Intestinal Problems

Reyes, Christopher Brian M.
Anatomy
Tubular structure
6 meters in adults
Three segments lying in series:
Duodenum
most proximal segment
lies in the retroperitoneum immediately adjacent to the
head and inferior border of the body of the pancreas.
demarcated from the stomach by the pylorus and from the
jejunum by the ligament of Treitz.
Anatomy
Jejunum and Ileum.
The jejunum and ileum lie within the peritoneal cavity and are
tethered to the retroperitoneum by a broad-based mesentery.
No distinct anatomic landmark demarcates the jejunum from the
ileum
the proximal 40% of the jejunoileal segment is arbitrarily defined
as the jejunum and the distal 60% as the ileum.
The ileum is demarcated from the cecum by the ileocecal valve.
contains mucosal folds

plicae circulares or valvulae conniventes that are visible
upon gross inspection
visible radiographically and help to distinguish between
small intestine and colon
more prominent in the proximal intestine than in the
distal small intestine
Anatomy
served by rich vascular traversing through the

mesentery.
base of the mesentery attaches to the posterior
abdominal wall to the left of the second lumbar vertebra
and passes obliquely to the right and inferiorly to the
right sacroiliac joint.
The blood supply of the small bowel comes entirely

from the superior mesenteric artery
Proximal duodenum celiac trunk
The superior mesenteric artery courses anterior to

the pancreas and the duodenum, where it divides to
supply the pancreas, distal duodenum, entire small
intestine, and ascending and transverse colon.
Anatomy
There is a collateral blood supply to the small
bowel by vascular arcades.
Venous drainage of the small bowel parallels the
arterial supply, with blood draining into the
superior mesenteric vein, which joins the splenic
vein behind the neck of the pancreas to form the
portal vein.
Anatomy
Intestinal Trauma
The majority of duodenal injuries are caused by
penetrating trauma
accompanied by other intra-abdominal injuries
motor vehicle accident causing impact of the
steering wheel on the epigastrium
most common mechanism
Hyperamylasemia occurs in about 50% of

patients with blunt injury to the duodenum
Intestinal Trauma
Plain films of the abdomen
mild scoliosis, obliteration of the right psoas shadow,
absence of air in the duodenal bulb, or air in the
retroperitoneum outlining the kidney
Definitive diagnosis requires a upper

gastrointestinal series or a CT scan of the
abdomen with oral and IV contrast in
hemodynamically stable patients
Extravasation of contrast material is an absolute
indication for laparotomy.
Intestinal Trauma
Intraoperative evaluation of the duodenum
requires adequate mobilization of the
duodenum by means of a Kocher maneuver.
The hepatic flexure of the colon is also mobilized to
provide adequate exposure of the anterior wall of
the second portion, and examination of the third
and fourth portions of the duodenum should also be
done.
The presence of retroperitoneal hematomas around
the duodenum should raise suspicion of an
associated pancreatic injury.
Intestinal Trauma
If the distal antrum or pylorus is severely damaged
reconstructed with a Billroth I or II procedure
With the almost universal use of CT for the diagnosis of

blunt abdominal injury, injury to the small intestine can be
missed.
80 Wounds of the mesenteric border also can be missed if
the exploration is not comprehensive.
Most injuries are treated with a lateral single-layer running
suture.
Multiple penetrating injuries often occur close together.
Rather than performing many lateral repairs, judicious
resections with end-to-end anastomosis may save
considerable time.
Reyes, Lisha Alyanna A.
Small Bowel Obstruction

- blockage of the small
bowel resulting to
failure of intestinal
contents to pass
through
- most frequently
encountered surgical
disorder of the small
intestine
Schwartzs Principles of Surgery, 9th Ed
Intraluminal
foreign bodies
gallstones
meconium
Intramural
tumors
Extrinsic
adhesions
hernias
partial small bowel obstruction vs

complete small bowel obstruction
simple mechanical obstruction - obstruction present,
no vascular compromise
strangulated bowel obstruction - increase in
intraluminal pressure that intestinal
microvasculature is impaired causing intestinal
ischemia and necrosis
closed loop obstruction - both the proximal and distal

segment of the intestine is obstructed
incarceration - constricted hernia that bowel

