Surgery small intestin

1. Small intestine
Dr Yasin

2. Anatomy
• Three main parts
• Duodenum
• Jejunum
• ileum

3. Anatomy
• Length varies from 300cm to 850 cm from DJ
flexure to ileocecal valve.
• There is no clear demarcation between
jejunum and ileum, but jejunum has bigger
diameter, larger mucosal fold and thicker wall.
• Small bowel has rich blood supply via SMA
and drained by corresponding veins into
portal venous system.

4. Physiology
• Small bowel concerned with digestion and
absorption of nutrients,
• Jejunum is the principal site for digestion
absorption of fluid, electrolytes, iron, folic
acid, fats, proteins and carbohydrates.

5. Inflammatory bowel disease
• It is a chronic idiopathic inflammatory
condition of the bowel,
• Crohn’s disease effects the small bowel where
Ulcerative effects more frequently on the
large bowel

6. Crohn’s disease
• It is deffined as chronic idiopathic
inflammatory condition effecting the Gi tract
from the lips to the anus but more frequently
encountered in the small bowel especially in
the terminal ileum.
• More common in North America and UK
• Slightly more common in females than males
between the age of 25-40yrs

7. • The disease is less common in Asia, Africa and
South America,

8. Etiology
• The etiology is incompletely understood
• Genetic factors, environmental factors and
food stuff plays an important role.

9. The risk factors are
• Smoking
• Genetics 10% of patients have 1st degree
relatives effected, and monozygotic twins
have 50% chance of getting effected.

10. Patholgy
• Most common site is the terminal ileum 65%,
perianal involvement is common in upto 50-
75% of cases , stomach and duodenum
effected in just 5% of patients.
• The inflammation is transmural , a
characteristic feature of CD

11. The features
• Colicky abdominal pain, fever, signs similar to
appendicitis,
• Diarrhaea for many months,
• On examination, there may be a palpable
mass, anemia, wt loss and
• In long standing cases features of small bowel
obstruction may dominate,

12. Extraintestinal manifestations,
• They r similar to UC , they are:
• Erythema Nodosum
• Ireitis/ uveitis
• Pyoderma gangrenosum
• Arthritis
• Aphthus ulcers
• Gallstones
• Renal stones
• Sclerosing cholangitis
• sacroileitis

13. Difference between CD and UC
CD UC
Can affect any part of GI tract Effects colon only
Full thickness disease Mucosal disease
Skip lessions Confluent disease
Causes fistulation and stricuring
Noncaseating granuloma
No fistulation
No granuloma
Associated with perianal disease
Resection does not cure the disease
Uncommon
Resection cures the disease

14. Investigations
• Baseline labs include CBC, may show anemia
of chronic disease, B12 defficiency or Iron
defficiency.
• Imaging may include, small bowel anema, Us
and Ct scan may show collections, dilatations,
stricturing or fistulations
• Colonoscopy is also useful.

15. Treatment
• Medical therapy:
• Steroides- Budesonide
• 5 ASA
• Metronidazole/ ciproxin
• Azathioprin
• Cyclosporine
• Infliximab
• Nutritional support, is important

16. • Surgical therapy, the indications include:
• Massive active bleeding
• Intestinal obstruction
• Perforation of the bowel
• Medical therapy failure
• Steroid dependency
• Maligant change
• Perianal disease- fistula , abscess

17. Top-down approach for CD
• Initially it used to be step up approach, where
the one therapy is started and additional
drugs added as required,
• The top down approached is advocated by
some doctors these days where initial therapy
starts with combination drugs and then taper
off gradually as clinical condition admitts

18. Surgery for CD
• The challenges are,
• Thick mesentery
• Malnutrition of the patient
• Overwhelming sepsis of the patient

19. The common procedures are
• Ileocecal resection, the commonest for CD
• Segemental resections of small or large bowel
• Colectomy and ileocecal anastomosis
• Subtotal colcetomy and ileostomy
• Temorary loop ileostomy
• sticturoplasty

20. Image

21. Infections of small bowel
• Compylobacteriosis , infection with gram
negative rods called Compylobeacter Jejuni,
• Causes diarrhaoe and abdomina pain may
resemble acute abdomen,
• There may be rectal bleeding and ulceration
similar to UC
• Treatment is supportive as the condition is self
limiting.

