Small Intestine James Taclin C. Banez,  MD, FPCS, FPSGS, DPBS,DPSA
Small Intestine <ul><li>one of the most important organs for immune defense </li></ul><ul><li>largest endocrine organ of t...
Anatomy <ul><li>Has plicae circulares or valves of Kerkring </li></ul><ul><li>Duodenum: </li></ul><ul><ul><li>Retro-perito...
Function <ul><li>Digestion & Absorption: </li></ul><ul><li>Endocrine Function: </li></ul><ul><ul><li>Secretes numerous hor...
Function <ul><li>Immune function: </li></ul><ul><ul><li>Major source of   IgA </li></ul></ul><ul><ul><li>Integrity of the ...
Small Bowel Surgical Lesions <ul><li>Small bowel obstruction: </li></ul><ul><ul><li>Mechanical </li></ul></ul><ul><ul><li>...
SMALL BOWEL OBSTRUCTION
Small Bowel Obstruction <ul><li>Causes of  Mechanical Obstruction : </li></ul><ul><ul><li>Post-operative adhesion  (75%) <...
Midgut Volvulous
Pathophysiology: <ul><li>Accdg. to it’s anatomical relationship to the intestinal wall: </li></ul><ul><ul><li>Intraluminal...
<ul><li>Classify Accdg to Degree of Obstruction </li></ul><ul><li>Partial small-bowel obstruction  – passage of gas and fl...
Manifestation: <ul><li>colicky abdominal pain </li></ul><ul><li>nausea / vomiting </li></ul><ul><li>obstipation </li></ul>...
Manifestation: <ul><li>Features of Strangulated obstruction : </li></ul><ul><ul><li>tachycardia </li></ul></ul><ul><ul><li...
Goals in its diagnosis: <ul><li>distinguish between mechanical obstruction from ileus </li></ul><ul><li>whether it is part...
Diagnosis: <ul><li>Clinical history & PE </li></ul><ul><li>Radiological examination: </li></ul><ul><ul><li>FPA (supine and...
SMALL BOWEL OBSTRUCTION (Air Fluid Level)
<ul><li>Air-fluid level: </li></ul><ul><ul><li>Gas – due to swallowed air </li></ul></ul><ul><ul><li>Fluid – a) swallowed ...
Diagnosis: <ul><li>CT scan  (90% sensitive / 90% specific) </li></ul><ul><ul><li>Findings of small bowel obstruction: </li...
Treatment: <ul><li>Correct fluid & electrolyte imbalance : </li></ul><ul><ul><li>Isotonic fluid </li></ul></ul><ul><ul><li...
Ileus / Pseudo-Obstruction <ul><li>Impaired intestinal motility </li></ul><ul><li>Most common cause of delayed discharge f...
Ileus / Pseudo-Obstruction <ul><li>Etiologies: </li></ul><ul><li>Abdominal surgery </li></ul><ul><li>Infection & inflammat...
ILEUS
Symptoms: <ul><li>Inability to tolerate solid & liquid by mouth </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Lack o...
Diagnosis: <ul><li>History of recent abdominal surgery </li></ul><ul><li>Discontinue opiates  </li></ul><ul><li>Serum elec...
Therapy: <ul><li>NPO, if prolong TPN is required </li></ul><ul><li>NGT to decompress the stomach </li></ul><ul><li>Correct...
CHRONIC IDIOPATHIC INFLAMMATORY DISEASE OF THE BOWEL
CROHN’S DISEASE <ul><li>Regional, transmural, granulomatous enteritis.  </li></ul><ul><li>Chronic, idiopathic inflammatory...
Etiology: <ul><li>Unknown </li></ul><ul><li>Hypothesis: </li></ul><ul><ul><li>Infectious:   - Chlamydia / Pseudomonas / My...
Pathology: <ul><li>Affect any portion of GIT: </li></ul><ul><ul><li>Small bowel alone (30%) </li></ul></ul><ul><ul><li>Ile...
CHRON’S DISEASE
Pathology: <ul><li>As the aphthous ulcer enlarge and coalesce transversely forming  cobblestone appearance. </li></ul><ul>...
ADVANCED CHRON’S DSE
CHRON’S DSE. ANAL FISTULA
Clinical Manifestation: <ul><li>Most common symptom: </li></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Diarr...
Diagnosis: <ul><li>Endoscopy (esophagogastroduodenoscopy (EGD) /colonoscopy) w/ biopsy. </li></ul><ul><li>Barium enema / i...
Treatment: <ul><li>Medical: </li></ul><ul><ul><li>Intravenous fluids </li></ul></ul><ul><ul><li>NGT to rest GIT (elemental...
<ul><li>Surgical: </li></ul><ul><ul><li>Indicated if:  </li></ul></ul><ul><ul><ul><li>with complications </li></ul></ul></...
Tuberculous Enteritis: <ul><li>In developing and under develop countries </li></ul><ul><li>Resurgence in develop countries...
Tuberculous Enteritis
Tuberculous Enteritis: <ul><li>Patterns: </li></ul><ul><ul><li>Hypertrophic – causes stenosis or obstruction </li></ul></u...
Typhoid enteritis: <ul><li>Caused by Salmonella typhi </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Culture from bloo...
DIVERTICULAR DISEASE OF THE SMALL BOWEL
Meckels Diverticulum <ul><li>Most prevalent congenital anomaly of GIT </li></ul><ul><li>True diverticula </li></ul><ul><li...
Meckels Diverticulum <ul><li>Rules of Twos: </li></ul><ul><ul><li>2% prevalence </li></ul></ul><ul><ul><li>2:1 female pred...
Meckels Diverticulum <ul><li>Complications: </li></ul><ul><ul><li>Bleeding (most common )  – due to ileal mucosal ulcerati...
Meckels Diverticulum <ul><li>Clinical manifestation: </li></ul><ul><ul><li>Asymptomatic </li></ul></ul><ul><ul><li>4% symp...
Meckels Diverticulum <ul><li>Diagnosis: </li></ul><ul><ul><li>For asymptomatic usually discovered as an incidental finding...
Meckels Diverticulum <ul><li>Management: </li></ul><ul><ul><li>Diverticulectomy: </li></ul></ul><ul><ul><ul><li>diverticul...
Acquired Small Bowel Diverticula <ul><li>Epidemiology: </li></ul><ul><li>False diverticula </li></ul><ul><li>Increases w/ ...
Acquired Small Bowel Diverticula <ul><li>Jejunoileal: </li></ul><ul><ul><ul><li>80% - jejunum (tends to be large and multi...
Acquired Small Bowel Diverticula <ul><li>Pathophysiology: </li></ul><ul><ul><li>Abnormalities of intestinal smooth muscle ...
Acquired Small Bowel Diverticula <ul><li>Diagnosis: </li></ul><ul><ul><li>Best diagnosed w/  enteroclysis </li></ul></ul><...
Acquired Small Bowel Diverticula <ul><li>Treatment: </li></ul><ul><ul><li>Diverticulectomy  if located  in the duodenum </...
MESENTERIC ISCHEMIA
Mesenteric Ischemia <ul><li>Clinical Syndrome: </li></ul><ul><li>Acute mesenteric ischemia </li></ul><ul><ul><li>Pathophys...
Mesenteric Ischemia <ul><li>Clinical Syndrome: </li></ul><ul><li>Chronic Mesenteric Ischemia: </li></ul><ul><ul><li>Develo...
Mesenteric Ischemia <ul><li>Manifestation: </li></ul><ul><ul><li>Acute mesenteric ischemia: </li></ul></ul><ul><ul><ul><li...
Mesenteric Ischemia <ul><li>No laboratory test sensitive for the detection of acute mesenteric ischemia prior to the onset...
Mesenteric Ischemia <ul><li>Angiography   – most reliable; 74 – 100% sensitivity and 100% specificity;  </li></ul><ul><ul>...
