenance of cell polarity. Cadherins bind to catenins, which are linked to the actin cytoskeleton through an additional family of molecules, including radixin, vinculin, and α-actinin. Molecules associated with the zona adherens, including rab, src, and yes, are involved in intracellular signaling through second messengers. Desmosomes are cadherin-like molecules that are linked to intermediate filaments. Gap junctions, made by an assembly of membrane spanning proteins called connexins, allows exchange of small molecules between neighboring cells. PD, potential difference.

Over the past four decades, our understanding of intestinal ion transport processes has been revolutionized by the elucidation of the molecular basis of two devastating diseases, cholera and cystic fibrosis. Although the two diseases effect opposite ends of the physiologic spectrum—too much versus insufficient fluid secretion, respectively—examination of their underlying physiologic, regulatory, and genetic parameters have vastly advanced our knowledge. This increased insight of how the intestine transports fluid and electrolytes has had significant clinical impact, most notably in the development of oral rehydration therapy (ORT) for diarrheal diseases, one of the major health advances of the 20th century.

In this chapter, we review the current understanding of the cellular and molecular underpinnings of the trafficking of ions and solutes in different regions of the small and large intestine and their regulation in health and disease states. The functional activities of intestinal transporters have long been recognized; however, only recently has it become apparent that there are a plethora of transport proteins that carry out these specific functions. This understanding is critical for appreciating normal intestinal function, the pathophysiology of intestinal absorptive abnormalities, and the development of therapeutic strategies for specific diseases.


The structural and functional design of the intestine is optimally geared to its functions of absorbing nutrients and transporting fluids. In the small intestine, a 600-fold amplification of the absorptive surface is achieved by structural features, such as the circular folds of Kerckring (plicae circulares), villus-crypt architecture, and microvilli. Using a cylinder as the model, it has been estimated that the surface area of the small intestine is about 3300 cm2; the plicae circulare, villi, and microvilli amplify the surface area by factors of 3, 10, and 20, respectively, ultimately giving a surface area of about 2,000,000 cm2. In the large intestine, the spatial separation of crypts and surface cells allows efficient reabsorption of fluid. The overall architecture of the intestinal musculature can influence bulk fluid flow and transit time via changes in motility patterns (see Chapters 97 and 98), but the work of fluid transport occurs in the epithelia.

Most epithelia serve as semipermeable barriers: They act as the first line of defense between the mucosal (luminal) and serosal (blood-side) compartments and are capable of bulk transport of fluid from one compartment to the other. These epithelia, including those of the intestine, share common characteristics. One fundamental property of epithelia is cellular polarity, with molecularly distinct apical (luminal) and basolateral (serosal) membranes demarcated by intercellular tight junctions. The permeability of the tight junctions vary from being relatively leaky in the small intestine to fairly tight in the large intestine, and these differences determine an individual epithelium’s effectiveness as a barrier. A loss of tight junction integrity disrupts the barrier function and the vectorial transport capabilities of the tissue.


All GI epithelial cells have two fundamental similarities: discrete apical and basolateral membranes, with distinct biochemical and biophysical properties, separated by tight junctions; and a basolateral Na+ pump (ouabain-inhibitable Na+,K+-ATPase [adenosine triphosphatase]) that establishes a specific intracellular electrochemical environment with a low intracellular Na+ concentration ([Na]i) and a negative intracellular voltage.

This basic cell model is modified by insertion of transporters into either the apical or basolateral membrane or by the characteristics of tight junctions that determine the unique qualities of a specific epithelial segment. A complex interaction of protein-sorting signals, cytoskeletal elements, and intracellular trafficking processes determines whether a newly synthesized protein is targeted to either the apical or basolateral membrane. For example, proteins with a glycosyl phosphatidyl inositol (GPI) anchor (e.g., alkaline phosphatase or carcinoembryonic antigen) are often associated with lipid rafts, and the GPI anchor serves to direct them toward the apical membrane.1 Membrane proteins destined to be delivered to the basolateral membrane carry specific membrane-sorting signals (amino acid sequences) in their cytoplasmic tails. In contrast, other proteins can insert randomly into either apical or basolateral domain, but they may be retained in the basolateral pole by specific components such as ankyrin.2

