Académique Documents
Professionnel Documents
Culture Documents
Small Intestine
one of the most important organs for
immune defense
largest endocrine organ of the body
Starts from the pylorus and ends at the
cecum
3 parts:
1. Duodenum (20cm)
2. Jejunum (100 to 110cm)
3. Ileum (150 to 160 cm)
Anatomy
A.
B.
Jejunum:
C.
Retro-peritoneal
Supplied by the celiac artery
Occupies upper left of the abdomen
Thicker wall and wider lumen than the
ileum
Mesentery has less fat and forms only
1-2 arcades
Ileum:
Function
A. Digestion & Absorption:
B. Endocrine Function:
Secretes numerous hormones involved in GIT
function.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Secretin
Cholecystokenin
Gastric inhibitory peptide
Enteroglucagon
Vasoactive intestinal peptide
Motilin
Bombesin
Somatostatin
Neurotensin
Function
C. Immune function:
1. Major source of IgA
2. Integrity of the GUT wall prevents bacterial
translocation into the wall of the intestine
and abdominal cavity which can lead to
sepsis
3. Gut associated lymphoid tissue part of the
immune defense system which clears the
abdominal cavity of pathogenic bacteria
found in Peyers patches
Pathophysiology:
Accdg. to its anatomical relationship to
the intestinal wall:
1. Intraluminal ( foreign bodies, gallstone, and
meconium)
2. Intramural (neoplasm, Crohns,
hematomas)
3. Extrinsic (adhesion, hernias &
carcinomatosis)
Pathophysiology:
Air-fluid level:
Gas due to swallowed air
Fluid a) swallowed fluid
b) gastrointestinal
secretion
(increase epithelial water
secretion).
Bowel distention /
elevated intramural
pressure ---> ischemia
------> necrosis.
(strangulated bowel
obstruction)
Pathophysiology:
Partial small-bowel obstruction
passage of gas and fluid.
Complete small-bowel obstruction
(obstipation)
Closed loop obstruction (obstructed
proximal and distal) ex. volvulus
Manifestation:
colicky abdominal pain
nausea / vomiting
obstipation
abdominal distention
hyperactive bowel sound
signs of dehydration (sequestration of fluid in
bowel wall and lumen as well as poor oral
intake)
7. lab. findings:
1.
2.
3.
4.
5.
6.
a.
b.
c.
hemoconcentration
fluid & electrolyte imbalance
leucocytosis
Manifestation:
Features of Strangulated obstruction:
1.
2.
3.
4.
5.
6.
tachycardia
localized abd. tenderness
fever
marked leucocytosis
acidosis
lab result:
- elevated serum amyase, lipase, LDH,
phosphate and potassium
Diagnosis:
Focus on the following goals:
1. distinguish between mechanical obstruction
from ileus
2. determine the etiology
3. whether it is partial or complete obstruction
4. differentiate between simple and
strangulating obstruction
Diagnosis:
1. Clinical history & PE
2. Radiological examination:
a. FPA (supine and upright)
Triad:
Diagnosis:
b. CT scan (90% sensitive / 90% specific)
Findings of small bowel obstruction:
a.
b.
c.
Strangulation is suggested:
a.
b.
c.
d.
e.
Diagnosis:
c. Small bowel series (barium / gastrografin)
d. Enteroclysis
200 to 250 ml of barium followed by 1 to 2 L of
methylcellulose in water is instilled into the
proximal jejunum via a long naso-enteric tube
Treatment:
1.
Isotonic fluid
Monitor resuscitation (foley catheter/CVP)
NPO / TPN
Broad spectrum antibiotic (due to bacterial
translocation)
4. Placed NGT to decompress the stomach and
decrease nausea, distention and risk of
aspiration
5. Expeditious celiotomy (to minimize risk of
strangulation).
2.
3.
Ileus / Pseudo-Obstruction
Impaired intestinal motility
Most common cause of delayed discharge
following abdominal operations
Temporary and reversible
Ileus / Pseudo-Obstruction
Etiologies:
1.
2.
3.
4.
5.
6.
Abdominal surgery
Infection & inflammation (sepsis/peritonitis)
Electrolyte imbalance (Hypo K, Mg & Na)
Drugs (anticholinergic, opiates)
Visceral myopathies (degeneration/fibrosis of
smooth muscle)
Visceral neuropathies (degenerative disorders of
myenteric & submucosal plexuses)
Symptoms:
1. Inability to tolerate solid & liquid by
2.