Mesenteric Ischemia <ul><li>CT scanning  is used to: </li></ul><ul><ul><li>Disorder other abd. condition causing abd. pain...
Mesenteric Ischemia <ul><li>Treatment: </li></ul><ul><ul><li>w/ signs of peritonitis --> celiotomy check for viability of ...
Mesenteric Ischemia <ul><ul><li>Surgical revascularization  (embolectomy / thrombectomy / mesenteric bypass). </li></ul></...
NEOPLASM OF THE SMALL BOWEL
Neoplasm <ul><li>Rare: </li></ul><ul><ul><li>Rapid transit time </li></ul></ul><ul><ul><li>Local immune system of the smal...
Neoplasm <ul><li>50 – 60 y/o </li></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Red meat </li></ul></ul><ul><ul><li>Ing...
Neoplasm <ul><li>Symptoms: </li></ul><ul><ul><li>Most are asymptomatic   </li></ul></ul><ul><ul><li>Symptoms: </li></ul></...
Neoplasm <ul><li>Diagnosis: </li></ul><ul><ul><li>For most are asymptomatic it is rarely diagnosed preoperatively </li></u...
Neoplasm <ul><li>Diagnosis: </li></ul><ul><ul><li>Radiological examination: </li></ul></ul><ul><ul><ul><li>Enteroclysis  (...
<ul><li>Benign tumors: </li></ul><ul><li>Adenomas:  (most common benign neoplasm): </li></ul><ul><ul><li>True adenomas: </...
Benign tumors: <ul><li>Leiomyoma: </li></ul><ul><ul><li>Most common symptomatic benign lesion </li></ul></ul><ul><ul><li>A...
Benign tumors: <ul><li>Lipoma: </li></ul><ul><ul><li>Most common in the  ileum </li></ul></ul><ul><ul><li>Causes obstructi...
Benign tumors: <ul><li>Peutz-Jeghers Syndrome: </li></ul><ul><ul><li>Inherited syndrome of: </li></ul></ul><ul><ul><ul><li...
Benign tumors: <ul><li>Peutz-Jeghers Syndrome: </li></ul><ul><ul><li>Inherited syndrome of: </li></ul></ul><ul><ul><ul><li...
Benign tumors: <ul><li>Peutz-Jeghers Syndrome: </li></ul><ul><ul><li>Symptoms: </li></ul></ul><ul><ul><ul><li>colicky abd....
<ul><li>Malignant neoplasm: </li></ul><ul><li>Histologic types: </li></ul>Tumor type Cell of origin Frequency Predominant ...
Malignant neoplasm: <ul><li>Adenocarcinoma: </li></ul><ul><ul><li>Most common CA  of small bowel </li></ul></ul><ul><ul><l...
Malignant neoplasm: <ul><li>Carcinoid: </li></ul><ul><ul><li>From  Enterochromaffin cells  or  Kultchitsky cells </li></ul...
Malignant neoplasm: <ul><li>Carcinoid: </li></ul><ul><ul><li>Aggressive behavior than the appendiceal carcinoid.  </li></u...
Malignant neoplasm: <ul><li>Lymphomas: </li></ul><ul><ul><li>Most common intestinal neoplasm in children under 10y/o. </li...
Malignant neoplasm: <ul><li>Lymphomas: </li></ul><ul><ul><li>Criteria of primary lymphomas of the small bowel: </li></ul><...
Treatment: <ul><li>For Benign lesions: </li></ul><ul><ul><li>All symptomatic benign tumors should be surgically resected o...
Treatment: <ul><li>Malignant lesions: </li></ul><ul><ul><li>Adenocarcinoma: </li></ul></ul><ul><ul><ul><li>Wide local rese...
Treatment: <ul><ul><li>Carcinoid: </li></ul></ul><ul><ul><ul><li>Segmental intestinal resection & regional lymphadenectomy...
Treatment: <ul><ul><li>Carcinoid: </li></ul></ul><ul><ul><ul><li>If w/ metastatic lesions---> debulking, associated w/ lon...
Treatment: <ul><li>Metastatic cancers: </li></ul><ul><ul><li>Melanoma  associated w/ propensity for metastasis to the smal...
SHORT BOWEL SYNDROME
Short Bowel Syndrome <ul><li>Presence of  less than 200cm  of residual small bowel in adult pts. </li></ul><ul><li>Functio...
Short Bowel Syndrome <ul><li>Etiologies (adult): </li></ul><ul><li>Acute mesenteric ischemia </li></ul><ul><li>Malignancy ...
Short Bowel Syndrome <ul><li>Medical therapy: </li></ul><ul><ul><li>Mx of primary condition causing intestinal resection <...
Short Bowel Syndrome <ul><li>Medical therapy: </li></ul><ul><ul><li>H2 receptor antagonist --> to reduce gastric acid secr...
Short Bowel Syndrome <ul><li>Surgical Therapy : </li></ul><ul><ul><li>Non-transplant: </li></ul></ul><ul><ul><ul><li>Goal ...
GOD BLESS <ul><li>SALAMAT PO </li></ul>
THANK  YOU
Diagnosis: <ul><li>Enteroclysis   </li></ul><ul><ul><li>200 to 250 ml of barium followed by 1 to 2 L of methylcellulose in...
Short Bowel Syndrome <ul><li>Factors predictive of achieving independence from TPN: </li></ul><ul><ul><li>Presence or abse...
Short Bowel Syndrome <ul><li>Surgical Therapy: </li></ul><ul><ul><li>Non-transplant: </li></ul></ul><ul><ul><ul><li>Intest...
Prognosis (CHRON’S DSE) <ul><li>High recurrence rate (most common proximal to the site of previous resection). </li></ul><...
Mesenteric Ischemia <ul><ul><li>NOMI  – std tx. Is infusion of vasodilator  (papavarine hydrochloride)  into the SMA. If w...
Malignant neoplasm: <ul><li>GISTs: (gastrointestinal stromal tumors) </li></ul><ul><ul><li>Most common  mesenchymal tumors...
Treatment: <ul><li>Small-intestine GISTs: </li></ul><ul><ul><li>Segmental resection </li></ul></ul><ul><ul><li>If was preo...