Regulation of intracellular trafficking ensures delivery of the right protein to the right membrane and is critical for establishing epithelial polarization and vectorial transport. When tight junctions are disrupted in vitro, diffusion and intermingling of apical and basolateral proteins in the fluid phase of the membrane result in a loss of epithelial cell polarity. There is some evidence that the distribution of Na+ pumps is altered during postischemic injury.3

The most prominent feature of epithelial cell polarity is targeting of the Na+,K+-ATPase pump to the basolateral membrane, for which expression of the beta subunit of Na+,K+-ATPase is critical. The Na+ pump is electrogenic, extruding three Na+ ions in exchange for two K+ ions, and thereby maintaining relatively low intracellular Na+ and high intracellular K+ concentrations compared with concentrations of these electrolytes in the extracellular environment (see Fig. 99-2). There also is greater membrane permeability for K+ over Na+, which favors diffusional exit of K+ from the cell over diffusional cellular entry of Na+. These features, in combination with the large number of intracellular proteins with fixed negative charges, lead to the characteristic negative intracellular potential difference compared with either the mucosal or serosal compartments.* Low [Na+] and electronegativity establish a favorable electrochemical gradient for passive Na+ entry into the cell. Functionally, the epithelial cell uses the energy of the favorable Na+ gradient to transport not only Na+ ions but also a variety of nutrients, vitamins, and electrolytes.

These properties provide the basic mechanisms of ion and water transport that apply to all epithelia. In the intestine, differences in transport can be seen along its cephalocaudal length as well as along the surface-crypt axis within a particular segment of intestine. Tissue- and segment-specific nuances arise from structural-functional and regulatory differences of both intracellular and intercellular proteins.4


All intestinal segments from the duodenum to the distal colon have mechanisms for absorbing and secreting water and electrolytes. The diverse physiologic functions along the length of the GI tract are supported by the varied array of transporters encountered in its different segments. For example, the glucose- and amino acid-coupled transporters in the jejunum are well suited for absorption of large volumes of nutrients and water. The cecum, proximal colon, and distal colon, however, exhibit distinctly different transporters, with electrogenic Na+ absorption in the distal colon accomplishing the necessary final fluid extraction in preparation of feces.58 Different transporter molecules have been identified in specific segments of the GI tract. What is not clear, however, is why an individual transporter is located only in a specific segment of the intestine. For example, the DRA (down-regulated in adenoma) protein is an anion exchanger, and although anion exchange function is recognized in different segments of the intestine, DRA is predominantly expressed in the colon910 (see the later discussion of bicarbonate transport).

There also is segmental heterogeneity along the crypt-villus axis. Stem cells near the base of the crypt differentiate and migrate upward to form villus enterocytes in the small intestine or surface colonocytes in the large intestine while undergoing important changes in their transport and barrier properties (Fig. 99-3).11,12 As epithelial cells migrate away from the proliferative zone, the complexity of their tight junctions increases, the microvillus architecture of their apical membrane becomes more pronounced, and underlying cytoskeleton and signaling molecules undergo change; there also is increased expression of Na+ nutrient-coupled transporters, apical Na+-H+ exchangers, and brush border membrane hydrolases. In contrast, the levels of the Na+ pumps remain relatively constant and others, such as the signaling molecule adenylate cyclase and the cyclic adenosine monophosphate (cAMP)-associated Cl channel CFTR (cystic fibrosis transmembrane conductance regulator), decrease in more mature villus cells.

This spatial distribution of transporters (Fig. 99-4) is consistent with a model in which secretory function resides primarily in the crypts and absorption occurs in villus or surface cells. This dichotomy between absorptive surface cells and secretory crypt cells, however, is far from absolute; for example, in the colon, crypts absorb Na+ and fluid, and surface cells secrete Cl.13,14 Thus, depending on their relative position along the crypt-villus axis, the crosstalk between transporters and their signaling molecules can vary and fine tune intestinal function. This segregation of absorptive and secretory functions might explain why, in diseases that selectively damage villi or surface epithelia—such as enteric infection, inflammatory bowel disease (IBD), and celiac disease—secretion predominates.