3.
4.
5.
mouth
Nausea/vomiting
Lack of flatus & bowel movements
Diminished or absent bowel sound
Abdominal pain and distention
Diagnosis:
1. History of recent abdominal surgery
2. Discontinue opiates
3. Serum electrolyte determination
4. CT scan better than FPA in postoperative
Therapy:
1. NPO, if prolong TPN is required
2. NGT to decompress the stomach
3. Correct fluid & electrolyte imbalance
4. Give ketorolac and reduce the dose of
opioids
CROHNS DISEASE
Regional, transmural, granulomatous
enteritis).
Chronic, idiopathic inflammatory dse
Ethnic groups ---> East Europe
(Ashkenazi Jewish)
Female predominance, 2x higher smokers
Familial association (30x in siblings / 13 x
in 1st degree relatives).
Higher socioeconomic status
Breast feeding is protective
Etiology:
Unknown
Hypothesis:
1. Infectious: - Chlamydia / Pseudomonas /
Mycobacterium paratuberculosis / Listeria
monocytogenesis / Measles / Yersinia
enterocolitica
2. Immunologic abnormalities:
3. Genetic factors:
Pathology:
Affect any portion of GIT:
Hallmark focal,
transmural inflammation of
the intestine
Earliest sign --> aphthous
ulcers surrounded by halo
erythema over a noncaseating granuloma.
Pathology:
As the aphthous ulcer enlarge
and coalesce transversely
forming cobblestone
appearance.
Advanced dse ---> transmural
inflammation. This results to:
1.
2.
3.
4.
Clinical Manifestation:
Most common symptom:
1. Abdominal pain
2. Diarrhea
3. Weight loss
obstruction (fibrosis)
perforation (peritonitis, fistula, intraabdominal abscess)
toxic megacolon (marked colonic dilatation, adb.
tenderness, fever & leukocytosis)
4. cancer (6x greater/more advanced---> poor prognosis)
5. perianal dse (fissure, fistula, stricture or abscess)
Extra-intestinal manifestation:
Diagnosis:
1. Endoscopy
2.
3.
4.
(esophagogastroduodenoscopy (EGD)
/colonoscopy) w/ biopsy.
Barium enema / intestinal series
Enteroclysis (small bowel) more accurate
CT scan to reveal intra-abd. abscesses
Treatment:
Medical:
I.
Intravenous fluids
NGT to rest GIT (elemental diet/TPN)
Medications:
1.
2.
3.
4.
5.
to relieve diarrhea
relieve pain
control infection (antibiotic)
Anti-inflammatory ( aminosalicylates, corticosteroid,
immunomodulators azathioprime 6mercaptopurine and cyclosporine
Infliximab chimeric monoclonal anti-tumornecrosis-factor antibody inducing remission and in
promoting closure of enterocutaneous fistulas
Surgical:
II.
Indicated if:
with complications
Medication-induced complications arise
Types:
Segmental resection w/ primary anastomosis:
Stricturoplasty
Bypass procedures (gastrojejunostomy)
Prognosis:
High recurrence rate (most common
proximal to the site of previous
resection).
70% recur w/in 1 yr and 85% w/in 3 yrs.
Most common complication:
1. Wound infection
2. Postoperative intra-abdominal abscess
3. Anastomotic leaks
Tuberculous Enteritis:
In developing and under develop countries
Resurgence in develop countries due to:
1.
2.
3.
AIDS epidemic
Influx of Asian migrants
Use of immunosuppressive agents
Forms:
1. Primary infection (caused by M. tuberculosis
bovine from ingested milk)
2. Secondary infection (swallowing bacilli from
active pulmonary) TB
Tuberculous Enteritis:
Patterns:
1.
2.
3.
Treatment:
Chemotherapy (given 2 wks prior to surgery up
to 1 yr).
Rifampicin
Isoniazid
Ethambutol
Typhoid enteritis:
Caused by Salmonella typhi
Diagnosis:
Culture from blood or feces
Agglutinins against O and H antigen
Treatment:
Medical:
Chloramphenicol / trimethropin-sulfamethoxazole /
amoxycillin / quinolones
Surgical:
perforations / hemorrhage
Segmental resection (w/ primary anastomosis or
ileostomy)
Neoplasm
Rare:
1. Rapid transit time
2. Local immune system of the small bowel mucosa
(IgA)
3. Alkaline pH
4. Relatively low concentration of bacteria; low
concentration of carcinogenic products of bacterial
metabolism.