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Small Intestine Ii

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Small Intestine Ii

  1. 1. Small Intestine James Taclin C. Banez, MD, FPCS, FPSGS, DPBS,DPSA
  2. 2. Small Intestine <ul><li>one of the most important organs for immune defense </li></ul><ul><li>largest endocrine organ of the body </li></ul><ul><li>Starts from the pylorus and ends at the cecum </li></ul><ul><li>3 parts: </li></ul><ul><ul><ul><li>Duodenum (20cm) </li></ul></ul></ul><ul><ul><ul><li>Jejunum (100 to 110cm) </li></ul></ul></ul><ul><ul><ul><li>Ileum (150 to 160 cm) </li></ul></ul></ul>
  3. 3. Anatomy <ul><li>Has plicae circulares or valves of Kerkring </li></ul><ul><li>Duodenum: </li></ul><ul><ul><li>Retro-peritoneal </li></ul></ul><ul><ul><li>Supplied by the celiac artery & SMA </li></ul></ul><ul><li>Jejunum: </li></ul><ul><ul><li>Occupies upper left of the abdomen </li></ul></ul><ul><ul><li>Thicker wall and wider lumen than the ileum </li></ul></ul><ul><ul><li>Mesentery has less fat and forms only 1-2 arcades </li></ul></ul><ul><li>Ileum: </li></ul><ul><ul><li>Occupies the lower right; has more fat and forms more arcades </li></ul></ul><ul><ul><li>Contains Payer’s patches </li></ul></ul><ul><ul><li>Ileum & jejunum is supplied by the SMA </li></ul></ul>
  4. 4. Function <ul><li>Digestion & Absorption: </li></ul><ul><li>Endocrine Function: </li></ul><ul><ul><li>Secretes numerous hormones involved in GIT function. </li></ul></ul><ul><ul><ul><li>Secretin </li></ul></ul></ul><ul><ul><ul><li>Cholecystokenin </li></ul></ul></ul><ul><ul><ul><li>Gastric inhibitory peptide </li></ul></ul></ul><ul><ul><ul><li>Enteroglucagon </li></ul></ul></ul><ul><ul><ul><li>Vasoactive intestinal peptide </li></ul></ul></ul><ul><ul><ul><li>Motilin </li></ul></ul></ul><ul><ul><ul><li>Bombesin </li></ul></ul></ul><ul><ul><ul><li>Somatostatin </li></ul></ul></ul><ul><ul><ul><li>Neurotensin </li></ul></ul></ul>
  5. 5. Function <ul><li>Immune function: </li></ul><ul><ul><li>Major source of IgA </li></ul></ul><ul><ul><li>Integrity of the GUT wall prevents bacterial translocation into the wall of the intestine and abdominal cavity which can lead to sepsis </li></ul></ul><ul><ul><li>Gut associated lymphoid tissue – part of the immune defense system which clears the abdominal cavity of pathogenic bacteria found in Peyer’s patches </li></ul></ul>
  6. 6. Small Bowel Surgical Lesions <ul><li>Small bowel obstruction: </li></ul><ul><ul><li>Mechanical </li></ul></ul><ul><ul><li>Ileus </li></ul></ul><ul><li>Small bowel infection </li></ul><ul><li>Chronic inflammation </li></ul><ul><li>Neoplasm </li></ul><ul><li>Diverticula </li></ul><ul><li>Ischemic enteritis </li></ul><ul><li>Short bowel syndrome </li></ul>
  7. 7. SMALL BOWEL OBSTRUCTION
  8. 8. Small Bowel Obstruction <ul><li>Causes of Mechanical Obstruction : </li></ul><ul><ul><li>Post-operative adhesion (75%) </li></ul></ul><ul><ul><li>Midgut volvulous </li></ul></ul><ul><ul><li>Hernias </li></ul></ul><ul><ul><li>Crohn’s disease </li></ul></ul><ul><ul><li>Neoplasm (primary or extrinsic compression or invasion) </li></ul></ul><ul><ul><li>Superior mesenteric artery syndrome (compression of transverse duodenum) </li></ul></ul>
  9. 9. Midgut Volvulous
  10. 10. Pathophysiology: <ul><li>Accdg. to it’s anatomical relationship to the intestinal wall: </li></ul><ul><ul><li>Intraluminal ( foreign bodies, gallstone, and meconium) </li></ul></ul><ul><ul><li>Intramural (neoplasm, Crohn’s, hematomas) </li></ul></ul><ul><ul><li>Extrinsic (adhesion, hernias & carcinomatosis) </li></ul></ul>
  11. 11. <ul><li>Classify Accdg to Degree of Obstruction </li></ul><ul><li>Partial small-bowel obstruction – passage of gas and fluid. </li></ul><ul><li>Complete small-bowel obstruction (obstipation) </li></ul><ul><ul><li>Closed loop obstruction (obstructed proximal and distal) ex. Volvulus </li></ul></ul><ul><li>Strangulated bowel obstruction </li></ul>
  12. 12. Manifestation: <ul><li>colicky abdominal pain </li></ul><ul><li>nausea / vomiting </li></ul><ul><li>obstipation </li></ul><ul><li>abdominal distention </li></ul><ul><li>hyperactive bowel sound / hypoactive BS </li></ul><ul><li>signs of dehydration (sequestration of fluid in bowel wall and lumen as well as poor oral intake) </li></ul><ul><li>lab. findings: </li></ul><ul><ul><li>hemoconcentration </li></ul></ul><ul><ul><li>fluid & electrolyte imbalance </li></ul></ul><ul><ul><li>leucocytosis </li></ul></ul>
  13. 13. Manifestation: <ul><li>Features of Strangulated obstruction : </li></ul><ul><ul><li>tachycardia </li></ul></ul><ul><ul><li>localized abd. tenderness </li></ul></ul><ul><ul><li>fever </li></ul></ul><ul><ul><li>marked leucocytosis </li></ul></ul><ul><ul><li>acidosis </li></ul></ul><ul><ul><li>lab result: </li></ul></ul><ul><ul><li>- elevated serum amyase, lipase, LDH, </li></ul></ul><ul><ul><li>phosphate and potassium </li></ul></ul>
  14. 14. Goals in its diagnosis: <ul><li>distinguish between mechanical obstruction from ileus </li></ul><ul><li>whether it is partial or complete obstruction </li></ul><ul><li>differentiate between simple and strangulating obstruction </li></ul><ul><li>determine the etiology </li></ul>
  15. 15. Diagnosis: <ul><li>Clinical history & PE </li></ul><ul><li>Radiological examination: </li></ul><ul><ul><li>FPA (supine and upright) </li></ul></ul><ul><ul><ul><li>Triad: </li></ul></ul></ul><ul><ul><ul><li>dilated small bowel (>3cm ) </li></ul></ul></ul><ul><ul><ul><li>air-fluid levels seen in upright </li></ul></ul></ul><ul><ul><ul><li>paucity of air in the colon </li></ul></ul></ul>
  16. 16. SMALL BOWEL OBSTRUCTION (Air Fluid Level)
  17. 17. <ul><li>Air-fluid level: </li></ul><ul><ul><li>Gas – due to swallowed air </li></ul></ul><ul><ul><li>Fluid – a) swallowed fluid </li></ul></ul><ul><ul><li> b) gastrointestinal </li></ul></ul><ul><ul><li>secretion </li></ul></ul><ul><ul><li>(increase epithelial water </li></ul></ul><ul><ul><li>secretion). </li></ul></ul><ul><li>Bowel distention / elevated intramural pressure ---> ischemia ------> necrosis. </li></ul><ul><li>(strangulated bowel obstruction) </li></ul>
  18. 18. Diagnosis: <ul><li>CT scan (90% sensitive / 90% specific) </li></ul><ul><ul><li>Findings of small bowel obstruction: </li></ul></ul><ul><ul><ul><li>Discrete transition zone </li></ul></ul></ul><ul><ul><ul><li>Intra-luminal contrast unable to passed beyond the transition zone </li></ul></ul></ul><ul><ul><ul><li>Colon containing little gas or fluid </li></ul></ul></ul><ul><ul><li>Strangulation is suggested: </li></ul></ul><ul><ul><ul><li>Thickening of the bowel wall </li></ul></ul></ul><ul><ul><ul><li>Pneumatosis intestinalis </li></ul></ul></ul><ul><ul><ul><li>Portal venous gas </li></ul></ul></ul><ul><ul><ul><li>Mesentery haziness </li></ul></ul></ul><ul><ul><ul><li>Poor uptake of intravenous contrast into the wall of the affected bowel </li></ul></ul></ul><ul><ul><li>Limitation: unable to detect partial intestinal </li></ul></ul><ul><ul><li>obstruction (<50% sensitivity) </li></ul></ul>