Movement of ions and solutes across the epithelium is bidirectional and occurs via the transcellular and paracellular routes. Paracellular movement is largely passive, in response to a variety of gradients, including concentration, electrical, osmotic, and hydrostatic; transcellular movement of ions and solutes occurs by active and passive transport mechanisms. Net transport is termed absorptive if the mucosal-to-serosal flux (Jms) is greater than the serosal-to-mucosal (Jsm) flux and, and it is termed secretory if Jsm > Jms. Changes in either or both can alter the direction of the net movement; for example, the ileum, which normally exhibits an absorptive flux, responds to cholera toxin with a decrease in Jms and an increase in Jsm for Cl, resulting in massive fluid secretion.

Characteristics of the tight junctions—for example, tight versus leaky—vary along the length of the intestine and dictate the contribution of paracellular fluxes to overall transport. The effectiveness of a transepithelial gradient may be modified by series of physical barriers, including an unstirred layer created by the glycocalyx above the apical membrane, the lipid composition of the apical and basolateral membrane, the tight junctions, the geometry of the basolateral space between cells, and the basement membrane. Generally, movement of an uncharged particle is dictated solely by concentration gradients. In contrast, the transport of an ion is governed by the electrical potential and concentration differences (the electrochemical gradient) across the transported surface. Solvent drag, a nonspecific entraining of solutes along with the movement of water across paracellular pathways, is an absorptive mechanism that may be especially important in the small intestine, for example, for Na+-coupled solute absorption.


The paracellular space and junctional complexes between cells define the barrier function of epithelia. Epithelia with a low transepithelial voltage and low resistance are considered leaky, and those that exhibit a high transepithelial voltage and high resistance are considered tight. The tight junctions in villi have higher resistance than do those in crypts. Transepithelial resistance increases in a cephalocaudal direction (see Fig. 99-1).13

Since the 1990s, the model of paracellular transport and tight junctions has rapidly evolved from a static rigid barrier to a dynamic complex structure that is finely regulated (see Fig. 99-2). Movement through the space is exclusively passive, but it is influenced by electrical conductivity, charge selectivity, and its ability to be regulated. Cell-to-cell communications along the paracellular pathway occur in several discrete structures: zona occludens (ZO; tight junction), zona adherens (ZA), desmosomes, and gap junctions. The ZO is composed of several families of proteins that determine its physical and biological properties. For example, claudins belong to a family of 24 membrane-spanning proteins (24-27 kd) that form pores by interactions of the extracellular domains of claudins of adjoining cells; homotypic adhesion claudins are important in determining the charge selectivity of the tight junction.15,16

Additional proteins in the tight junction include occludins, junctional adhesion molecules (JAMs), and scaffolding proteins such as the zona occludens proteins (ZO-1, ZO-2) and multi-PDZ domain protein 1 (MUPP-1). The scaffolding proteins serve to link membrane proteins to an array of protein kinases, phosphatases and, via filamentous actin, to myosin in the terminal web, thereby influencing paracellular permeability.17,18 For example, disruption of tight junctions by enteropathogenic Escherichia coli is specifically associated with protein kinase Cζ activation.19 Another junctional complex that allows cell-to-cell interaction is the zona adherens. In epithelia, the zona adherens primarily is made up of E-cadherins, 120-kd transmembrane glycoproteins, with extracellular motifs that engage in calcium-dependent homotypic interaction with cadherins of adjoining cells. Intracellularly, cadherins bind to a family of adhesion molecules, the catenins, which in turn anchor to a dense actin-filament network. Alterations in cadherin-catenin distribution or function have been implicated in carcinogenesis.20

Desmosomes are junctional complexes that are structurally similar to zona adherens junctions, although instead of actin, they link to intermediate filaments through a dense plaque of intracellular anchor proteins. Gap junctions have a unique function: They bridge gaps between cells, thus allowing neighboring cells to exchange small molecules. They are made up of an assembly of connexins, a four-pass membrane-spanning protein, six of which join to form a hemichannel. When these hemichannels in two adjoining cells are aligned, they form a continuous pore that connects the interior of the two cells.1


