smallintestineii-100306104807-phpapp02.pdf

Small Intestine
Small Intestine
James Taclin C. Banez,
James Taclin C. Banez, MD,
MD,
FPCS, FPSGS, DPBS,DPSA
FPCS, FPSGS, DPBS,DPSA

Small Intestine
Small Intestine
one of the most important organs for
one of the most important organs for
immune defense
immune defense
largest endocrine organ of the body
largest endocrine organ of the body
Starts from the pylorus and ends at the
Starts from the pylorus and ends at the
cecum
cecum
3 parts:
3 parts:
1.
1. Duodenum
Duodenum (20cm)
(20cm)
2.
2. Jejunum
Jejunum (100 to 110cm)
(100 to 110cm)
3.
3. Ileum
Ileum (150 to 160 cm)
(150 to 160 cm)

Anatomy
Anatomy
Has plicae circulares or valves of
Has plicae circulares or valves of
Kerkring
Kerkring
B.
B. Duodenum:
Duodenum:
 Retro-peritoneal
Retro-peritoneal
 Supplied by the celiac artery & SMA
Supplied by the celiac artery & SMA
C.
C. Jejunum:
Jejunum:
 Occupies upper left of the abdomen
Occupies upper left of the abdomen
 Thicker wall and wider lumen than the
Thicker wall and wider lumen than the
ileum
ileum
 Mesentery has less fat and forms only
Mesentery has less fat and forms only
1-2 arcades
1-2 arcades
D.
D. Ileum:
Ileum:
 Occupies the lower right; has more fat
Occupies the lower right; has more fat
and forms more arcades
and forms more arcades
 Contains
Contains Payer’s patches
Payer’s patches
 Ileum & jejunum is supplied by the SMA
Ileum & jejunum is supplied by the SMA

Function
Function
A.
A. Digestion & Absorption:
Digestion & Absorption:
B.
B. Endocrine Function:
Endocrine Function:
– Secretes numerous hormones involved in GIT
Secretes numerous hormones involved in GIT
function.
function.
1.
1. Secretin
Secretin
2.
2. Cholecystokenin
Cholecystokenin
3.
3. Gastric inhibitory peptide
Gastric inhibitory peptide
4.
4. Enteroglucagon
Enteroglucagon
5.
5. Vasoactive intestinal peptide
Vasoactive intestinal peptide
6.
6. Motilin
Motilin
7.
7. Bombesin
Bombesin
8.
8. Somatostatin
Somatostatin
9.
9. Neurotensin
Neurotensin

Function
Function
A.
A. Immune function:
Immune function:
1.
1. Major source of
Major source of IgA
IgA
2.
2. Integrity of the GUT wall
Integrity of the GUT wall prevents bacterial
prevents bacterial
translocation into the wall of the intestine
translocation into the wall of the intestine
and abdominal cavity which can lead to
and abdominal cavity which can lead to
sepsis
sepsis
3.
3. Gut associated lymphoid tissue
Gut associated lymphoid tissue – part of the
– part of the
immune defense system which clears the
immune defense system which clears the
abdominal cavity of pathogenic bacteria
abdominal cavity of pathogenic bacteria
found in
found in Peyer’s patches
Peyer’s patches

Small Bowel Surgical Lesions
Small Bowel Surgical Lesions
1.
1. Small bowel obstruction:
Small bowel obstruction:
a.
a. Mechanical
Mechanical
b.
b. Ileus
Ileus
2.
2. Small bowel infection
Small bowel infection
3.
3. Chronic inflammation
Chronic inflammation
4.
4. Neoplasm
Neoplasm
5.
5. Diverticula
Diverticula
6.
6. Ischemic enteritis
Ischemic enteritis
7.
7. Short bowel syndrome
Short bowel syndrome

SMALL BOWEL
SMALL BOWEL
OBSTRUCTION
OBSTRUCTION

Small Bowel Obstruction
Small Bowel Obstruction
Causes of
Causes of Mechanical Obstruction
Mechanical Obstruction:
:
Post-operative adhesion
Post-operative adhesion (75%)
(75%)
Midgut volvulous
Midgut volvulous
Hernias
Hernias
Crohn’s disease
Crohn’s disease
Neoplasm (primary or extrinsic compression or
Neoplasm (primary or extrinsic compression or
invasion)
invasion)
Superior mesenteric artery syndrome
Superior mesenteric artery syndrome
(compression of transverse duodenum)
(compression of transverse duodenum)