  19. 19. Treatment: <ul><li>Correct fluid & electrolyte imbalance : </li></ul><ul><ul><li>Isotonic fluid </li></ul></ul><ul><ul><li>Monitor resuscitation (foley catheter/CVP) </li></ul></ul><ul><li>NPO / TPN </li></ul><ul><li>Broad spectrum antibiotic (due to bacterial translocation) </li></ul><ul><li>Placed NGT to decompress the stomach and decrease nausea, distention and risk of aspiration </li></ul><ul><li>Expeditious celiotomy (to minimize risk of strangulation). </li></ul><ul><ul><li>Type of operation based on operative finding causing intestinal obstruction </li></ul></ul>
  20. 20. Ileus / Pseudo-Obstruction <ul><li>Impaired intestinal motility </li></ul><ul><li>Most common cause of delayed discharge following abdominal operations </li></ul><ul><li>Temporary and reversible </li></ul>
  21. 21. Ileus / Pseudo-Obstruction <ul><li>Etiologies: </li></ul><ul><li>Abdominal surgery </li></ul><ul><li>Infection & inflammation (sepsis/peritonitis) </li></ul><ul><li>Electrolyte imbalance (Hypo K, Mg & Na) </li></ul><ul><li>Drugs (anticholinergic, opiates) </li></ul><ul><li>Visceral myopathies (degeneration/fibrosis of smooth muscle) </li></ul><ul><li>Visceral neuropathies (degenerative disorders of myenteric & submucosal plexuses) </li></ul>
  22. 22. ILEUS
  23. 23. Symptoms: <ul><li>Inability to tolerate solid & liquid by mouth </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Lack of flatus & bowel movements </li></ul><ul><li>Diminished or absent bowel sound </li></ul><ul><li>Abdominal pain and distention </li></ul>
  24. 24. Diagnosis: <ul><li>History of recent abdominal surgery </li></ul><ul><li>Discontinue opiates </li></ul><ul><li>Serum electrolyte determination </li></ul><ul><li>CT scan better than FPA in postoperative setting to exclude presence of abscess or mechanical obstruction </li></ul>
  25. 25. Therapy: <ul><li>NPO, if prolong TPN is required </li></ul><ul><li>NGT to decompress the stomach </li></ul><ul><li>Correct fluid & electrolyte imbalance </li></ul><ul><li>Give ketorolac and reduce the dose of opioids </li></ul>
  26. 26. CHRONIC IDIOPATHIC INFLAMMATORY DISEASE OF THE BOWEL
  27. 27. CROHN’S DISEASE <ul><li>Regional, transmural, granulomatous enteritis. </li></ul><ul><li>Chronic, idiopathic inflammatory dse </li></ul><ul><li>Ethnic groups ---> East Europe (Ashkenazi Jewish) </li></ul><ul><li>Female predominance, 2x higher smokers </li></ul><ul><li>Familial association (30x in siblings / 13 x in 1 st degree relatives). </li></ul><ul><li>Higher socioeconomic status </li></ul><ul><li>Breast feeding is protective </li></ul>
  28. 28. Etiology: <ul><li>Unknown </li></ul><ul><li>Hypothesis: </li></ul><ul><ul><li>Infectious: - Chlamydia / Pseudomonas / Mycobacterium paratuberculosis / Listeria monocytogenesis / Measles / Yersinia enterocolitica </li></ul></ul><ul><ul><li>Immunologic abnormalities: </li></ul></ul><ul><ul><ul><li>Humeral & cell-mediated immune reactions against gut cells. </li></ul></ul></ul><ul><ul><li>Genetic factors: </li></ul></ul><ul><ul><ul><li>Chromosome 16 (IBD1 --> NOD2) </li></ul></ul></ul>
  29. 29. Pathology: <ul><li>Affect any portion of GIT: </li></ul><ul><ul><li>Small bowel alone (30%) </li></ul></ul><ul><ul><li>Ileocolitis (55%) </li></ul></ul><ul><ul><li>Colon alone (15%) </li></ul></ul><ul><li>Hallmark – focal, transmural inflammation of the intestine </li></ul><ul><li>Earliest sign --> aphthous ulcers surrounded by halo erythema over a non-caseating granuloma. </li></ul>
  30. 30. CHRON’S DISEASE
  31. 31. Pathology: <ul><li>As the aphthous ulcer enlarge and coalesce transversely forming cobblestone appearance. </li></ul><ul><li>Advanced dse ---> transmural inflammation. This results to COMPLICATIONS </li></ul><ul><ul><li>adhesions to adjacent bowel, </li></ul></ul><ul><ul><li>stricture formation (fibrosis), </li></ul></ul><ul><ul><li>intra-abdominal abscesses, </li></ul></ul><ul><ul><li>fistula or free perforation (peritonitis) </li></ul></ul><ul><li>Skip lesions and w/ fat wrapping (encroachment of mesenteric fat onto the serosal surface) --> pathognomonic for Crohn’s. </li></ul>
  32. 32. ADVANCED CHRON’S DSE
  33. 33. CHRON’S DSE. ANAL FISTULA
  34. 34. Clinical Manifestation: <ul><li>Most common symptom: </li></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><li>Other symptoms depends on type of complications: </li></ul><ul><ul><li>obstruction (fibrosis) </li></ul></ul><ul><ul><li>perforation (peritonitis, fistula, intraabdominal abscess) </li></ul></ul><ul><ul><li>toxic megacolon (marked colonic dilatation, adb. tenderness, fever & leukocytosis) </li></ul></ul><ul><ul><li>cancer (6x greater/more advanced---> poor prognosis) </li></ul></ul><ul><ul><li>perianal dse (fissure, fistula, stricture or abscess) </li></ul></ul><ul><li>Extra-intestinal manifestation: </li></ul><ul><ul><li>erythema nodosum & peripheral arthritis are correlated w/ severity of intestinal inflammation. </li></ul></ul>
  35. 35. Diagnosis: <ul><li>Endoscopy (esophagogastroduodenoscopy (EGD) /colonoscopy) w/ biopsy. </li></ul><ul><li>Barium enema / intestinal series </li></ul><ul><li>Enteroclysis (small bowel) more accurate </li></ul><ul><li>CT scan – to reveal intra-abd. abscesses </li></ul>
  36. 36. Treatment: <ul><li>Medical: </li></ul><ul><ul><li>Intravenous fluids </li></ul></ul><ul><ul><li>NGT to rest GIT (elemental diet/TPN) </li></ul></ul><ul><ul><li>Medications: </li></ul></ul><ul><ul><ul><li>to relieve diarrhea </li></ul></ul></ul><ul><ul><ul><li>relieve pain </li></ul></ul></ul><ul><ul><ul><li>control infection (antibiotic) </li></ul></ul></ul><ul><ul><ul><li>Anti-inflammatory ( aminosalicylates, corticosteroid, immunomodulators – azathioprime 6-mercaptopurine and cyclosporine) </li></ul></ul></ul>
  37. 37. <ul><li>Surgical: </li></ul><ul><ul><li>Indicated if: </li></ul></ul><ul><ul><ul><li>with complications </li></ul></ul></ul><ul><ul><li>Types: </li></ul></ul><ul><ul><ul><li>Segmental resection w/ primary anastomosis: </li></ul></ul></ul><ul><ul><ul><ul><li>Microscopic evidence of the dse at the resection margin does not compromise a safe anastomosis, hence, a frozen section is unnecessary. </li></ul></ul></ul></ul><ul><ul><ul><li>Stricturoplasty </li></ul></ul></ul><ul><ul><ul><li>Bypass procedures (gastrojejunostomy) </li></ul></ul></ul>
  38. 38. Tuberculous Enteritis: <ul><li>In developing and under develop countries </li></ul><ul><li>Resurgence in develop countries due to: </li></ul><ul><ul><li>AIDS epidemic </li></ul></ul><ul><ul><li>Influx of Asian migrants </li></ul></ul><ul><ul><li>Use of immunosuppressive agents </li></ul></ul><ul><li>Forms: </li></ul><ul><ul><li>Primary infection (caused by M. tuberculosis bovine from ingested milk) </li></ul></ul><ul><ul><li>Secondary infection (swallowing bacilli from active pulmonary TB) </li></ul></ul>
