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1. Common small and large
intestinal surgical diseases
Luay Ahmed Naeem
Assistant Professor of Surgery
3/11/2024
2. Topics
• Anatomy of small and large intestine.
• Physiology of small and large intestine.
• Bowel obstruction.
• Small bowel neoplasms.
• Meckel's diverticulum.
• Colorectal cancer.
• Atresia anai
3/11/2024 Shwartz
3. Anatomy of small intestine
The small intestine measures between 1.0 and
1.5 m in cats and between 2 and 5 m in dogs.
The small intestine is composed of the
1- Duodenum,
2- Jejunum, and
3- Ileum
and therefore extends from the pylorus to the
ileocolic junction.
4.
5. Function of Small Intestine
• The small intestine is the primary area of food
digestion and absorption.
• The functional unit of the small intestine is the
villus with its associated crypts.
• The jejunum absorbs 50% of the fluid presented
to its segment of the intestinal tract, and the
ileum absorbs 75%.
• Digestion is achieved using a combination of
enzymes from the small intestinal luminal brush
border cells and the pancreas and, for fat
digestion, bile released from the gallbladder.
6. Anatomy of large intestine
The large intestine is approximately
1.5m long comprises the caecum, colon,
rectum, anal canal and anus.
The structure of the large intestine is
very similar to that of the small intestine,
except that its mucosa is completely
devoid of villi.
3/11/2024
7.
8. Functions of the large intestine
• Meals pass from the small to the large
intestine within 8-9 hours of ingestion.
• The small intestine will have absorbed
about 90% of the ingested water.
• The large intestine absorbs most of the
remaining water, a process that converts
liquid chyme residue into semi-solid
stools or faeces.
9. Cont……..
The large intestine has three major
functions:
• Chemical digestion by gut microbes.
• Absorption of water and electrolytes;
• Formation and transport of faeces; and
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12. 12
Intestinal Obstruction
• Intestinal obstruction exists when blockage
prevents the normal flow of intestinal
contents through the intestinal tract.
• Two types of processes can impede this flow.
– Mechanical.
– Functional.
13. 13
Intestinal Obstruction
• Mechanical obstruction:
– An intra-luminal obstruction or a mural obstruction
from pressure on the intestinal walls occurs.
– Examples are:
• Intussusception.
• Polypoid tumors and neoplasms.
• Stenosis.
• Adhesions.
• Hernias.
• Abscesses.
14. 14
Intestinal Obstruction
• Functional obstruction:
–The intestinal musculature cannot propel the
contents along the bowel.
–Examples are:
• Amyloidosis (Protein build up, amyloid).
• Muscular dystrophy (Intestinal movement).
• Endocrine disorders such as diabetes mellitus(V.N.).
15. 15
Intestinal Obstruction
• The obstruction can be partial or
complete.
• Its severity depends on:
–The region of bowel affected
–The degree to which the lumen is occluded
–The degree to which the vascular supply to
the bowel wall is disturbed.
16. 16
Intestinal Obstruction
• Most bowel obstructions occur in the small intestine
• Adhesions are the most common cause of small
bowel obstruction, followed by hernias and
neoplasms.
• Other causes include intussusception, volvulus (ie,
twisting of the bowel), and paralytic ileus.
• About 15% of intestinal obstructions occur in the
large bowel; most of these are found in the sigmoid
colon
19. SMALL-BOWEL OBSTRUCTION
• Causes can be divided into three categories:
1. Extraluminal causes such as adhesions, hernias,
carcinomas, and abscesses
2. Intrinsic to the bowel wall (e.g., primary tumors)
3. Intraluminal obturator obstruction (e.g.,
gallstones, enteroliths, foreign bodies, and
bezoars)
3/11/2024 Shwartz
20. SMALL-BOWEL OBSTRUCTION
• PATHOPHYSIOLOGY:
– Obstruction onset
• Gas and fluid accumulate within the intestinal lumen
proximal to the site of obstruction.
• The bowel distends and intramural pressures rise.
• Microvascular perfusion to the intestine is impaired,
leading to intestinal ischemia, and, ultimately, necrosis.
