BY PROF. SALEH M AL SALAMAH FRCS Prof. surgery and consultant general and laparoscopic surgeon college of medicine king Saud university Riyadh ksa.

SURGICAL DISEASES OF THE SMALL INTESTINE

BYPROF. SALEH M AL SALAMAH FRCS

Prof. surgery and consultant general and laparoscopic surgeon college of medicine king

Saud university Riyadh ksa

OBJECTIVESAt the end of this lecture students will be able to

describe:

The clinical presentation and Management of Small bowel obstruction.

The clinical features and Management of Crohn’s disease.

Presentation and Management of Small bowel tumors.

Clinical features and Management of Small bowel ischemia.

Short bowel syndrome , causes and management.

Meckel’s Diverticulum, presentation and management.

INTESTINAL OBSTRUCTION

CLASSIFICATION

MECHANICAL (Dynamic) vs ILEUS (Adynamic)

ACUTE vs CHRONIC SMALL vs LARGE INTESTINAL

CLINICAL FEATURES

Colicky central abdominal

pain

Vomiting

Abdominal distension

Constipation

INVESTIGATIONS

Complete Blood Count

Blood Chemistry

Abdominal X Ray, erect and supine

films

CT abdomen with oral and I/V

contrast

Investigations required for GA

fitness if surgery is planned

Paralytic Ileus ( ADYNAMIC OBSTRUCTION)

This may be defined as a state in which there is failure of transmission of peristaltic waves secondary to neuromuscular failure.

The resultant stasis leads to accumulation of fluid and gas within the bowel, with associated distension, vomiting, absence of bowel sounds and constipation.

Post open cholecystectomy paralytic ileus

Vascular Disease of IntestineMESENTERIC ISCHEMIA

Arterial or Venous Acute or Chronic Symptoms: Acute: Sudden abdominal

pain, passage of altered blood, shock. Chronic: Abdominal angina, weight loss or diarrhoea.

Investigations: AXR, CT angiography Treatment: Resuscitation, Gut Resection,

Embolectomy, Vascular bypass or Endarterectomy.

CROHN’S DISEASEREGIONAL ILEITIS

A disease of uncertain aetiology, but thought to be result of inflammation caused by an unusual strains of mycobacteria.

It is characterized by full thickness inflammatory process of any part of GIT from lips to anal margin.

Pathological features include full thickness inflammation, edema, fissures/ulceration, non- caseating foci of epithelioid and giant cells.

CLINICAL FEATURES CROHN’S DISEASE

ACUTE Pain right iliac fossa

with tenderness mimicking acute appendicitis.

Features of low small bowel obstruction

Rarely perforation of small intestine causing peritonitis.

CHRONIC Colicky abdominal

pain with diarrhoea Weight loss Perianal fistulas Fistulation into

adjacent organs like bladder, colon, vagina.

INVESTIGATIONS

Barium meal and follow through

CT abdomen with oral and I/V contrast

Blood : Anemia, high C- reactive protein

and low Vit-B12 levels

Colonoscopy/ Enteroscopy with biopsy

Barium follow through showing “String sign of Kantor”

TREATMENT

Corticosteroids

Aminosalicylates

Immunomodulators e.g.

azathioprine

Monoclonal antibodies

Antibiotics for perianal disease

Surgery: Resections,

strictureplasty or colectomies.

Intestinal Tuberculosis

Uncommon in developed countries except when associated with AIDS.

Both human and bovine strains of mycobacterium can affect.

Starts when ingested from infected source or from swallowed sputum from open pulmonary tuberculosis.

Pathology: Ulceration, stricture formation and lymph node enlargement.

Clinical Features & Investigations

General: Weight loss, low grade fever, fatigue. Abdominal: Vague lower abdominal pain,

distension, borborygmi, diarrhoea, constipation and ulceration leading to lower GI blood loss. Palpable mass in right iliac fossa.

Blood / Serum: CBC, ESR, PCR, Culture. Radiological: CXR, CT abdomen, Barium follow

through. Endoscopy

TREATMENT OF INTESTINAL TUBERCULOSIS

Course of Anti-tuberculosis drugs Surgery for complications like:

Stricture formation Perforation Haemorrhage

Meckel’s Diverticulum

Embryological remnant of Vitello-intestinal duct.

Occurs in 2% population, 2 feet from ileocecal valve and 2 inches long and 2 times common in men.

Presents as :o Persistent vitello-intestinal fistulao Acute diverticulitiso Perforation and peritonitiso Intestinal obstructiono Bleeding due to ectopic gastric mucosa.

Treatment

Asymptomatic and incidentally discovered Meckel’s diverticulum are left as such.

Narrow necked, inflamed or symptomatic diverticulum is excised.

Tumors of the Small Intestine

Primary tumours of small gut are uncommon and form only 5% of the GIT neoplasms.

Aetiological factors include:A. Inherited Conditions: Polyposis coli, Peutz-Jegherz Syndrome, Gardner's syndrome.

B. Immunocompromised states: Coeliac disease, AIDS, transplant recipients.

C. Geographical Areas: Lymphomas more common in Middle East.

Classification of Tumours

Benign

Adenomas

GIST (Gastrointestinal

Stromal tumours)

Lipomas

Neurofibromas

Malignant

Lymphomas both primary and part of

generalised disease.

Adenocarcinomas

Carcinoids

Secondary tumours from lung, breast or malignant melanoma.

Small intestinal Lymphoma

Clinical Presentation

It can be Acute or Chronic

Acute presentation is with intestinal obstruction, GI bleeding or perforation leading to peritonitis.

Chronic symptoms include malaise, abdominal pain, weight loss, diarrhoea and anaemia.

Investigations & Treatment

Blood : Anemia and high ESR, Tumour markers, high 5-HIAA levels in Carcinoids.

Radiological: CT or MRI abdomen with oral and intravenous contrast.

Endoscopy: Upper GI endoscopy, Enteroscopy,

Colonoscopy.

TREATMENT: This depends upon presentation, stage and type of the tumour.

SHORT GUT SYNDROME

Short gut syndrome has been arbitrarily defined as the presence of less than 200 cm of residual small bowel in adult patients.

OR A functional definition, in which

insufficient intestinal absorptive capacity results in

the clinical manifestations of diarrhoea, dehydration and malnutrition.

Aetiological Causes

Crohn's disease; Mesenteric infarction Radiation enteritis Midgut volvulus Multiple fistulae Small-bowel tumours

Treatment

Nutritional Support including TPN.

Gut lengthening procedures

Intestinal Transplantation

THANK YOU