  39. 39. Tuberculous Enteritis
  40. 40. Tuberculous Enteritis: <ul><li>Patterns: </li></ul><ul><ul><li>Hypertrophic – causes stenosis or obstruction </li></ul></ul><ul><ul><li>Ulcerative – diarrhea and bleeding </li></ul></ul><ul><ul><li>Ulcero-hypertrophic </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Chemotherapy (given 2 wks prior to surgery up to 1 yr). </li></ul></ul><ul><ul><ul><li>Rifampicin </li></ul></ul></ul><ul><ul><ul><li>Isoniazid </li></ul></ul></ul><ul><ul><ul><li>Ethambutol </li></ul></ul></ul><ul><ul><li>Surgery (perforation, obstruction, hemorrhage). </li></ul></ul>
  41. 41. Typhoid enteritis: <ul><li>Caused by Salmonella typhi </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Culture from blood or feces </li></ul></ul><ul><ul><li>Agglutinins against O and H antigen </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Medical: </li></ul></ul><ul><ul><ul><li>Chloramphenicol / trimethropin-sulfamethoxazole / amoxycillin / quinolones </li></ul></ul></ul><ul><ul><li>Surgical: </li></ul></ul><ul><ul><ul><li>perforations / hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Segmental resection (w/ primary anastomosis or ileostomy) </li></ul></ul></ul>
  42. 42. DIVERTICULAR DISEASE OF THE SMALL BOWEL
  43. 43. Meckels Diverticulum <ul><li>Most prevalent congenital anomaly of GIT </li></ul><ul><li>True diverticula </li></ul><ul><li>60% contains heterotopic mucosa: </li></ul><ul><ul><li>Gastric mucosa (60%) </li></ul></ul><ul><ul><li>Pancreatic acini </li></ul></ul><ul><ul><li>Brunner’s gland </li></ul></ul><ul><ul><li>Pancreatic islets </li></ul></ul><ul><ul><li>Colonic mucosa </li></ul></ul><ul><ul><li>Endometriosis </li></ul></ul><ul><ul><li>Hepatobiliary tissues </li></ul></ul>
  44. 44. Meckels Diverticulum <ul><li>Rules of Twos: </li></ul><ul><ul><li>2% prevalence </li></ul></ul><ul><ul><li>2:1 female predominance </li></ul></ul><ul><ul><li>Location 2 feet proximal to the ileocecal valve in adults. </li></ul></ul><ul><ul><li>Half of those are asymptomatic are younger than 2 years of age. </li></ul></ul>
  45. 45. Meckels Diverticulum <ul><li>Complications: </li></ul><ul><ul><li>Bleeding (most common ) – due to ileal mucosal ulceration. </li></ul></ul><ul><ul><li>Obstruction: </li></ul></ul><ul><ul><ul><li>Volvulus of the intestine </li></ul></ul></ul><ul><ul><ul><li>Entrapment of intestine by the mesodiverticular band </li></ul></ul></ul><ul><ul><ul><li>Intussuception </li></ul></ul></ul><ul><ul><ul><li>Stricture due to diverticulitis </li></ul></ul></ul><ul><ul><ul><li>As Littre’s hernia – found in inguinal or femoral hernia sac. </li></ul></ul></ul>
  46. 46. Meckels Diverticulum <ul><li>Clinical manifestation: </li></ul><ul><ul><li>Asymptomatic </li></ul></ul><ul><ul><li>4% symptomatic due to complication </li></ul></ul><ul><ul><ul><li>50% are younger than 10y/o </li></ul></ul></ul><ul><ul><ul><li>Symptomatic (Bleeding > obstruction > diverticulitis) </li></ul></ul></ul><ul><ul><ul><ul><li>bleeding is 50% in children and pt younger 18y/o </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>bleeding is rare in pt older than 30y/o </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>intestinal obstruction most common in adult </li></ul></ul></ul></ul><ul><ul><ul><ul><li>diverticulitis is indistinguishable to appendicitis </li></ul></ul></ul></ul><ul><ul><li>Neoplasm seen: --- > Carcinoid </li></ul></ul>
  47. 47. Meckels Diverticulum <ul><li>Diagnosis: </li></ul><ul><ul><li>For asymptomatic usually discovered as an incidental findings in radiographic imaging, endoscopy, or intraoperatively. </li></ul></ul><ul><ul><li>Enteroclysis has 75% accuracy but not applicable during acute cases. </li></ul></ul><ul><ul><li>Radionuclide scans (99m Tc-pertechnate) for ectopic gastric mucosa or in active bleeding </li></ul></ul><ul><ul><li>Angiography to localize site of bleeder </li></ul></ul>
  48. 48. Meckels Diverticulum <ul><li>Management: </li></ul><ul><ul><li>Diverticulectomy: </li></ul></ul><ul><ul><ul><li>diverticulitis </li></ul></ul></ul><ul><ul><ul><li>obstruction (w/ removal of associated band) </li></ul></ul></ul><ul><ul><li>Segmental resection for: </li></ul></ul><ul><ul><ul><li>Bleeding </li></ul></ul></ul><ul><ul><ul><li>If with tumor </li></ul></ul></ul>
  49. 49. Acquired Small Bowel Diverticula <ul><li>Epidemiology: </li></ul><ul><li>False diverticula </li></ul><ul><li>Increases w/ age; seldom seen < 40y/o (50-70y/o) </li></ul><ul><ul><li>Duodenum: </li></ul></ul><ul><ul><ul><li>Most common; usually adjacent to ampulla </li></ul></ul></ul><ul><ul><ul><li>Called periampullary, juxtapapillary, or peri-Vaterian diverticula </li></ul></ul></ul><ul><ul><ul><li>75% arise in the medial wall </li></ul></ul></ul>
  50. 50. Acquired Small Bowel Diverticula <ul><li>Jejunoileal: </li></ul><ul><ul><ul><li>80% - jejunum (tends to be large and multiple) </li></ul></ul></ul><ul><ul><ul><li>15% - ileum (tends to be small and solitary) </li></ul></ul></ul><ul><ul><ul><li>5% - both ileum and jejunum </li></ul></ul></ul>
  51. 51. Acquired Small Bowel Diverticula <ul><li>Pathophysiology: </li></ul><ul><ul><li>Abnormalities of intestinal smooth muscle or dysregulated motility leading to herniation. </li></ul></ul><ul><ul><li>Associated w/: </li></ul></ul><ul><ul><ul><li>Bacterial overgrowth – vit B12 deficiency, megaloblastic anemia, malabsorption & steatorrhea </li></ul></ul></ul><ul><ul><ul><li>Periampullary duodenal diverticula : </li></ul></ul></ul><ul><ul><ul><ul><li>Obstructive jaundice </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pancreatitis </li></ul></ul></ul></ul><ul><ul><ul><li>Intestinal obstruction due to compression of adjacent bowel </li></ul></ul></ul>
  52. 52. Acquired Small Bowel Diverticula <ul><li>Diagnosis: </li></ul><ul><ul><li>Best diagnosed w/ enteroclysis </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Asymptomatic ---> left alone </li></ul></ul><ul><ul><li>Bacterial overgrowth --> antibiotics </li></ul></ul><ul><ul><li>Bleeding and obstruction ---> segmental resection for jejunoileal diverticula. </li></ul></ul>
  53. 53. Acquired Small Bowel Diverticula <ul><li>Treatment: </li></ul><ul><ul><li>Diverticulectomy if located in the duodenum </li></ul></ul><ul><ul><ul><li>For medial duodenal diverticula ---> do lateral duodenotomy and oversewing of the bleeder </li></ul></ul></ul><ul><ul><ul><li>May invaginate the diverticula into the duodenal lumen then excised </li></ul></ul></ul><ul><ul><ul><li>If related to the ampulla ---> extended sphincterotoplasty </li></ul></ul></ul><ul><ul><ul><li>If perforated ----> excised and closed w/ omental patch; if inflammed ---> placed gastrojejunostomy </li></ul></ul></ul>
  54. 54. MESENTERIC ISCHEMIA