becomes irreducible
Clinical Manifestations
colicky abdominal pain
as gas and fluid accumulate within intestinal lumen
proximal to obstruction, increase effort to overcome
obstruction
earlier stage: hyperactive bowel sounds
later stage: minimal bowel sounds
vomiting
proximal obstruction > distal obstruction
characteristic: feculent (chronic distal obstruction)
abdominal distention
distal obstruction > proximal obstruction
partial obstruction: continuous passage of flatus and/or stool
strangulated obstruction: abdominal pain is disproportionate
to abdominal findings highly suggestive of ischemia
tachycadia, localized abdominal tenderness, fever, marked
leukocytosis, acidosis, need for early surgical intervention
Goals of Diagnosis
distinguish mechanical obstruction from ileus
ileus: no mechanical barrier, characterized by impaired
intestinal motility that prevents intestinal contents to pass
determine etiology of obstruction
discriminate partial from complete obstruction
distinguish simple from strangulating obstruction
Abdominal Series
Sn 70-80%, low Sp ileus and colonic obstruction mimic
triad: dilated of dilated small bowel loops (>3 cm in
diameter), air-fluid levels seen on upright films, paucity of
air in the colon
false negative: obstruction in the proximal bowel, bowel
filled with fluid but no air (closed loop obstruction)
CT (Sn 80-90%, Sp 70-90%)

prognostic and therapeutic: appearance of contrast after
24 hours is predictive of nonsurgical resolution of bowel
obstruction
discrete transition zone with dilation of bowel proximally
decompression of bowel distally
colon containing little gas or fluid
CT (Sn 80-90%, Sp 70-90%)

closed loop: U shaped dilated bowel loop with a radial
distribution of mesenteric vessels converging toward a
torsion point
strangulation: thickening of bowel wall, pneumatosis
inestinalis (air in bowel wall), portal venous gas,
mesenteric haziness, poor uptake of IV into wall of
affected bowel
low sensitivity (>50%): low grade or small partial
obstruction
Small Bowel Series (small bowel follow-through)

water soluble contrast agents Gastrografin if perforation is
suspected; oral or NGT
abdominal radiograph taken serially
greater sensitivity in detection of luminal and mural
etiologies, primary intestinal tumor
Enteroclysis
200-250 mL barium followed by 1-2 L methycellulose in
water; proximal jejunum via nasoenteric catheter
double contrast: mucosal surface assessment, detection of
small lesions
Treatment
fluid resuscitation
NG decompression
> Conservative Treatment

partial small bowel obstruction
obstruction occurring in the early postoperative period
intestinal obstruction due to Crohns disease
carcinomatosis
* non operative therapy: bowel rest, continuous hydration/TPN
*observe for signs and symptoms of strangulation, intestinal
ischemia, and peritonitis: surgical procedure
Treatment
surgical procedure is dependent on etiology
adhesions: lysed
tumors: resected
hernias: reduced and repaired
observe fore viability: color, peristalsis, marginal arterial
pulsations
nonviable bowel: resected
Prevention of Adhesion
good surgical technique
careful handling of tissue
minimal exposure of peritoneum to foreign bodies
Ileus and
Intestinal Pseudo-obstruction
clinical syndrome caused by impaired intestinal
motility
characterized by signs and symptoms of intestinal
obstructions in the absence of lesion-causing
mechanical obstruction
Ileus
- temporary motility disorder
reversed with time as
inciting factor is corrected
- most frequently implicated
cause of delayed discharge
following abdominal
operation
- surgical stress-induced
sympathetic reflexes
- inflammatory response
mediator release
- anesthetic/analgesic effects
Intestinal
Pseudo-obstruction
- comprises a spectrum of
specific disorders associated
with irreversible intestinal
motility
inability to tolerate liquids and solids
no flatus or bowel movement
vomiting
abdominal distention
diminished or absent bowel sounds
Diagnosis: Ileus
persists beyond 3-5 days postoperatively
Post-operative motility
o small intestinal: 24 hours
o colonic: 48 hours
o gastric: 3-5 days
o listening for bowel sounds not reliable
o functional evidence: passing of flatus or bowel movement
review medications
measurement of electrolytes
radiograph: difficulty in distinguishing mechanical
obstruction from ileus
CT scan: test of choice
detect presence of intra-abdominal abscess
evidence of peritoneal sepsis
rule out mechanical obstruction
Diagnosis: Chronic Pseudo-obstruction