Our current understanding of the movement of ions, solutes, and fluid across epithelia is gleaned from a combination of in vitro studies using reductionist models of cell lines or isolated epithelial sheets, and from complex in vivo methodologies such as the triple-lumen perfusion technique. All these models underscore that transepithelial ion (largely Na+) movement from the mucosa to the serosa drives fluid absorption, whereas net ion (largely Cl) movement in the reverse direction drives fluid secretion. Although different approaches help elucidate a complex mechanism, at times they give confounding results. For example, some in vitro studies report decreased Cl secretion and increased Na+ absorption in the jejunum of cystic fibrosis patients, implying that the intestinal manifestations of the disease are due to hyperabsorption of water. In contrast, in vivo studies show decreases in both Cl secretion and passive Cl absorption, suggesting that rather than a hyperabsorption of fluid, the severity of the disease is reflected by decreased fluid absorption.21

The reductionist models allow us to focus on transport processes at the cellular and paracellular level. In the intact intestine, however, things are more complicated. The geometry of the intestinal wall and the unstirred layer influence the distance that an individual molecule must traverse to reach the apical membrane. The extracellular glycosylated domains of apical membrane proteins make up the glycocalyx, which contributes to the thickness and permeability of the unstirred layer; this layer can be a diffusive barrier to the movement of large lipophilic molecules in a chiefly aqueous milieu. Physical parameters such as the mixing of luminal contents by peristalsis, villus motility, and the finer movement of the microvilli influence this rate.


Although water movement is a major property of the intestine, the mechanism(s) of intestinal water transport have not been clearly delineated. The movement of water is inextricably linked to the movement of solutes, in response to osmotic gradients. The standing-gradient hypothesis of water absorption suggests that even a small increase (2-3 mOsm) in the osmolarity of the intercellular and subepithelial spaces can cause movement of water across the epithelium, both through and around the cells.22 In the early 1950s, “water pores” were postulated to explain transepithelial water movement, but it was not until the remarkable discovery of the aquaporin (AQP) family of water transporters that a role of specific membrane proteins was implicated in erythrocyte and renal water transport.23,24 Although AQP2, AQP3, and AQP7 have been localized to the small intestine and AQP1, AQP3, AQP4, and AQP8 have been localized to the large intestine, the specific intestinal apical water channel, if any, has eluded discovery.25 Wright and associates proposed that the apical Na+-glucose transporter (SGLT) also may be able to transport water, perhaps as much as 5 L/day,26,27 but whether this can compensate for the puzzling lack of functional apical AQPs remains to be determined.


Small hydrophobic and uncharged molecules move across the lipid bilayer of the cell by diffusion, the rate of transport determined by the concentration gradients and diffusion coefficients (Fig. 99-5). Oxygen, carbon dioxide, fat-soluble vitamins, and unconjugated bile acids are examples of substances transported by diffusion. Because the majority of ions and solutes cannot cross the phospholipid membrane by diffusion, the cell employs an array of distinct integral membrane proteins, including channels, carriers, and pumps to cross cell membranes (Fig. 99-5).1

Channels are pores that allow the swift (>106 ions/sec) and controlled (by rapid opening and closing) transit of ions across the membrane, driven by the electrochemical gradient. The advent of molecular cloning techniques, patch clamp methodology (which allows the measurement of function of single channels), and membrane protein crystallography has greatly advanced our knowledge of how these proteins function. Channels tend to be ion selective. For example, Na+ channels exclude K+ despite its same charge and smaller size. Selectivity is determined by the hydration radius of the ion and the physiochemical nature of the pore. The overall transport of a particular ion is determined by the electrochemical gradient, the density of channels, and the gating (open-close time) of the channel; gating may be modulated by voltage, ion, concentration, or intracellular regulation. Mutations of critical residues in the channel protein can have dire functional consequences; for example, in cystic fibrosis, specific mutations of the CFTR affect the ability to transport chloride and bicarbonate.28,29

Carriers are another class of integral membrane proteins responsible for transport of ions and solutes at rates several orders of magnitude lower than channels. Carrier-mediated transport exhibits substrate specificity, saturation, and inhibitory kinetics. Carriers undergo a series of sequential conformational changes to facilitate the transport of substrates across a membrane. When concentration or electrochemical gradients drive carrier-mediated transport, the process is downhill and is termed facilitated diffusion. For example, the entry of fructose into the enterocyte via Glut-5 is by facilitated diffusion. The entering fructose is rapidly isomerized to glucose, maintaining the downhill gradient for fructose.