Midgut Volvulous
Midgut Volvulous

Pathophysiology:
Pathophysiology:
Accdg. to it’s anatomical relationship to the
Accdg. to it’s anatomical relationship to the
intestinal wall:
intestinal wall:
1.
1. Intraluminal
Intraluminal ( foreign bodies, gallstone, and
( foreign bodies, gallstone, and
meconium)
meconium)
2.
2. Intramural
Intramural (neoplasm, Crohn’s, hematomas)
(neoplasm, Crohn’s, hematomas)
3.
3. Extrinsic
Extrinsic (adhesion, hernias & carcinomatosis)
(adhesion, hernias & carcinomatosis)

Classify Accdg to Degree of
Classify Accdg to Degree of
Obstruction
Obstruction
Partial small-bowel obstruction
Partial small-bowel obstruction –
–
passage of gas and fluid.
passage of gas and fluid.
Complete small-bowel obstruction
Complete small-bowel obstruction
(obstipation)
(obstipation)
– Closed loop obstruction
Closed loop obstruction (obstructed
(obstructed
proximal and distal) ex. Volvulus
proximal and distal) ex. Volvulus
Strangulated bowel obstruction
Strangulated bowel obstruction

Manifestation:
Manifestation:
colicky abdominal pain
colicky abdominal pain
nausea / vomiting
nausea / vomiting
obstipation
obstipation
abdominal distention
abdominal distention
hyperactive bowel sound / hypoactive BS
hyperactive bowel sound / hypoactive BS
signs of dehydration (sequestration of fluid in
signs of dehydration (sequestration of fluid in
bowel wall and lumen as well as poor oral
bowel wall and lumen as well as poor oral
intake)
intake)
lab. findings:
lab. findings:
hemoconcentration
hemoconcentration
fluid & electrolyte imbalance
fluid & electrolyte imbalance
leucocytosis
leucocytosis

Manifestation:
Manifestation:
Features of Strangulated obstruction
Features of Strangulated obstruction:
:
1.
1. tachycardia
tachycardia
2.
2. localized abd. tenderness
localized abd. tenderness
3.
3. fever
fever
4.
4. marked leucocytosis
marked leucocytosis
5.
5. acidosis
acidosis
6.
6. lab result:
lab result:
-
- elevated serum amyase, lipase, LDH,
elevated serum amyase, lipase, LDH,
phosphate and potassium
phosphate and potassium

Goals in its diagnosis:
Goals in its diagnosis:
distinguish between mechanical obstruction
distinguish between mechanical obstruction
from ileus
from ileus
whether it is partial or complete obstruction
whether it is partial or complete obstruction
differentiate between simple and
differentiate between simple and
strangulating obstruction
strangulating obstruction
determine the etiology
determine the etiology

Diagnosis:
Diagnosis:
1.
1. Clinical history & PE
Clinical history & PE
2.
2. Radiological
Radiological
examination:
examination:
a.
a. FPA (supine and
FPA (supine and
upright)
upright)
Triad:
Triad:
dilated small bowel (>3cm )
dilated small bowel (>3cm )
air-fluid levels seen in
air-fluid levels seen in
upright
upright
paucity of air in the colon
paucity of air in the colon

SMALL BOWEL OBSTRUCTION
SMALL BOWEL OBSTRUCTION
(Air Fluid Level)
(Air Fluid Level)

Air-fluid level:
Air-fluid level:
 Gas – due to swallowed air
Gas – due to swallowed air
 Fluid – a) swallowed fluid
Fluid – a) swallowed fluid
b) gastrointestinal
b) gastrointestinal
secretion
secretion
(increase epithelial water
(increase epithelial water
secretion).
secretion).
Bowel distention /
Bowel distention /
elevated intramural
elevated intramural
pressure ---> ischemia
pressure ---> ischemia
------> necrosis.
------> necrosis.
(strangulated bowel
(strangulated bowel
obstruction)
obstruction)