manometric studies: disorder of intestinal motility
laparotomy or laparoscopy with biopsy: establish specific
underlying cause
Treatment: Ileus
limiting oral intake
correcting underlying cause
NG decompression
fluid and electrolyte or TPN administration
postoperative ileus
early ambulation
administration of NSAIDs with reduction of opioid dosing
perioperative thoracic epidural anesthesia/analgesia with local
anesthetics with reduction or systemic opioids reduced duration of
postoperative ileus
alvimopan: peripherally active -opioid receptor antagonist, reduce
duration of postoperative ileus, hospital stay, rate of readmission in
several prospective, randomized placebo-controlled trials with
subsequent meta-analysis
Prevention: Ileus
Treatment: Chronic Pseudo-obstruction

palliative: fluid, electrolyte, and nutritional management
no standard therapy is curative
refractory disease: limit oral intake, long term TPN
decompressive gastrostomy
extended small bowel resection
Inflammatory Diseases
of the Small Intestine
Reyes, Ma. Katrina Bernadette O.
Crohns Disease
Etiology/Pathogenesis: Unknown
Clinical Manifestations:
Diagnosis:
Treatment:
a. Medical Anti-inflammatory drugs, anti-biotics, corticosteroids
b. Surgery Bowel resection
TB Enteritis
Etiology: Mycobacterium tuberculosis
Abdominal pain
Hematochezia
Palpable mass
Fever
Weight loss
Night sweats
Diagnosis:
CT scan of the abdomen
Ascitic fluid analysis

Peritoneal biopsy
Colonoscopy
Treatment:
Resection with Quadruple Anti-TB therapy
Typhoid Enteritis
Etiology/Pathogenesis: Salmonella typhi
Bleeding
Abdominal pain
Diarrhea
Fever
Diagnosis:
C/S of stool
Biopsy
Treatment:
a.
b.
Medical Broad spectrum antibiotics

Surgical Bowel resection
(bleeding and perforation)
Meckels Diverticulum
Reyes, Maria Laura Bielle G.
Most prevalent congenital
anomaly of the GI tract
Designated as true
diverticula
Location varies but usually
found in the ileum within
100cm of ileocecal valve
occurs on the antimesenteric border of the
ileum, usually 40-60 cm proximal to the
ileocecal valve
3 cm long and 2 cm wide
Slightly more than one half contain ectopic
mucosa
Meckel diverticulum is typically lined by ileal
mucosa, but other tissue types are also found
with varying frequency.
Mnemonics for describing Meckels Diverticula
(the rule of twos):
2% prevalence
2:1 female predominance
Location of 2 ft proximal to the ileocecal valve in
adult
of those who are symptomatic under 2 yrs of
age
Pathophysiology
Failure or incomplete vitelline duct
obliteration results in a spectrum of
abnormalities, most common is Meckels
diverticum
Remnant of left vitelline artery can persist to
form mesodiverticular band tethering a
meckels diverticulum to the ileal mesentery
Asymptomatic unless associated
complications arise
Symptomatic Meckels diverticula presents:
Bleeding: most common presentation in children
Intestinal obstruction: most common in adults
diverticulitis
Bleeding is usually result of ileal
mucosal ulceration
Intestinal obstruction can result
from several mechanisms:
Volvulus of intestine around
fibrous band attaching the
diverticulum to umbilicus
Entrapment of intestine by a
mesodiverticular band
Intussusception with
diverticulum acting as lead point
Stricture secondary to chronic
diverticulitis
Diagnosis
Routine laboratory findings, including CBC count, electrolyte levels, glucose

