SMALL AND LARGE INTESTINE

Small Intestine
Divided into three parts. Length is ~7mts
Duodenum
25cm, four parts Ampulla in 2nd part

Jejunum-proximal 2/5
Valvulae conneventes 2 arcades in mesentery

Ileum-distal 3/5
Characterless Many arcades in mesentery

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The differences between the ileal arteries and the jejunal arteries can be summarized as follows:
Type

Appearance

Jejunal arteries

Number of arcades one (or few)

Layer of fat thin

Ileal arteries

many

thick

Intestinal Villi
A series of fingerlike projections in mucosa Covered with microvilli Microvilli are brush border Villi contain capillary and lacteal
Lacteal- specialized lymph capillary used in lipid transport

 Villi
fingerlike projections on mucosa Surface cells for absorption Contains capillary bed and lacteal (lymph capillary)

 Microvilli
tiny plasma membrane projections of absorptive cells of mucosa Fuzzy appearance called brush border
Brush border enzymes located here

The Large Intestine

Is horseshoe-shaped Extends from end of ileum to anus, comprising of Appendix, cecum, ascending, transverse, descending, sigmoid colon and rectum Lies inferior to stomach and liver Frames the small intestine Is about 1.5 meters long and 7.5 cm wide

3 Parts of the Large Intestine

1. Cecum:
the pouch like first portion Ileum attached at ileocecal valve

2. Colon:
the largest portion

3. Rectum:
the last 15 cm of digestive tract

Ileocecal Valve

Muscles
The longitudinal layer of the muscularis externa is reduced to the muscular bands of taeniae coli 3 longitudinal bands of smooth muscle (taeniae coli):
run along outer surfaces of colon deep to the serosa

Muscle tone in taeniae coli creates the haustra

CONSTIPATION

Definition: <1 stool every 3 days

Megacolonic
Non Hirschprungs

Non megacolonic
Normal transit

Hirschprungs

Slow transit

 Segmental Aganglionosis. Rectum involved commonly. Proximally Dilated normal bowel , affected end is constricted. Diagnosis by Ba Enema and biopsy.

ormal dilated segment Transition zone .

Treatment: Age, length of involved segment, severity Initial colostomy Definitive Short segment- extended myectomy Long segmentSoave`s Duhamel Swenson`s

VASCULAR ANOMALIES ANGIODYSPLASIA Old age, a/w aortic stenosis Ascending colon and cecum No cutaneous lesions Dilated tortuous submucosal veins Bleeding P/R Colonoscopy-few mm of raised red area Angiography- Blush Tc99 labelled RBC shows site of bleeding Treatment: Colonoscopic diathermy, colectomy

DIVERTICULAR DISEASE
Congenital All 3 coats + Acquired Lacks proper muscular coat

Small intestinal
Duodenal (mesenteric side, at entry of BV) Jejunal (mesenteric side, at entry of BV) Meckel`s diverticulum (antimesenteric)

Jejunal diverticulae:

Multiple symptom less/ ab pain, flatulence, malabsorption, rupture Rx- resection and anastomosis

Jejunal Diverticulae

MECKEL`S DIVERTICULUM
Has all 3 muscle coats Own blood supply Antimesenteric border Rule of 2: 2% of population, 2ft from DJ, 2`` long, 2cm wide 20% has heterotopic gastric, colonic or pancreatic epithelium Symptoms: severe hemorrhage-maroon stools intussusception diverticulitis Dx- Tc99 labelled RBC scanning Treatment: Broad based- no Rx Diverticulitis- excision with ileum and anastomosis Littre`s hernia: Meckel`s diverticulum in inguinal or femoral hernia

DIVERTICULAR DISEASE OF COLON

ALWAYS Acquired Herniation of mucosa at vessel penetration betn taeniae Common in sigmoid and cecum A/W decreased roughage in diet SAINT`S TRIAD: Sigmoid diverticulae Gall stones Hiatus hernia

Saw tooth appearance

PRESENTATIONS
DIVERTICULOSIS
.Symptomatic . PAINLESS .Distension .Flatulence .Sensation of heaviness .Treatment .Roughage .Bulk formers .Rest, antispasmodics

DIVERTICULITIS
.Lower ab pain with tenderness Rx- Rest, Antibiotics Sx-recurrent attacks, complications

ULCERATIVE COLITIS
Cause inconclusive 20-40yr age gp Smoking protects Starts in rectum, spreads proximally Mucosa + submucosa Chr-pseudopolyps Fulminant- Toxic megacolon Microscopy- Crypt abscess C/F: Watery/bloody diarrhoea with Mucus tenesmus, urgency Complications: megacolon, perforation hemorrhage

Extraintestinal manifestations: Arthritis, erythema nodosum, iritis, sclerosing cholangitis Treatment: Medical- Steroids, ASA derivatives Surgery- Failure of med Rx, dysplasia extraintestinal, bleeding - Total proctocolectomy with ileoanal pouch

CROHN`S DISEASE
Lip- anal margin Ileocolic is most common Smoking increases risk F>M 25-40yr Pathology: Ileal-60% Deep ulcers Cobble stone appearance Fistulas Skip leisions Transmural C/F: Diarrhoea, pain, perianal abscess, fissure

Cobble stone appearance

Treatment: Steroids, ASA Sx for complications Anal disease- I&D

String sign of Kantor

Skip lesions, deep mucosal ulcers, Transmural inflammation

TUBERCULOSIS OF INTESTINE Involves ileum, proximal colon, peritoneum Stasis, decreased acid ileal disease ULCERATIVE sec to pul TB, ingestion of bacilli Multiple transverse ulcers in ileum Diarrhoea, wt loss Rx. Chemotherapy HYPERPLASTIC Ingestion of resistant MTB Infection in follicles Thick wall and intestinal obstruction Pain ab, RIF mass Rx. chemotherapy

Amoebiasis

TUMOURS OF SMALL INTESTINE

Benign: Adenoma, lipoma leiomyoma,
Peutz-Jeghers synd Familial Intestinal hamartomas Jejunal polyps Melanosis of lips, perianal skin

Malignant: Carcinoma Carcinoid-Appendix, ileum, rectum

- liver mets>carcinoid syndrome - 5HIAA in urine

TUMOURS OF LARGE INTESTINE BENIGN:(polyps) Inflammatory Metaplastic Hamartomas( Peutz-Jeghers, juvenile) Neoplastic FAMILIAL ADENOMATOUS POLYPOSIS Thousands of polyps in colon Dominant inheritance A/W-desmoid, osteomas, epidermal cysts Dx- sigmoidoscopy->100 c/f- diarrhoea, wt loss, bleeding P/R Familial screening Rx- Colectomy

Malignant tumours of large intestine ADENOCARCINOMA >50yr age gp Annular, tubular, ulcerative, cauliflower Left colon: Stenosing, obstruction alternating constipation diarrhoea Sigmoid: Pain, tenesmus Transverse colon: Anaemia, lassitude Right colon: Anaemia, RIF mass Sigmoidoscopy, colonoscopy, double contrast, apple core appearance Rx: Resection

FECAL FISTULA Previous surgery is most common cause High output >1 lit/day Low output<1 lit/day Initial conservative management with iv fluids, iv hyperalimentation and later surgical Rx for high output fistulas.