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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.
Anatomy
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
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
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
Intraluminal
foreign bodies
gallstones
meconium
Intramural
tumors
Extrinsic
adhesions
hernias
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
Schwartzs Principles of Surgery, 9th Ed
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)
Treatment
fluid resuscitation
NG decompression
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
Clinical Manifestations
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
Schwartzs Principles of Surgery, 9th Ed
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
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
Clinical Manifestations:
Abdominal pain
Hematochezia
Palpable mass
Fever
Weight loss
Night sweats
Diagnosis:
CT scan of the abdomen
Treatment:
Resection with Quadruple Anti-TB therapy
Typhoid Enteritis
Etiology/Pathogenesis: Salmonella typhi
Clinical Manifestations:
Bleeding
Abdominal pain
Diarrhea
Fever
Diagnosis:
C/S of stool
Biopsy
Treatment:
a.
b.
Meckels Diverticulum
Reyes, Maria Laura Bielle G.
Meckels Diverticulum
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
Meckels Diverticulum
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.
Meckels Diverticulum
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
Clinical Manifestations
Asymptomatic unless associated
complications arise
Symptomatic Meckels diverticula presents:
Bleeding: most common presentation in children
Intestinal obstruction: most common in adults
diverticulitis
Clinical Manifestations
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
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
Incidence
Adenocarcinomas
35-50%
Carcinoid tumors
20-40%
Lymphomas
10-15%
Clinical manifestation
Mostly asymptomatic
Physical Exam- unrevealing
Palpable abdominal mass- 25%
Carcinoid tumors
Diarrhea, flushing, hypotension and tachycardia
Lymphoma
Located in the ileum
Partial small bowel obstruction
GIST
hemorrhage
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
Carcinoid tumors
Segmental intestinal resection and regional
lymphadenectomy
GIST
Segmental resection
Resistant to chemotherapy
Outcomes
Complete resection of duodenal adenocarcinoma
Post operative 5 year survival rate= 50-60%