22. • Yersiniosis , caused by Yersinia Enterocolitica,
a gram –ve rod , it can infect the terminal
ileum, colon, mesentery lymph nodes, and
appendix,
• It presents with fever, abdominal pain
• Diagnosis made on stool culture
• Treated with chloramphenicol.

23. • Paratyphoid, caused by Salmonella
Paratyphoid, a gram –ve rods,
• Common causes mild self limiting
gastroenteritis.
• Presents with fever, diarrhae , headache,
• When severe , hospital admission, iv fluids and
antibiotic may be required,

24. • Typhoid fever, caused by salmonella typhi,
presents with abdominal pain, distension over 10
days incubation period, in 2nd week there may be
splenomegaly, rashes rose spots due vascullitis,
• Diagnosis made on blood or stool culture,
• There may be systemic dissemination of the
sepsis , with septic arthritis, meningitis,
encephalitis, DIC , pancreatitis, and osteomyelitis.

25. • Perforation of the terminal ileum may occur in
the 3rd week of illness and may be the 1st sign
of the disease,
• Perforation is longitudinal to long axis of the
bowel, needs surgery , washing and repair of
the defect, resection is avoided in these
settings.

26. • Tuberculosis: like CD effects any part of the GI
tract from mouth to anus,
• Commonly effects the terminal ileum,
proximal colon and peritoneum.

27. • There are two principal TB presentations,
• Ulcerative TB, arising secondary to pulmonary
TB due swallowing to TB bacilli, ulcerations lie
transversely, and overlying mucosa is
thickened
• Presents with diarrhea, wt loss, subacute
obstruction, or even perforation,
• Treatment is with ATT

28. • Hyperplastic TB:
• Caused by ingestion of the organism, effects
the terminal ileum, leads to fiberosis,
thickening and narrowing of the lumen .
• Presents with ill health, anemian wt loss, mass
in the RIF.
• DD include carcinoma, CD, Lymphoma and
Actinomycosis, snd appendicular mass.

29. • Diagnosed with small bowel anema or follow
through,
• Treated with ATT if no obstructive features
and resection if there are obstructive
symptoms, or diagnosis in doubt.

30. Image

31. • Actinomyceosis , caused by Actinomycesis
Israeli, a rare disease, follows routinely done
perforated appendix, with discharging sinus,
over the rt side of the abdomen, may spread
to retroperitoneal space and in contrast to TB ,
no mesenteric LN involvement.
• Treatment is with penicillins in high dose in
longer period.

32. Tumours of small bowel
• Benign tumours’
• Include adenoma, leimyoma, and fiberoma,
they are found incidentally during surgery for
other reasons, may cause, bleeding
obstruction or intussception,

33. Peutz-Jeghers syndrome
• Autosomal dominant disease, characterized by
pigmentation of mouth and lips with
hamartomatous polyps on the small and large
bowel. Melanin spots may be on digits and
perianal skin.
• Treatment is follow up and removal
endoscopical or surgically if they cause
concern

34. Image

35. Malignant tumours
• Adenocarcimona, a rare tumour but
commonest in small bowel cancers, presents
late and diagnosed incidentally when
operated for small bowel obstruction.

