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Small Intestine
Anatomy and Physiology
Jejunum
suspended in a mobile mesentery
2/5 of whole intestinal length
may be involved in adhesions
Ileum
3/5 of whole intestinal length
Blood Supply
INVESTIGATIONS
SMALL BOWEL DISORDERS
3. Enteroclysis
Enteroclysis
minimally invasive radiographic procedure of the small
intestine, which requires the introduction of a catheter
into the intestine, followed by the injection of barium and
methylcellulose.
The barium coats the intestine and the methylcellulose
distends the lumen to give a double contrast exam that
allows for fluoroscopic visualization of the entire small
bowel.
Enteroclysis
may be helpful in diagnosing almost all diseases that affect
the small bowel
Disadvantages :
placement of the enteroclysis catheter can be
uncomfortable for the patient, even with the use of
anesthetic spray and Xylocaine jelly
patient will receive higher doses of radiation in
comparison to the traditional small bowel follow
through exam during this exam.
Advantages :
much quicker than a routine single contrast Small Bowel
Follow Through exam
distention of the small bowel makes it possible to display
all dilated bowel loops simultaneously at the end of the
exam
INVESTIGATIONS
SMALL BOWEL
INVESTIGATIONS
Ultrasound of the abdomen
can differentiate fluid-filled dilated small bowel loop
from abdominal cystic structures
can assess free fluid within peritoneal cavity
can assess a solid mass belonging to the small bowel if
large enough
INVESTIGATIONS
Isotope scintigraphy
Isotope-labelled red cells- occult GI bleeding
INVESTIGATIONS
Quantitative estimation of fecal fat- remains the most sensitive test of disorders of
digestion and absorption
INVESTIGATIONS
Jejunal mucosal biopsy
Celiac disease- subtotal villous atrophy
Whipples- abnormal mucosal pathogens
INVESTIGATIONS
BACTERIAL OVERGROWTH
small bowel becomes colonized by bacteria
increase in the concentration organisms which are
normally confined to the lower small bowel and colon
affected intestine becomes inflammed and dilated
Symptoms and signs- colicky pain, meteorism, diarrhea,
anemia
INVESTIGATIONS
Causes of bacterial overgrowth:
1. Excessive entry of bacteria into the small bowel
2. Intestinal stasis
BACTERIAL OVERGROWTH
1. Excessive entry of bacteria
Achlorhydria
Gastro-jejunostomy
Gastrectomy
Enterocolic fistulas
Cholangitis
BACTERIAL OVERGROWTH
2. Intestinal stasis:
Stenotic Crohns disease
Stenotic intestinal stasis
Small bowel diverticulosis
Afferent loop stasis
Entero- enteric anastomosis
Diabetis mellitus- autonomic neuropathy
Radiation enteritis- stenosis
Scleroderma- impaired intestinal motility
BACTERIAL OVERGROWTH
Clinical features:
Abdominal colicky pain
BACTERIAL OVERGROWTH
Treatment :
Surgical treatment of the underlying condition whenever
possible
Jejunal diverticulosis, scleroderma- tetracycline and
metronidazole for 10-14 days
SHORT-GUT SYNDROME
SHORT-GUT SYNDROME
Conditions necessitating extensive resection of the small
bowel:
Crohns disease
Mesenteric infarction
Radiation enteritis
Multiple fistulas
SHORT-GUT SYNDROME
Resections of more than half of the small bowel lengthserious malabsorbtion
Pts.with residual small bowel length of < 2m- diminished
work capacity
Pts. with residual small bowel length of less 1m require
home parenteral nutrition on an indefinite basis
Ileal resections are less well tolerated than jejunal
resections
SHORT-GUT SYNDROME
Treatment:
Massive small bowel resection- TPN regimen that must
provide 40 Kcal/Kg. body weight
Pts. with about 1m. of small bowel- TPN discontinued
with time coz small bowel will hypertrophy
PROTEIN-LOSING ENTEROPATHY
Loss of plasma proteins- low plasma proteins
secondary hyperaldosteronism with water and salt
retention- edema
Causes:
- mucosal disease- Whipples
Adenomatous polyps
Hamartomatous polyps- Peutz-Jaegers syn.