  55. 55. Mesenteric Ischemia <ul><li>Clinical Syndrome: </li></ul><ul><li>Acute mesenteric ischemia </li></ul><ul><ul><li>Pathophysiology </li></ul></ul><ul><ul><ul><li>Arterial embolus : (most common-50%; heart; usually lodge distal to origin of the middle colic </li></ul></ul></ul><ul><ul><ul><li>Arterial thrombosis : occlusion occurs at proximal near it’s origin. </li></ul></ul></ul><ul><ul><ul><li>Vasospasm (nonocclusive mesenteric ischemia – NOMI): usually in critically-ill pt. receiving vasopressors. </li></ul></ul></ul><ul><ul><ul><li>Venous thrombosis : (5-15%) and 95% SMV </li></ul></ul></ul><ul><ul><ul><ul><li>Primary – no etiologic factor identified </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Secondary – heritable or acquired coagulation disorder </li></ul></ul></ul></ul>
  56. 56. Mesenteric Ischemia <ul><li>Clinical Syndrome: </li></ul><ul><li>Chronic Mesenteric Ischemia: </li></ul><ul><ul><li>Develops insidiously allows for collateral circulation to develop </li></ul></ul><ul><ul><li>Rarely leads to infarction. </li></ul></ul><ul><ul><li>Usually due to arteriosclerosis </li></ul></ul><ul><ul><li>Usually two mesenteric arteries are involved </li></ul></ul>
  57. 57. Mesenteric Ischemia <ul><li>Manifestation: </li></ul><ul><ul><li>Acute mesenteric ischemia: </li></ul></ul><ul><ul><ul><li>Severe abdominal pain out of proportion to the degree of abd. tenderness (hallmark) </li></ul></ul></ul><ul><ul><ul><ul><li>Colicky at the mid-abdomen. </li></ul></ul></ul></ul><ul><ul><ul><li>Nausea / vomiting, diarrhea </li></ul></ul></ul><ul><ul><ul><li>abd. distention,peritonitis, passage bloody stool </li></ul></ul></ul><ul><ul><li>Chronic mesenteric ischemia: </li></ul></ul><ul><ul><ul><li>Postprandial abd. pain “food-fear”, (most common) </li></ul></ul></ul>
  58. 58. Mesenteric Ischemia <ul><li>No laboratory test sensitive for the detection of acute mesenteric ischemia prior to the onset of intestinal infarction. </li></ul><ul><li>The presence of it’s hallmark sign, is an indication for immediate celiotomy. </li></ul>
  59. 59. Mesenteric Ischemia <ul><li>Angiography – most reliable; 74 – 100% sensitivity and 100% specificity; </li></ul><ul><ul><li>It is gold standard for the diagnosis of arterial mesenteric ischemia. </li></ul></ul>
  60. 60. Mesenteric Ischemia <ul><li>CT scanning is used to: </li></ul><ul><ul><li>Disorder other abd. condition causing abd. pain </li></ul></ul><ul><ul><li>Evidence of occlusion or stenosis of mesenteric vasculature. </li></ul></ul><ul><ul><li>Evidence of ischemia in the intestine & mesentery </li></ul></ul><ul><ul><li>Test of choice for acute mesenteric venous thrombosis </li></ul></ul>
  61. 61. Mesenteric Ischemia <ul><li>Treatment: </li></ul><ul><ul><li>w/ signs of peritonitis --> celiotomy check for viability of the bowel: </li></ul></ul><ul><ul><ul><li>Necrotic ----> segmental resection </li></ul></ul></ul><ul><ul><ul><li>Questionable viability ----> second look laparotomie s </li></ul></ul></ul>
  62. 62. Mesenteric Ischemia <ul><ul><li>Surgical revascularization (embolectomy / thrombectomy / mesenteric bypass). </li></ul></ul><ul><ul><ul><li>Not done if: </li></ul></ul></ul><ul><ul><ul><ul><li>segment is necrotic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>is too unstable patient </li></ul></ul></ul></ul><ul><ul><ul><li>Done pt diagnosed w/ emboli or thrombus-induced acute mesenteric ischemia w/o signs of peritonitis. </li></ul></ul></ul><ul><ul><ul><li>May give thrombolysis (streptokinase, urokinase , recombinant tissue plasminogen activator). Useful only in partially occluded vessels and has given w/in 12 hrs. after onset of symptoms. </li></ul></ul></ul>
  63. 63. NEOPLASM OF THE SMALL BOWEL
  64. 64. Neoplasm <ul><li>Rare: </li></ul><ul><ul><li>Rapid transit time </li></ul></ul><ul><ul><li>Local immune system of the small bowel mucosa (IgA) </li></ul></ul><ul><ul><li>Alkaline pH </li></ul></ul><ul><ul><li>Relatively low concentration of bacteria; low concentration of carcinogenic products of bacterial metabolism. </li></ul></ul><ul><ul><li>Presence of mucosal enzymes (hydrolases) that destroy certain carcinogens </li></ul></ul><ul><ul><li>Efficient epithelial cellular apoptotic mechanisms that serve to eliminate clones harboring genetic mutation </li></ul></ul>
  65. 65. Neoplasm <ul><li>50 – 60 y/o </li></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Red meat </li></ul></ul><ul><ul><li>Ingestion of smoked or cured foods </li></ul></ul><ul><ul><li>Crohn’s dse </li></ul></ul><ul><ul><li>Celiac sprue </li></ul></ul><ul><ul><li>Hereditary nonpolyposis colorectal cancer (HNPCC) </li></ul></ul><ul><ul><li>Familial adenomatous polyposis (FAD) – 100% to develop duodenal CA </li></ul></ul><ul><ul><li>Peutz-Jeghers syndrome </li></ul></ul>
  66. 66. Neoplasm <ul><li>Symptoms: </li></ul><ul><ul><li>Most are asymptomatic </li></ul></ul><ul><ul><li>Symptoms: </li></ul></ul><ul><ul><li>Vague abdominal pain (epigastric discomfort, N/V, abd. pain, diarrhea). </li></ul></ul><ul><ul><li>Bleeding (hematochezia or hematemesis) </li></ul></ul><ul><ul><li>Obstruction (intussuception, circumferencial growth, kinking of the bowel, intramural growth). </li></ul></ul><ul><li>Most common mode of presentation is ---> crampy abd. pain, distention, nausea / vomiting </li></ul><ul><li>Hemorrhage usually indolent 2 nd common mode of presentation </li></ul>
  67. 67. Neoplasm <ul><li>Diagnosis: </li></ul><ul><ul><li>For most are asymptomatic it is rarely diagnosed preoperatively </li></ul></ul><ul><ul><li>Serological examination </li></ul></ul><ul><ul><ul><li>Serum 5-hydroxyindole acetic acid (HIAA) for carcinoid. </li></ul></ul></ul><ul><ul><ul><li>CEA associated w/ small intestinal adenocarcinoma but only if w/ liver metastasis. </li></ul></ul></ul>
  68. 68. Neoplasm <ul><li>Diagnosis: </li></ul><ul><ul><li>Radiological examination: </li></ul></ul><ul><ul><ul><li>Enteroclysis (test of choice – 90% sensitivity) </li></ul></ul></ul><ul><ul><ul><li>UGIS w/ intestinal follow through </li></ul></ul></ul><ul><ul><ul><li>CT scan </li></ul></ul></ul><ul><ul><ul><li>Angiography / RBC scan --> bleeding lesions </li></ul></ul></ul><ul><ul><li>Endoscopy: </li></ul></ul><ul><ul><ul><li>EGD (esophagus, gastric, and duodenum) </li></ul></ul></ul><ul><ul><ul><li>Colonoscopy </li></ul></ul></ul>
  69. 69. <ul><li>Benign tumors: </li></ul><ul><li>Adenomas: (most common benign neoplasm): </li></ul><ul><ul><li>True adenomas: </li></ul></ul><ul><ul><ul><li>Associated w/ bleeding and obstruction </li></ul></ul></ul><ul><ul><ul><li>Usually seen in the ileum </li></ul></ul></ul><ul><ul><ul><li>Majority are asymptomatic </li></ul></ul></ul><ul><ul><li>Villous adenoma: </li></ul></ul><ul><ul><ul><li>Most common in the duodenum </li></ul></ul></ul><ul><ul><ul><li>“ soap bubble” appearance on contrast radiography </li></ul></ul></ul><ul><ul><ul><li>No report of secretory diarrhea </li></ul></ul></ul><ul><ul><li>Brunner’s gland adenoma </li></ul></ul><ul><ul><ul><li>In the duodenum </li></ul></ul></ul><ul><ul><ul><li>No malignant potential </li></ul></ul></ul><ul><ul><ul><li>Mimic PUD </li></ul></ul></ul>