36. Large intestine
• Anatomy :
• Begins at ileocecal valve, ends at anus,
devided into cecum, ascending colon,
transverse colon, descending colon, sigmoid
and rectum,
• The colon is differentiated fron the small
bowel by the appendices apiploice and tenia
coli,

37. Blood supply
SMA supplies from cecum to transverse colon,
and the rest is supplied by the IMA,

38. Anatomy

39. Physiology
• Principal function is absortion of water,
1000ml reaches the colon and only 200 ml is
lost in the feces,

40. Tumours of the colon,
• Polyp means any protrusion of mucosa, may
be solitary, multiple or part of polyposis
syndrome,

41. Classification of polyps
Inflammatory polyps Seen in inflammatory conditions like UC
metaplastic Metaplastic or hyperplastic
Hamartomatous Peutz-Jeghar’s syndrome
Juvenile
Neoplastic Edenoma
tubular
vilous
mixed
Adenocarcinoma- carcinoids

42. Familial Adenomatous Polyposis
• FAP defined as the presence of more than 100
polyps, with duodenal adenoma and
extraintestinal manifestation,
• An autosomal dominat condition , carries
100% of malignancy transformation,

43. Features
• Polyps are seen at the age of 15 yrs on
sigmoidoscopy, carcinoma develops 10-20 yrs
after development of polyps,
• If diagnosis is made at 15 yrs or below is
deferred before 17 yrs unless symptoms
develop,

44. Treatment
• The aim of treatment is to prevent
development of cancer ,
• The options are :
• Colectomy and ileorectal anastomosis
• Proctocolectomy and ileoanal pouch
• Total proctectomy and end ileostmy

45. • The patients are young and likely to avoid
permanent ileostomy,

46. Hereditary nonpolyposis colorectal
cancer
• Characterized by increased risk of colorectal
cancer, an autosomal dominant condition
caused by mutation of DNA mismatch repair,
• The risk of developing Ca is 80% at around 45
yrs of age

47. Diagnosis
• HNPCC diagnosed by genetic testing and
Amsterdam Criteria, :
• Three or more family relatives with NHPCC
cancer diagnosis
• Two successive affected generation
• At least one diagnosed before 50 yrs
• FAP excluded
• Tumour proven with histopathology

48. Colorectal cancer
• The 2nd most common cause of death ,
• 1/3 occur in the rectum and 2/3 in the colon

49. Etiology
• Genetic mutations like APC gene, K ras, p53
gene, nd DCC gene.
• Environmental,
• Diet
• Smoking
•

50. The spread of colorectal ca
• Local
• Lymphatic
• Hematogenous
• Tranceolomic

51. Staging of colorectal ca
• Aimed to predict prognosis and guide
adjuvant therapy,
• There are two commonly used systemes , the
Duke’s classification and TNM system

52. Duke’s system
• A – invading but not breaching muscularis
propria
• B- breaching the muscularis but not involving
the lymph nodes
• C – lymph node involved
• D – distant metastatic disease

53. TNM system
• T1 –into submucosa
• T2 – into muscularis propria
• T3 – into perirectal fat but not breaching the
serosa
• T4 – breaches serosa or adjacent organs

54. • N0- no nodes involved
• N1 – 1-3 nodes involved
• N2 – 4 or more nodes
• M0 – no distant mets
• M1 – distant mets present

55. Features
• Anemia
• Altered bowel habits
• Bleeding per rectum
• Mass
• Obstructive symtoms

56. Investigations
• Screening with fecal occult blood
• Colonoscopy, flexible sigmoidoscopy or
colonoscopy, upto cecum can be seen , 120
cm long instrument, needs colon preparation,
• Barrium anema has been traditionally used to
diagnose colonic cancer , appears apple core

61. • Barrium anema is less invasive as compared to
colonoscopy but does not have the ability to
take biopsy or remove polyps , it can also miss
early lesions .

62. • Spiral ct of the chest , abdomen and pelvis is
the standard staging for CRC,
• MRI is more commonly used for rectal tumors.

63. Surgery for CRC
• Preparation comprises bowel preparation,
antithrombotic stocking, subcutaneous
heparin for prophylaxis,
• Antibiotic cover
• Careful counseling regarding stoma if need
arises.