5. Presence of mucosal enzymes (hydrolases) that
destroy certain carcinogens
6. Efficient epithelial cellular apoptotic mechanisms
that serve to eliminate clones harboring genetic
mutation
Neoplasm
50 60 y/o
Risk factors:
1.
2.
3.
4.
5.
Red meat
Ingestion of smoked or cured foods
Crohns dse
Celiac sprue
Hereditary nonpolyposis colorectal cancer
(HNPCC)
6. Familial adenomatous polyposis (FAD) 100% to
develop duodenal CA
7. Peutz-Jeghers syndrome
Neoplasm
Symptoms:
Neoplasm
Diagnosis:
For most are asymptomatic it is rarely
diagnosed preoperatively
Serological examination
Serum 5-hydroxyindole acetic acid (HIAA) for
carcinoid.
CEA associated w/ small intestinal
adenocarcinoma but only if w/ liver metastasis.
Neoplasm
Diagnosis:
Radiological examination:
1. Enteroclysis (test of choice 90% sensitivity)
2. UGIS w/ intestinal follow through
3. CT scan
4. Angiography / RBC scan --> bleeding lesions
Endoscopy:
EGD (esophagus, gastric, and duodenum)
Colonoscopy
I.
Benign tumors:
duodenum):
1. True adenomas:
Associated w/ bleeding and obstruction
Usually seen in the ileum
Majority are asymptomatic
2. Villous adenoma:
Most common in the duodenum
soap bubble appearance on contrast radiography
No report of secretory diarrhea
Benign tumors:
B. Leiomyoma:
Most common symptomatic benign lesion
Associated w/ bleeding
Diagnosed by angiography and commonly
located in the jejunum
2 growth pattern:
1. Intramurally ----> obstruction
2. Both intramural and extramural (Dumbbell
shaped)
Benign tumors:
C. Lipoma:
Most common in the ileum
Causes obstruction (lead point of an
intussusception)
Bleeding due to ulcer formation
No malignant degeneration
Benign tumors:
D. Peutz-Jeghers Syndrome:
Inherited syndrome of:
1.
2.
Symptoms:
1.
2.
Treatment:
Segmental resection of the bowel causing obstruction or
bleeding.
Cure impossible due to widespread intestinal involvement
II.
Malignant neoplasm:
Histologic types:
Tumor type
adenocarcinoma
Epithelial cell
35 50%
Duodenum
carcinoid
Enterochromaffin
cell
20 40%
Ileum
lymphoma
lymphocyte
10 15%
Ileum
GIST
? Interstitial cell
of Cajal
10 15%
(gastrointestinal
stromal tumors)
Malignant neoplasm:
1. Adenocarcinoma:
Most common CA of small bowel
Most common in duodenum and proximal
jejunum
Half involve the ampulla of Vater.
Malignant neoplasm:
2. Carcinoid:
From enterochromaffin cells or
Kultchitsky cells
Arise from foregut, midgut & hindgut
Appendix (46%) > Ileum (28%) >
Rectum (17%)
Malignant neoplasm:
2. Carcinoid:
Aggressive behavior than the appendiceal
carcinoid.
appendix 3% metastasize; Ileum 35% metastasize
Appendix solitary; Ileum 30% multiple
Diarrhea
Flushing
Hypotension
tachycardia
fibrosis of endocardium and valves of the right heart.
Malignant neoplasm:
3. Lymphomas:
Most common intestinal neoplasm in
children under 10y/o.
In adult = 10-15% of small bowel malignant
tumors
Most common presentation
1. intestinal obstruction
2. Perforation (10%)
Malignant neoplasm:
3. Lymphomas:
Criteria of primary lymphomas of the small
bowel:
1. Absence of peripheral lymphadenopathy
2. Normal chest x-ray w/o evidence of
mediastinal LN enlargement.
3. Normal WBC count and differential
4. At operation, the bowel lesion must
predominate and the only nodes are
associated w/ the bowel lesion
5. Absence of disease in the liver and spleen
Malignant neoplasm:
4.
Leiomyomas
Leiomyosarcomas
Smooth muscle tumors of small bowel
Treatment:
For Benign lesions:
I.
Treatment:
Malignant lesions:
II.
1.
Adenocarcinoma:
Wide local resection w/ its mesentery to
achieve regional lymphadenectomy
Chemotherapy has no proven efficacy in the
adjuvant or palliative treatment of smallintestinal adenoCA.