  70. 70. Benign tumors: <ul><li>Leiomyoma: </li></ul><ul><ul><li>Most common symptomatic benign lesion </li></ul></ul><ul><ul><li>Associated w/ bleeding </li></ul></ul><ul><ul><li>Diagnosed by angiography and commonly located in the jejunum </li></ul></ul><ul><ul><li>2 growth pattern: </li></ul></ul><ul><ul><ul><li>Intramurally ----> obstruction </li></ul></ul></ul><ul><ul><ul><li>Both intramural and extramural (Dumbbell shaped) </li></ul></ul></ul>
  71. 71. Benign tumors: <ul><li>Lipoma: </li></ul><ul><ul><li>Most common in the ileum </li></ul></ul><ul><ul><li>Causes obstruction (lead point of an intussusception) </li></ul></ul><ul><ul><li>Bleeding due to ulcer formation </li></ul></ul><ul><ul><li>No malignant degeneration </li></ul></ul>
  72. 72. Benign tumors: <ul><li>Peutz-Jeghers Syndrome: </li></ul><ul><ul><li>Inherited syndrome of: </li></ul></ul><ul><ul><ul><li>Mucocutaneous melatonic pigmentation (face, buccal mucosa, palm, sole, peri-anal area) </li></ul></ul></ul><ul><ul><ul><li>Gastrointestinal polyp (enteric jejunum and ileum are most frequent part of GIT followed by colon, rectum and stomach). </li></ul></ul></ul>
  73. 73. Benign tumors: <ul><li>Peutz-Jeghers Syndrome: </li></ul><ul><ul><li>Inherited syndrome of: </li></ul></ul><ul><ul><ul><li>Mucocutaneous melatonic pigmentation (face, buccal mucosa, palm, sole, peri-anal area) </li></ul></ul></ul><ul><ul><ul><li>Gastrointestinal polyp (enteric jejunum and ileum are most frequent part of GIT followed by colon, rectum and stomach). </li></ul></ul></ul>
  74. 74. Benign tumors: <ul><li>Peutz-Jeghers Syndrome: </li></ul><ul><ul><li>Symptoms: </li></ul></ul><ul><ul><ul><li>colicky abd. pain (due to intermittent intussuception) </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Segmental resection of the bowel causing obstruction or bleeding. </li></ul></ul></ul><ul><ul><ul><li>Cure impossible due to widespread intestinal involvement </li></ul></ul></ul>
  75. 75. <ul><li>Malignant neoplasm: </li></ul><ul><li>Histologic types: </li></ul>Tumor type Cell of origin Frequency Predominant Site adenocarcinoma Epithelial cell 35 – 50% Duodenum carcinoid Enterochromaffin cell 20 – 40% Ileum lymphoma lymphocyte 10 – 15% Ileum GIST (gastrointestinal stromal tumors) ? Interstitial cell of Cajal 10 – 15% -
  76. 76. Malignant neoplasm: <ul><li>Adenocarcinoma: </li></ul><ul><ul><li>Most common CA of small bowel </li></ul></ul><ul><ul><li>Most common in duodenum and proximal jejunum </li></ul></ul><ul><ul><li>Half involve the ampulla of Vater. </li></ul></ul>
  77. 77. Malignant neoplasm: <ul><li>Carcinoid: </li></ul><ul><ul><li>From Enterochromaffin cells or Kultchitsky cells </li></ul></ul><ul><ul><li>Arise from foregut, midgut & hindgut </li></ul></ul><ul><ul><li>Appendix (46%) > Ileum (28%) > Rectum (17%) </li></ul></ul>
  78. 78. Malignant neoplasm: <ul><li>Carcinoid: </li></ul><ul><ul><li>Aggressive behavior than the appendiceal carcinoid. </li></ul></ul><ul><ul><ul><li>appendix – 3% metastasize; Ileum – 35% metastasize </li></ul></ul></ul><ul><ul><ul><li>Appendix – solitary; Ileum – 30% multiple </li></ul></ul></ul><ul><ul><li>25-50% w/ carcinoid tumor with liver metastasis develops carcinoid syndrome . </li></ul></ul><ul><ul><ul><li>Secretes serotonin, bradykinin and substance P </li></ul></ul></ul><ul><ul><ul><ul><li>Diarrhea </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flushing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul></ul><ul><ul><ul><ul><li>tachycardia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>fibrosis of endocardium and valves of the right heart . </li></ul></ul></ul></ul>
  79. 79. Malignant neoplasm: <ul><li>Lymphomas: </li></ul><ul><ul><li>Most common intestinal neoplasm in children under 10y/o. </li></ul></ul><ul><ul><li>In adult = 10-15% of small bowel malignant tumors </li></ul></ul><ul><ul><li>Most common presentation </li></ul></ul><ul><ul><ul><ul><li>intestinal obstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Perforation (10%) </li></ul></ul></ul></ul>
  80. 80. Malignant neoplasm: <ul><li>Lymphomas: </li></ul><ul><ul><li>Criteria of primary lymphomas of the small bowel: </li></ul></ul><ul><ul><ul><ul><li>Absence of peripheral lymphadenopathy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Normal chest x-ray w/o evidence of mediastinal LN enlargement. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Normal WBC count and differential </li></ul></ul></ul></ul><ul><ul><ul><ul><li>At operation, the bowel lesion must predominate and the only nodes are associated w/ the bowel lesion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Absence of disease in the liver and spleen </li></ul></ul></ul></ul>
  81. 81. Treatment: <ul><li>For Benign lesions: </li></ul><ul><ul><li>All symptomatic benign tumors should be surgically resected or removed endoscopically (EGD / colonoscopy). </li></ul></ul><ul><ul><li>Duodenal tumors: </li></ul></ul><ul><ul><ul><li>1 cm. ----> endoscopic polypectomy </li></ul></ul></ul><ul><ul><ul><li>2cm. ----> surgically resected (Whipples – located near the ampulla of Vater). </li></ul></ul></ul><ul><ul><ul><li>Duodenal adenomas w/ FAP shd undergo Whipples for it is usually multiple and sessile and has 100% degenerate to CA. </li></ul></ul></ul>
  82. 82. Treatment: <ul><li>Malignant lesions: </li></ul><ul><ul><li>Adenocarcinoma: </li></ul></ul><ul><ul><ul><li>Wide local resection w/ it’s mesentery to achieve regional lymphadenectomy </li></ul></ul></ul><ul><ul><ul><li>Chemotherapy has no proven efficacy in the adjuvant or palliative treatment of small-intestinal adenoCA. </li></ul></ul></ul><ul><ul><li>Small intestinal lymphoma: </li></ul></ul><ul><ul><ul><li>For localized: segmental resection w/ adjacent mesentery </li></ul></ul></ul><ul><ul><ul><li>If w/ diffused involvement: -->chemotherapy rather than surgery, is primary therapy </li></ul></ul></ul>
  83. 83. Treatment: <ul><ul><li>Carcinoid: </li></ul></ul><ul><ul><ul><li>Segmental intestinal resection & regional lymphadenectomy. </li></ul></ul></ul><ul><ul><ul><ul><li>< 1cm rarely has LN metastases </li></ul></ul></ul></ul><ul><ul><ul><ul><li>> 3cm 75 to 90% LN metastases </li></ul></ul></ul></ul><ul><ul><ul><li>30% are multiple, hence entire small bowel shd be examined prior to surgery . </li></ul></ul></ul>
  84. 84. Treatment: <ul><ul><li>Carcinoid: </li></ul></ul><ul><ul><ul><li>If w/ metastatic lesions---> debulking, associated w/ long-term survival & amelioration of symptoms of carcinoid syndrome </li></ul></ul></ul><ul><ul><ul><li>Chemotherapy: ---> 30 -50% response </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Doxorubicin </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>5-fluorouracil </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Streptozocin </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Octreotide : - most effective for management of symptoms of carcinoid syndrome </li></ul></ul></ul>