64. Operations
• The aim is to remove the primary tumour with
the intentions of curative resection
• Right hemicolectomy, used for cecal and
ascending colon tumurs ,

66. • Extended right hemicolectomy, used for
hepatic flexure and proximal transverse colon
tumors .

68. • Left hemicolectomy , used for left colonic
tumors,

69. • Laparoscopic surgery , increasing interest
these days, reports of port site recurrence are
equavocal, the benefits are less infection
rates, early recovery,
• It has limitations of specemen retreval and
intracorporeal anastomosis.

70. Chemotherapy
• Neoadjuvent roles are not clear , but there is
clear evidence of adjuvent therapy for node
positive patients after surgery .

71. Ulcerative colitis
• Effects the rectum and the colon
• Disease of middle age
• Effects male and female equally,
• Characterised by submucosal inflammation of
the mucosa and submucosa,

72. Severity of UC
• Mild UC: less than 4 stools per day, no
systemic toxicity, with or without bleeding
• Moderate UC: 4-6 stools per day , fever,
abdominal pain, and moderate systemic
toxicity,
• Severe UC: more than 6 stools, tackycardia,
fever, raised inflammatory markers,
hypoalbumenia,

73. • Fulminant UC: more than10 stools , fever,
sepsis, continues bleeding,hypoalbumenemia,
abdominal tenderness and distension.

74. Investigation
• Colonoscopy and biopsy, it has the following
advantages:
• Establishes the diagnosis
• Distingueshes between UC and CD may be
difficult
• To monitor the response to treatment
• To rule out malignancy tranformation

75. • Plain x ray: may show toxic megacolon, a
serious complication and high risk of
perforation , seen in severe/ fullmenant forms
of UC,
• BA shows featureless colon, though replaced
by Ct scan,

77. Treatment of UC
• Medical therapy, 5ASA, corticosteroids,
cyclosporine, and azathioprine are all used to
control the disease, infliximab isalso used.

78. Indications for surgery,
• The greatest risk of surgery is during first year of
diagnosis
• The indications are:
• Severe / fullminent disease failing to medical therapy
• Steroid dependency
• Malignant change,
• Hemorrhage,
• Stenosis
• Non compliant to medical therapy,
• Chronic disease with poor control of symptoms.

79. Infections of large bowel
• Compylobacter , causes diarrhea and
abdominal pain, as already discussed,
• Others like emoebiasis, shegalla and
sellmonella are common as discussed in small
bowel, with similar course of illness,

80. Colonic diverticula
• Defined as hollow out pouching of mucosa,
they are classified as:
• Congenital, contain all 3 layers like mikals
diverticula,
• Aqcuired does not contain all 3 layers and
muscularis layer is missing

81. Complications of diverticular disease
• Diverticulitis
• Abscess
• Peritonitis
• Obstruction
• Fistulation
• haemorrhage

82. Features
• Lower abdominal pain
• Fever
• Distension and flatulance.

83. Investigations
• Plain x ray may show pneumoperitoneum
• Ct scan is the investigation of choice,
• Colonoscopy may be used also

84. Treatment
• Initial treatment is concervative, with pain
killers, iv antibiotics, and fluids resuscitation,
• Abscess may be drained percutaneously,
• Generalised peritonits and perforation needs
laparotomy and washout.

85. Colostomy
• Colostomy or ileostomy is defined as making a
planed opening in the colon, to divert flatus or
feces to abdominal wall , where they can be
collected in an external appliance

86. • The stomas:
• May be colostomy or ileostomy
• May be temporary or permanent
• An ileostomy spouted, colostomy flushed
• Ileostomy effluent liquid but solid effluent in
colostomy
• Ileostomy more problems with fluid and
electrolyte disturbance
• Ileostomy in rt iliac fossa and colostomy on left
side

87. Stoma complications
• Skin irritation
• Prolapse
• Retraction
• Parastomal hernia
• Ischemia
• Bleeding
• Stenosis
• Fistulation

88. Stoma