test results, BUN levels, creatinine levels, and coagulation screen results
Aymptomatic
radiographic imaging
Endoscopy
At the time of surgery
Symptomatic
Radionuclide scans (99mTc-pertechnetate) can be helpful in the diagnosis
of Meckel's diverticulum; however, positive only when the diverticulum
contains associated ectopic gastric mucosa that is capable of uptake of
the tracer
Enteroclysis - associated with an accuracy of 75%, but usually is not
applicable during acute presentations of complications related to
Meckel's diverticula
Angiography - can localize the site of bleeding during acute hemorrhage
related to Meckel's diverticula
Diagnosis
Technetium-99m pertechnetate scintiscan
(0.2mCi/kg in children and 10-20mCi in adults)
The pertechnetate is taken up by gastric mucosa and
after intravenous injection of the isotope, the gamma
camera is used to scan the abdomen. Gastric mucosa
secretes the radioactive isotope; thus, if the
diverticulum contains this ectopic tissue, it is
recognized as a hot spot.
The Meckel scan is the preferred procedure because it is
noninvasive, involves less radiation exposure, and is more
accurate than an upper GI and small-bowel follow-through
study.
Treatment
Symptomatic Meckels Diverticula
Diverticulectomy with removal of associated
bands connecting the diverticulum to abdominal
wall or mesentery
Segmental ileal resection
Treatment
Asymptomatic Meckels Diverticula
Prophylactic removal of asymptomatic Meckels
Divertivula
Prophylactic diverticulectomy
Small bowel Neoplasms

Reyes, Nicole Marie O.
Incidence
Adenocarcinomas
35-50%
Carcinoid tumors
20-40%
Lymphomas
10-15%
Adenomas are the most common benign neoplasms of

the small intestine
50- 60 years of age
Consumption of red meat, smoked or cured foods,
crohns disease, celiac sprue, FAP
Schwartzs principle on surgery
9th Ed
Clinical manifestation
Mostly asymptomatic
Physical Exam- unrevealing
Palpable abdominal mass- 25%
Partial small bowel obstruction, abdominal

pain and distention, nausea and vomiting
Hemorrhage
Adenocarcinoma-> duodenum
Diagnosed earlier
9th Ed
Carcinoid tumors
Diarrhea, flushing, hypotension and tachycardia
Lymphoma
Located in the ileum
Partial small bowel obstruction
GIST
hemorrhage

9th Ed
Diagnosis
Enteroclysis
90% sensitivity
Test of choice
CT scanning
Low sensitivity for detecting mucosal or intramural
lesion
Useful in staging
EGD
Tumors in the duodenum
Visualize and biopsy
Intraoperative enteroscopy
Schwartzs principles on
surgery 9th Ed
Therapy
Duodenal tumors <1 cm
endoscopic polypectomy
Duodenal tumors >2 cm

Transduodenal Polypectomy and segmental duodenal
resection
2nd portion of duodenum- pancreaticoduodenectomy
Jejunal and ileal malignancies

Wide local resection
Excision of the corresponding mesentery
9th Ed
Carcinoid tumors
Segmental intestinal resection and regional
lymphadenectomy
small Intestinal lymphoma

Localized: Segmental intestinal resection adjacent
mesentery
Diffusely affected: chemotherapy
GIST
Segmental resection
Resistant to chemotherapy

9th Ed
Outcomes
Complete resection of duodenal adenocarcinoma
Post operative 5 year survival rate= 50-60%
Complete resection of adenocarcinoma in

jejunum or ileum
5 year survival rate of 5-30%
Resection of localized carcinoid tumors

75-95% 5 year survival rate
Diagnosed with Intestinal lympoma

20-40%
GIST following resection

35-60% 5 year survival

9th Ed

Intestinal Problems

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Intestinal Problems

Caricato da

Copyright:

Formati disponibili

Reyes, Christopher Brian M.

Reyes, Christopher Brian M.

contains mucosal folds

Reyes, Christopher Brian M.

Reyes, Christopher Brian M.

served by rich vascular traversing through the

The blood supply of the small bowel comes entirely

The superior mesenteric artery courses anterior to

Reyes, Christopher Brian M.

Reyes, Christopher Brian M.

Reyes, Christopher Brian M.

Hyperamylasemia occurs in about 50% of

Reyes, Christopher Brian M.

Definitive diagnosis requires a upper

Reyes, Christopher Brian M.

Reyes, Christopher Brian M.

With the almost universal use of CT for the diagnosis of

Reyes, Lisha Alyanna A.

Small Bowel Obstruction

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

partial small bowel obstruction vs

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

closed loop obstruction - both the proximal and distal

incarceration - constricted hernia that bowel

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

CT (Sn 80-90%, Sp 70-90%)

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

CT (Sn 80-90%, Sp 70-90%)

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Small Bowel Series (small bowel follow-through)

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

> Conservative Treatment

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Schwartzs Principles of Surgery, 9th Ed

Reyes, Lisha Alyanna A.

Reyes, Lisha Alyanna A.