2.
Treatment:
3. Carcinoid:
Segmental intestinal resection & regional
lymphadenectomy.
< 1cm rarely has LN metastases
> 3cm 75 to 90% LN metastases
Treatment:
3. Carcinoid:
Is w/ metastatic lesions---> debulking,
associated w/ long-term survival &
amelioration of symptoms of carcinoid
syndrome
Chemotherapy: ---> 30 -50% response
1. Doxorubicin
2. 5-fluorouracil
3. Streptozocin
Treatment:
4.
Small-intestine GISTs:
Segmental resection
If was preoperatively diagnosed, lymphadenectomy
shd not be done, for rarely associated w/ LN
metastases.
Resistant to conventional chemotherapy
IMATINIB (Gleevec):
Treatment:
5. Metastatic cancers:
Melanoma associated w/ propensity for
metastasis to the small bowel.
Palliative resection / bypass procedure
Systemic therapy depends on the responds
of the primary site.
Meckels Diverticulum
Most prevalent congenital anomaly of GIT
3:2 (male:female)
True diverticula
60% contains heterotopic mucosa:
1.
2.
3.
4.
5.
6.
7.
Meckels Diverticulum
Rules of Twos:
1.
2.
3.
2% prevalence
2:1 female predominance
Location 2 feet proximal to the ileocecal valve in
adults.
4. Half of those are asymptomatic are younger than 2
years of age.
Complications:
1. Bleeding (most common) due to ileal mucosal
ulceration.
2. Obstruction:
a.
b.
c.
d.
e.
Meckels Diverticulum
Clinical manifestation:
1. Asymptomatic
2. 4% symptomatic due to complication
50% are younger than 10y/o
Symptomatic (Bleeding > obstruction > diverticulitis)
bleeding is 50% in children and pt younger 18y/o
bleeding is rare in pt older than 30y/o
intestinal obstruction most common in adult
diverticulitis is indistinguishable to appendicitis
Meckels Diverticulum
Diagnosis:
1.
2.
3.
Meckels Diverticulum
Management:
Diverticulectomy:
diverticulitis
obstruction (w/ removal of associated band)
Vaterian diverticula
3. 75% arise in the medial wall
2. Jejunoileal:
80% - jejunum (tends to be large and multiple)
15% - ileum (tends to be small and solitary)
5% - both ileum and jejunum
adjacent bowel
Treatment:
Asymptomatic ---> left alone
Bacterial overgrowth --> antibiotics
Bleeding and obstruction ---> segmental
resection for jejunoileal diverticula.
Mesenteric Ischemia
Clinical Syndrome:
1. Acute mesenteric ischemia
Pathophysiology
1. Arterial embolus: (most common-50%; heart;
2.
3.
4.
Mesenteric Ischemia
Clinical Syndrome:
2. Chronic Mesenteric Ischemia:
Develops insidiously allows for collateral
circulation to develop
Rarely leads to infarction.
Usually due to arteriosclerosis
Usually two mesenteric arteries are involved
Chronic mesenteric venous thrombosis can
lead to portal hypertension
Mesenteric Ischemia
Manifestation:
A. Acute mesenteric ischemia:
Severe abdominal pain out of proportion to the
degree of abd. tenderness (hallmark)
Colicky at the mid-abdomen.
Mesenteric Ischemia
No laboratory test sensitive for
the detection of acute mesenteric
ischemia prior to the onset of
intestinal infarction.
The presence of its hallmark
sign, is an indication for
immediate celiotomy.
Mesenteric Ischemia
Angiography most reliable; 74 100%
sensitivity and 100% specificity;
Mesenteric Ischemia
Treatment:
Therapeutic option for acute mesenteric
ischemia is based on:
1.
2.
3.
4.
Mesenteric Ischemia
Surgical revascularization (embolectomy /
thrombectomy / mesenteric bypass).
Not done if:
segment is necrotic
is too unstable patient
Mesenteric Ischemia
NOMI std tx. Is infusion of vasodilator
(papavarine hydrochloride) into the SMA. If
w/ signs of peritonitis --> immediate celiotomy
and resect necrotic segment.
Acute mesenteric venous thrombosis
Std tx. anticoagulant (heparin / warfarin).
Signs of peritonitis --> explore and resects if needed
Diarrhea
Dehydration
malnutrition
Intestinal transplant
THANK YOU