  85. 85. Treatment: <ul><li>Metastatic cancers: </li></ul><ul><ul><li>Melanoma associated w/ propensity for metastasis to the small bowel. </li></ul></ul><ul><ul><li>Palliative resection / bypass procedure </li></ul></ul><ul><ul><li>Systemic therapy depends on the responds of the primary site. </li></ul></ul>
  86. 86. SHORT BOWEL SYNDROME
  87. 87. Short Bowel Syndrome <ul><li>Presence of less than 200cm of residual small bowel in adult pts. </li></ul><ul><li>Functional definition: - insufficient intestinal absorptive capacity results in the clinical manifestations of: </li></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>malnutrition </li></ul></ul>
  88. 88. Short Bowel Syndrome <ul><li>Etiologies (adult): </li></ul><ul><li>Acute mesenteric ischemia </li></ul><ul><li>Malignancy </li></ul><ul><li>Crohn’s disease </li></ul><ul><li>Etiologies (pediatric): </li></ul><ul><li>Intestinal atresias </li></ul><ul><li>Volvulus </li></ul><ul><li>Necrotizing enterocolitis </li></ul>
  89. 89. Short Bowel Syndrome <ul><li>Medical therapy: </li></ul><ul><ul><li>Mx of primary condition causing intestinal resection </li></ul></ul><ul><ul><li>Correct fluid & electrolyte imbalance due to severe diarrhea </li></ul></ul><ul><ul><li>TPN, enteral nutrition is gradually introduced, once ileus is resolved </li></ul></ul>
  90. 90. Short Bowel Syndrome <ul><li>Medical therapy: </li></ul><ul><ul><li>H2 receptor antagonist --> to reduce gastric acid secretion </li></ul></ul><ul><ul><li>Antimotility agents (loperamide HCL or diphenoxylate) </li></ul></ul><ul><ul><li>Octreotide – to reduce volume of gastrointestinal secretion </li></ul></ul><ul><ul><li>TPN complication: </li></ul></ul><ul><ul><ul><li>Catheter sepsis </li></ul></ul></ul><ul><ul><ul><li>Venous thrombosis </li></ul></ul></ul><ul><ul><ul><li>Liver and kidney failure </li></ul></ul></ul><ul><ul><ul><li>osteoporosis </li></ul></ul></ul>
  91. 91. Short Bowel Syndrome <ul><li>Surgical Therapy : </li></ul><ul><ul><li>Non-transplant: </li></ul></ul><ul><ul><ul><li>Goal is to increase nutrient and fluid absorption by either slowing intestinal transit or increasing intestinal length </li></ul></ul></ul><ul><ul><ul><li>Slow intestinal transit: </li></ul></ul></ul><ul><ul><ul><ul><li>Segmental reversal of the small bowel </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Interposition of a segment of colon </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Construction of small intestinal valves </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Electrical pacing of the small bowel </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Limited case report </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Frequently associated w/ intestinal obstruction </li></ul></ul></ul></ul>
  92. 92. GOD BLESS <ul><li>SALAMAT PO </li></ul>
  93. 93. THANK YOU
  94. 94. Diagnosis: <ul><li>Enteroclysis </li></ul><ul><ul><li>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 </li></ul></ul>
  95. 95. Short Bowel Syndrome <ul><li>Factors predictive of achieving independence from TPN: </li></ul><ul><ul><li>Presence or absence of an intact colon (capacity to absorb fluid & electrolytes and absorb short-chain FA). </li></ul></ul><ul><ul><li>Intact ileocecal valve </li></ul></ul><ul><ul><li>A healthy, rather disease, residual small intestine is associated w/ decreased severity of malabsorption </li></ul></ul><ul><ul><li>Resection of jejunum is better tolerated than the ileum, due to bile salt and vit B12 absorption capacity of the ileum. </li></ul></ul>
  96. 96. Short Bowel Syndrome <ul><li>Surgical Therapy: </li></ul><ul><ul><li>Non-transplant: </li></ul></ul><ul><ul><ul><li>Intestinal lengthening operation: </li></ul></ul></ul><ul><ul><ul><ul><li>Longitudinal Intestinal lengthening and tailoring (LILT) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Serial transverse enteroplasty procedure (STEP) </li></ul></ul></ul></ul><ul><ul><li>Intestinal transplant </li></ul></ul>
  97. 97. Prognosis (CHRON’S DSE) <ul><li>High recurrence rate (most common proximal to the site of previous resection). </li></ul><ul><li>70% recur w/in 1 yr and 85% w/in 3 yrs. </li></ul><ul><li>Most common complication: </li></ul><ul><ul><ul><li>Wound infection </li></ul></ul></ul><ul><ul><ul><li>Postoperative intra-abdominal abscess </li></ul></ul></ul><ul><ul><ul><li>Anastomotic leaks </li></ul></ul></ul><ul><li>60-300 x more frequent to develop CA </li></ul>
  98. 98. Mesenteric Ischemia <ul><ul><li>NOMI – std tx. Is infusion of vasodilator (papavarine hydrochloride) into the SMA. If w/ signs of peritonitis --> immediate celiotomy and resect necrotic segment. </li></ul></ul><ul><ul><li>Acute mesenteric venous thrombosis </li></ul></ul><ul><ul><ul><li>Std tx. anticoagulant (heparin / warfarin). </li></ul></ul></ul><ul><ul><ul><li>Signs of peritonitis --> explore and resects if needed </li></ul></ul></ul><ul><ul><li>For chronic arterial mesenteric ischemia: </li></ul></ul><ul><ul><ul><li>Surgical revascularization </li></ul></ul></ul><ul><ul><ul><ul><li>Aortomesenteric bypass grafting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mesenteric endarterectomy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Percutaneous transluminal mesenteric angioplasty alone or w/ stent. </li></ul></ul></ul></ul>
  99. 99. Malignant neoplasm: <ul><li>GISTs: (gastrointestinal stromal tumors) </li></ul><ul><ul><li>Most common mesenchymal tumors arising in the small bowel </li></ul></ul><ul><ul><li>70% arises from the stomach followed by the small bowel </li></ul></ul><ul><ul><li>15% of small bowel malignancies </li></ul></ul><ul><ul><li>Formerly classified as: </li></ul></ul><ul><ul><ul><li>Leiomyomas </li></ul></ul></ul><ul><ul><ul><li>Leiomyosarcomas </li></ul></ul></ul><ul><ul><ul><li>Smooth muscle tumors of small bowel </li></ul></ul></ul><ul><ul><li>Associated w/ overt hemorrhage </li></ul></ul><ul><ul><li>Has its expression of the receptor tyrosine kinase KIT (CD117). There is pathological KIT signal transduction </li></ul></ul>
  100. 100. Treatment: <ul><li>Small-intestine GISTs: </li></ul><ul><ul><li>Segmental resection </li></ul></ul><ul><ul><li>If was preoperatively diagnosed, lymphadenectomy shd not be done, for rarely associated w/ LN metastases. </li></ul></ul><ul><ul><li>Resistant to conventional chemotherapy </li></ul></ul><ul><ul><li>IMATINIB (Gleevec): </li></ul></ul><ul><ul><ul><li>Formerly known as ST1571 </li></ul></ul></ul><ul><ul><ul><li>80% of pt w/ unresectable lesions showed clinical benefits </li></ul></ul></ul><ul><ul><ul><li>50 – 60% showed evidence of reduction in tumor volume </li></ul></ul></ul><ul><ul><ul><li>Role as neoadjuvant and adjuvant tx under investigation </li></ul></ul></ul>
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