Leiomyomas, lipomas, fibromas
Hemangiomas, neurofibromas
CARCINOID TUMORS
Derived from enterochromaffin cells
CARCINOID TUMORS
Diagnosis:
- elevated levels of 5 HIAA- 5 hydroxyindolacetic
acid- the breakdown product of serotonin in the
urine
TREATMENT:
resection of the primary tumor and metastastatic tumor
Lymphoma
presents with fatigue, weight loss and abdominal
pain
GIST-CLINICAL PRESENTATION
Often asymptomatic, especially when small
Colon
10% 15%
50%
Stomach
25%
Small
intestine
GIST
2 major histologic patterns, which overlap with many
non-GIST sarcomas and other malignancies
Spindle cell
Epithelioid
In the past, GIST were usually classified as:
Leiomyoma
Leiomyoblastoma
Leiomyosarcoma
Many patients previously diagnosed with one of these
tumors actually had a GIST
GIST DIAGNOSIS
Initial workup should include imaging:
CT of abdomen and pelvis with oral/IV contrast
Consider 18FDG-PET
Endoscopic ultrasound
Liver function tests
Complete blood counts
Surgical assessment
Resectable vs non-resectable
Primary tumor only vs metastatic
FDG - PET
FDG - PET (Fluorodeoxyglucose- positron emission
tomography)
Provides the status of glucose metabolism in
tumors
GIST are highly metabolically active
Easy detection highly-sensitivebut not specific for
metabolically active GIST
Staging workup
Evaluate the extent of the disease
Assess for metastatic disease
GIST- TREATMENT
Surgery remains the principal treatment for resectable
primary GIST
Standard sarcoma chemotherapy is ineffective
Limited response rate ~5%
Median time to progression 3-4 months
No impact on survival
SURGICAL CONSIDERATIONS
Complete gross resection with the intact pseudocapsule is
the goal of resection
Careful tumor handling is critical
Rupturing of the pseudocapsule can cause tumor
bleeding and/or dissemination
intrinsic or extrinsic
Etiology: SBO
Extraluminal
Abscesses
Infant
Young
Adult
Adult
Adhesions
Adhesions
(70%)
Groin Hernia
Groin
Intussusception
Hernia
(10%)
Groin Hernia
Meckels
Diverticulum
Cancer
(5%)
Causes
Symptoms
Signs
Plain films
SBO
Colonic
Adhesions and
Cancer
Groin Hernias Inflammation
cramps and
cramps and
vomiting
vomiting less
regular
frequent
interval
mild-moderate moderatemarked
distension
distension
dilated loops
dilated airwith air-fluid filled colon
levels, paucity
w/w/o SB
distally
distension
CAUSES: SBO
Intramural
Neoplasms
Adenocarcinomas: 50%, distal duodenum or proximal
jejunum- cause hemorrhage or ulceration
Lymphomas: 20%, non-Hodgkins. Ileum> jejunum>
duodenum. Occasionallyobstruct
CAUSES: SBO
Inflammatory
Crohns 5%. Acute inflammation and edema or
chronic strictures.
Infectious
Congenital
Malrotation, duplication, congenital bands
Others: Traumatic, Intussusception, radiation
CAUSES: SBO
Intraluminal
Gallstones, enteroliths, Bezoars, foreign bodies
Classical presentation:
Diarrhea
Compromised ventilation:
- Increased abdominal pressure, decreased venous return,
elevationof diaphragm
Fever:
- Strangulated bowel; Closed loop obstruction has
increased intraluminal pressures with decrease in
mucosal blood flow.
Electrolyte Imbalance
Radiology
Plain film:
- diagnostic in 50-60% of cases
- small bowel distention, multiple air-fluid levels, and
decreased colonic gas and stool
- Widely available and low cost
Enteroclysis
Sequential infusion promotes antegrade flow beyond point
of obstruction
Treatment
Non-operative:
- 60-85% resolution
- NG tube decompression, fluid resuscitation, bowel rest
- Serial exams and electrolyte management
- IFC
- Broad spectrum antibiotics
Operative
Adhesions
Internal herniation
Inflammation
NG tube
gastrograffin challenge
CT SCAN
POSTOPERATIVE ILEUS
Postoperative Ileus
Pathophysiology of Ileus
Gallstone ileus
Gallstone ileus
Infectious Diseases
1. TB Enteritis
Primary infection
Secondary Infection
Indication for surgery- obstruction
2. Typhoid enteritis
Diagnosis blood culture
Medical management
Indications for surgery- bleeding, perforation
ENTEROCUTANEOUS FISTULA
ETIOLOGY
Radiation
IBD
diverticular disease
ischemic bowel
appendicitis
malignancies
ETIOLOGY
Anastomotic breakdown
unrecognized bowel injuries during dissection or
abdominal closure.
Operations for cancer, IBD, and lysis of adhesions are
most at risk.
CLASSIFICATION
I. Output:
Low:200 ml/24-hour
Foreign body
Radiation
Neoplasm
Distal obstruction
DIAGNOSIS
Clinical presentation:
Fever
prolonged ileus
DIAGNOSIS
Clinical presentation:
sepsis
Radiologic studies:
Plain radiography
GI contrast studies
Fistulograms
Ultrasonography
CT scan
MANAGEMENT
Divided into three phases:
1. Diagnosis and recognition
2. Stabilization and investigation
3. Definitive care
- usually occurs if the fistula fails to respond to medical
treatment after 4 to 6 weeks.
MANAGEMENT
NPO
NG tube
H2 antagonist or PPI
skin protection
drainage of abscess
MANAGEMENT
Malnutrition is present in 5590% of patients with ECF and is responsible
for much of the morbidity and mortality in these patients.
Definitive Care:
- usually occurs if the fistula fails to respond to medical
treatment after 4 to 6 weeks.
Operative interventions:
- oversewing of the fistula
- resection of the diseased segment with primary
anastomosis
- exteriorization
- serosal patch with either jejunum or a defunctionalized
Roux.
Thank You