In contrast, other carriers harness the electrochemical energy established by the downhill movement of a second ion, usually Na+, to move a solute or another ion uphill. This process is termed secondary active transport because the specific gradient is indirectly created by a distinct energy-using process. For example, glucose uptake via the apical membrane Na+-dependent glucose transporter, SGLT, is driven by the Na+ gradient generated by the basolateral Na+,K+-ATPase. Carriers exhibit substrate specificity; thus, SGLT transports d-glucose but not l-glucose. Equally important, carriers can transport single or multiple substrates and perform the transport in different directions. Uniporters, such as Glut-2 in the basolateral membrane, transport one type of substrate, hexoses. Symporters, such as the Na+/K+/2Cl cotransporter, move Na+, K+, and Cl in the same direction, whereas antiporters, such as the Na+-H+ exchangers, move the two ions in opposite directions.

Pumps are the third class of integral membrane proteins and directly use energy, generally adenosine triphosphate (ATP) hydrolysis, to move ions against an electrochemical gradient. This process is termed primary active transport. Na+,K+-ATPase is the quintessential pump in the intestine. Other pumps important in GI epithelial transport include the luminal gastric and colonic H+,K+-ATPases and the basolateral Ca2+-ATPases.



In the GI tract, the surface epithelial cells of the distal colon and rectum exhibit electrogenic Na+ absorption against a fairly steep concentration gradient. The downhill electrochemical gradient created by the Na+ pump drives Na+ entry via an apical membrane Na+-specific ion channel (Fig. 99-6), which belongs to the family of epithelial Na+ channels (ENaCs). Members of the ENaC family are found in many epithelia.3032 They are multimeric proteins composed of α, β, and γ subunits; they exhibit a high sensitivity to the diuretic amiloride; and they are stimulated by mineralocorticoids and cAMP. Colonic ENaCs are inhibited by increases in intracellular Ca2+. Unlike many other channels that regulate transport by gating, ENaCs modulate transport by varying the channel density in the cell membrane; this variation may be accomplished through changes (increases or decreases) in synthesis (e.g., aldosterone) or exocytosis (e.g., cAMP, vasopressin) of the channels. Additionally, both aldosterone and cAMP block the association of ENaC with Nedd4-2, a ubiquitin protein ligase, which normally flags the protein for degradation; this block of degradation increases ENaC. Mutations in this pathway can result in the increased Na+ absorption and hypertension characteristic of Liddle’s syndrome, an autosomal dominant disorder with features of hyperaldosteronism that is a cause of infantile hypertension.


By and large, nutrient transporters are the purview of the small intestine. Transport of many hydrophilic nutrients including glucose, amino acids, and some vitamins occurs against their concentration gradients via secondary active transport at the apical membrane and facilitated diffusion across the basolateral membrane.

Glucose transport processes, elegantly elucidated by Wright and coworkers, provide a good example of nutrient transport.33 Transport across SGLT1 is electrogenic (2 Na+ to 1 glucose), is stereospecific (d-isomer), and transports galactose but not fructose.33 Glucose exit across the basolateral membrane occurs via a separate family of facilitated diffusion carriers, the glucose transporters (GLUT-2) (see Fig. 99-6). Fructose enters the cell via another member of this family, GLUT-5, and exits via GLUT-2.