–strangulating bowel obstruction
• Progression to strangulation occurs quicker with
complete bowel obstruction and more rapidly with
closed loop obstruction which a segment of intestine is
obstructed both proximally and distally (e.g., with
volvulus).
3/11/2024 Shwartz
21. – The common intestinal obstruction are:
• Adhesion: loop of intestine become adherent to
areas of healing after abdominal surgery.
• Intussusception: invagination or shortening of the
colon caused by the movement of one segment
of bowel into another.
• Volvulus: volvulus of the sigmoid colon, the twist
is counterclockwise in most cases with note the
edematous bowel.
• Hernias: when the hernial sac content are
intestine, omentum, or other abdominal contents
that pass through the hernial ring into the hernial
sac.
28. BOWEL OBSTRUCTION
• Clinical Presentation
– Symptoms:
• Colicky abdominal pain
• Nausea
• Vomiting
• Continued passage of flatus and/or stool
beyond 6–12 h after onset of symptoms is
characteristic of partial rather than complete
obstruction.
• Obstipation.
29. Cont.………
– Signs
• Abdominal distention
• Hyperactive bowel sounds. “borborygmi”
• Features of strangulated obstruction include
–Tachycardia
–Localized abdominal tenderness
–Painful
–Fever
–Marked leukocytosis
–Acidosis
30. SMALL-BOWEL OBSTRUCTION
• Diagnosis
– The diagnostic evaluation should focus on the
following goals:
1. Distinguishing mechanical obstruction from
ileus
2. Determining the etiology of the obstruction
3. Discriminating a partial from complete
obstruction
4. Discriminating simple from strangulating
obstruction.
5. Determining the site of obstruction.
31. SMALL-BOWEL OBSTRUCTION
• Diagnosis
– Careful history taking:
• Hx of abdominal operations ? presence of adhesions.
• Hx of abdominal disorders (e.g., intraabdominal cancer
or inflammatory bowel disease).
– Careful examination:
• A meticulous search for hernias (particularly in the
inguinal, umbilical and femoral regions) should be
conducted.
• The stool should be checked for gross or occult blood,
the presence of which is suggestive of intestinal
strangulation.
32. SMALL-BOWEL OBSTRUCTION
• X-RAY:
• Obstruction is usually confirmed with radiographic
examination.
• Abdominal series consists of :
– Supine Abdominal X-ray
– Upright Abdominal X-ray
– Upright Chest X-ray
• The finding most specific for small-bowel obstruction is
the triad of
• Dilated small-bowel loops (>3 cm in diameter)
• Air–fluid levels seen on upright films
• A paucity of air in the colon.
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33. LARGE BOWEL OBSTRUCTION
• Pathophysiology
• As in small bowel obstruction
– large bowel obstruction results in an accumulation of
intestinal contents, fluid, and gas proximal to the
obstruction.
– Obstruction in the large bowel can lead to severe
distention and perforation unless some gas and
fluid can flow back through the ileal valve.
– Large bowel obstruction, even if complete, may be
undramatic if the blood supply to the colon is not
disturbed.
34. 34
Cont……..
• If the blood supply is cut off intestinal
strangulation and necrosis (tissue death)
occur; this condition is life threatening.
• Dehydration occurs more slowly than in the
small intestine because the colon can absorb
its fluid contents and can distend to a size
considerably beyond its normal full capacity.
35. 35
LARGE BOWEL OBSTRUCTION
Clinical Manifestations:
• Large bowel obstruction differs clinically from
small bowel obstruction in that the symptoms
develop and progress relatively slowly.
• In patients with obstruction in the sigmoid
colon or the rectum, constipation may be the
only symptom for days. loops of large bowel
become visibly outlined through the abdominal
wall, and the patient has crampy lower
abdominal pain.
• Finally, feculent vomiting develops. Symptoms
of shock may occur.
36. BOWEL OBSTRUCTION
• Therapy
– Fluid resuscitation.
– A nasogastric (NG) tube to evacuate air and fluid from
stomach.
– An indwelling bladder catheter to monitor urine output.
– Central venous or pulmonary artery catheter monitoring
may be necessary
– Broad-spectrum antibiotics
– The standard therapy for bowel obstruction is
expeditious surgery with the exception of specific
situations.
3/11/2024 Shwartz