Although it is clear that Na+ and glucose absorption stimulates water absorption, the mechanism is not fully delineated. The classic explanation is that basolateral exit of glucose creates a hypertonic compartment in the paracellular space, thereby generating an osmotic gradient for the entry of fluid from the lumen. Some enticing evidence suggests that secondary to transcellular transport through SGLT, passive processes triggers the contraction of the actomyosin ring in the terminal web, resulting in increased paracellular permeability to glucose and to water. Additionally, SGLT activation results in a protein kinase-dependent recruitment of GLUT2 to the apical membrane, which then serves as a high-capacity, low-affinity route for sugar entry during feeding.34,35 Evidence suggests that SGLT can serve as a water channel (210 water to 2 Na+ to 1 glucose) and might account for up to 5 L of fluid reabsorption in the fed state.36 How molecular regulation of transporters is translated into net nutrient absorption during feeding in vivo is a critical area of inquiry. For a description of similar advances made in our understanding of amino acid and vitamin transport, see Chapters 100 and 101.


The exchange of extracellular Na+ for intracellular H+ is a process that is driven by the electrochemical gradient for Na+ and by a pH gradient resulting from a moderately acidic intracellular environment; this process occurs in almost every cell. In mammalian intestine, members of the Na+-H+ exchange (NHE) gene family play an important role in electroneutral sodium absorption. Electroneutral Na+ absorption may be down-regulated during eating and increases upon postprandial nutrient absorption.

Ten mammalian isoforms of NHE have been cloned. NHE1-4 and 6-9 exhibit species- and segment-specific distribution in the GI tract.3739 NHE1 is a plasma membrane protein found in epithelial and nonepithelial cells. It is expressed on epithelial basolateral membranes and functions as the housekeeper regulator of intracellular pH, cell volume, and growth. NHE2 and NHE3 are apical membrane proteins restricted to epithelia and are the major conduits for electroneutral Na+ absorption in the intestine (see Fig. 99-6). NHE2 is expressed throughout the GI tract, but maximal expression is in the proximal colon. NHE3 is considered a marker for the absorptive cells of the small intestine and colon; it is expressed only in the villus or surface cells, and not in the crypts. NHE4 is located in the basolateral membrane and is primarily expressed in gastric parietal and chief cells, where it might have a role in acid secretion. NHE5 and NHE10 are not expressed in the GI tract, and the roles of NHE6-9 remain to be determined.

NHE activity is differentially modulated by neural, paracrine, or endocrine stimuli through intricate scaffolding complexes that include the exchanger itself, a family of NHE regulatory factors (NHERFs) that act as a bridge between the exchanger, and a variety of kinases and phosphatases.40,41 Different stimuli use differing scaffolding complexes to exert their effect. For example, glucocorticoids stimulate Na+ absorption and up-regulate NHE3 but not NHE1, 2, or 4, consistent with their respective roles in vectorial transport and housekeeping. Glucocorticoids act via a serum and glucocorticoid inducible kinase, SGK1; SGK1 stimulates the activity of NHE3 by interacting directly with NHERF2.

Alternatively, cAMP inhibits NHE3 by activating protein kinase A, which is recruited to the C-terminus of NHE3 by NHERF1, NHERF2, and an additional cytoskeletal protein, ezrin. In this location, PKA induces its inhibitory effect by phosphorylating NHE3. Cyclic guanosine monophosphate (cGMP) can inhibit NHE3 by triggering the formation of a complex between cGMP-dependent protein kinase II (cGKII) and NHERF2, which anchors cGMP kinase protein (GKAP). Activation of guanylate cyclase C by guanylin or E. coli–stable toxin A increases cGMP content near the brush border to locally activate cGKII (Fig. 99-7), which then inhibits NHE3 activity.40


Figure 99-7. Second messengers: cAMP and cGMP. Five steps are involved in the transduction of an external signal into a change in cellular function: (1) Binding of either a stimulatory or an inhibitory agonist to an appropriate receptor of the membrane-bound adenylate cyclase or guanylate cyclase system. (2) Binding of ligand to receptor, modulates the cyclase activity either within the same molecule in the case of guanylate cyclase, or by activating the corresponding membrane-bound heterotrimeric guanine nucleotide regulatory proteins (G proteins) in the case of adenylate cyclase. (3) An intracellular signal results from production of cAMP from ATP and cGMP from GTP. (4) Increase in [cAMP]i (intracellular cAMP concentration) activates protein kinases such as PKA and increase in [cGMP]i activates protein kinases such as protein kinase G II, which is fixed to the membrane by myristoylation. Involvement of kinase-anchoring proteins such as A kinase-anchoring proteins (AKAPs) and G kinase-anchoring proteins (GKAPs) has been demonstrated in the signaling. (5) Protein kinase phosphorylation of specific target proteins results in change in the activity of channels or transporters such as chloride channel or the Na+-H+ exchanger.

In cAMP signaling, binding of stimulatory regulators, such as VIP and prostaglandins, to specific receptors causes activation. Activated receptors couple via Gs to signal adenylate cyclases to catalyze the conversion of ATP to cAMP, which then activates specific cAMP kinases. An inherent GTPase returns Gs to its nascent state; in cholera, the toxin prevents this occurrence by covalently modifying Gs, leaving enterocyte turnover as the only recourse to returning the tissue to its basal state. Other hormones, such as somatostatin, trigger the activation of inhibitory G proteins (Gi) to decrease cAMP. The adenylate cyclase cascade is localized to the basolateral membrane of epithelial cells.

In cGMP signaling, cGMP is generated by the activation of membrane or soluble guanylate cyclases (GCs). In contrast to the adenylate cyclases, membrane GCs are single-pass transmembrane proteins for which the extracellular domain serves as the receptor-binding domain and the intracellular domain catalyzes conversion of GTP to cGMP. Thus, the GCs are specific for their ligands, which include the endogenous atrial natriuretic peptides, guanylin and uroguanylin, as well as enterotoxins such as the heat-stable enterotoxin of E. coli. The intestinal cGMP protein kinase (PGII) is tethered to the membrane via a myristoylated N-terminal region. The soluble GCs are the target of nitric oxide (NO) activation; they are minimally expressed in the small intestinal epithelium, but they are present in colonic epithelia, subepithelial elements, and smooth muscle, where they cause muscular relaxation. ATP, adenosine triphosphate; cAMP, cyclic adenosine monophosphate; cGMP, cyclic guanosine monophosphate; Gi, inhibitory G protein; Gs, stimulatory G protein; GTP, guanosine triphosphate; PKA, protein kinase A; PKG, protein kinase G; STa, heat-stable toxin; VIP, vasoactive intestinal peptide.


The transepithelial, lumen negative potential difference contributes to the passive movement of Cl and other anions via the paracellular pathway in the jejunum.7 While coupled Cl-HCO3 and Na-H exchangers govern electroneutral transport in the ileum and proximal colon, sodium-independent Cl-HCO3 exchange occurs in the distal colon (see Fig. 99-6) (see the discussion of HCO3 transport, later).


The principal driving force for the secretion of fluid is the transcellular movement of Cl from the serosal to the luminal compartment. Na+ and water follow passively in response to the ensuing electrical and osmotic gradients (Fig. 99-8). The small and large intestine exhibit a basal rate of Cl secretion that is maintained by the interplay of cell volume, [Cl]i, and paracrine, autocrine, neuronal, endocrine, luminal, and immune modulators. Disruptions in the balance of these regulatory processes can lead to secretory diarrhea.

Several epithelia in the GI tract exhibit electrogenic Cl secretion. Although there are some tissue-specific regulatory differences, the mechanisms underlying this secretion are remarkably similar. The Na+ pump provides the driving force, Cl enters the cell across the basolateral membrane via an electroneutral cotransporter (NKCC1) that couples the movement of 1Na+:1K+:2Cl, and Cl leaves the cell via specific channels on the apical membrane. The Na+ entering the cell via NKCC1 exits via the Na+ pump, and the K+ leaves via K+ channels either on the apical or the basolateral membrane. This complex interplay of transporters is an elegant demonstration of cellular economy. The NKCC1 cotransporter effectively moves 2 Cl and 1 K+ uphill for the expenditure of a single Na+ ion. The pump-to-leak relation between K+ channels and the Na+ pump helps to maintain the interior of the cell as electronegative, thereby providing the driving force for Cl exit. Basolateral K+ exit electrically balances the large Cl flux across the apical membrane. NKCC cotransporters belong to a superfamily of cation transporters and are characterized by their inhibition by the loop diuretics bumetanide and furosemide.4244

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