Diagnosis:
Diagnosis:
a.
a. CT scan
CT scan (90% sensitive / 90% specific)
(90% sensitive / 90% specific)
– Findings of small bowel obstruction:
Findings of small bowel obstruction:
a.
a. Discrete
Discrete transition zone
transition zone
b.
b. Intra-luminal contrast unable to passed beyond the
Intra-luminal contrast unable to passed beyond the
transition zone
transition zone
c.
c. Colon containing little gas or fluid
Colon containing little gas or fluid
− Strangulation is suggested:
Strangulation is suggested:
a.
a. Thickening of the bowel wall
Thickening of the bowel wall
b.
b. Pneumatosis intestinalis
Pneumatosis intestinalis
c.
c. Portal venous gas
Portal venous gas
d.
d. Mesentery haziness
Mesentery haziness
e.
e. Poor uptake of intravenous contrast into the wall of the
Poor uptake of intravenous contrast into the wall of the
affected bowel
affected bowel
− Limitation:
Limitation: unable to detect partial intestinal
unable to detect partial intestinal
obstruction
obstruction (<50% sensitivity)
(<50% sensitivity)

Treatment:
Treatment:
1.
1. Correct fluid & electrolyte imbalance
Correct fluid & electrolyte imbalance:
:
– Isotonic fluid
Isotonic fluid
– Monitor resuscitation (foley catheter/CVP)
Monitor resuscitation (foley catheter/CVP)
2.
2. NPO / TPN
NPO / TPN
3.
3. Broad spectrum antibiotic
Broad spectrum antibiotic (due to bacterial
(due to bacterial
translocation)
translocation)
4.
4. Placed NGT
Placed NGT to decompress the stomach and
to decompress the stomach and
decrease nausea, distention and risk of
decrease nausea, distention and risk of
aspiration
aspiration
5.
5. Expeditious celiotomy
Expeditious celiotomy (to minimize risk of
(to minimize risk of
strangulation).
strangulation).
– Type of operation based on operative finding
Type of operation based on operative finding
causing intestinal obstruction
causing intestinal obstruction

Ileus / Pseudo-Obstruction
Impaired intestinal motility
Impaired intestinal motility
Most common cause of delayed discharge
Most common cause of delayed discharge
following abdominal operations
following abdominal operations
Temporary and reversible
Temporary and reversible

Etiologies:
Etiologies:
2.
2. Abdominal surgery
Abdominal surgery
3.
3. Infection & inflammation (sepsis/peritonitis)
Infection & inflammation (sepsis/peritonitis)
4.
4. Electrolyte imbalance (Hypo K, Mg & Na)
Electrolyte imbalance (Hypo K, Mg & Na)
5.
5. Drugs (anticholinergic, opiates)
Drugs (anticholinergic, opiates)
6.
6. Visceral myopathies (degeneration/fibrosis of
Visceral myopathies (degeneration/fibrosis of
smooth muscle)
smooth muscle)
7.
7. Visceral neuropathies (degenerative disorders of
Visceral neuropathies (degenerative disorders of
myenteric & submucosal plexuses)
myenteric & submucosal plexuses)

Symptoms:
Symptoms:
1.
1. Inability to tolerate solid & liquid by
Inability to tolerate solid & liquid by
mouth
mouth
2.
2. Nausea/vomiting
Nausea/vomiting
3.
3. Lack of flatus & bowel movements
Lack of flatus & bowel movements
4.
4. Diminished or absent bowel sound
Diminished or absent bowel sound
5.
5. Abdominal pain and distention
Abdominal pain and distention

Diagnosis:
Diagnosis:
1.
1. History of recent abdominal surgery
History of recent abdominal surgery
2.
2. Discontinue opiates
Discontinue opiates
3.
3. Serum electrolyte determination
Serum electrolyte determination
4.
4. CT scan better than FPA in postoperative
CT scan better than FPA in postoperative
setting to exclude presence of abscess or
setting to exclude presence of abscess or
mechanical obstruction
mechanical obstruction

Therapy:
Therapy:
1.
1. NPO, if prolong TPN is required
NPO, if prolong TPN is required
2.
2. NGT to decompress the stomach
NGT to decompress the stomach
3.
3. Correct fluid & electrolyte imbalance
Correct fluid & electrolyte imbalance
4.
4. Give
Give ketorolac
ketorolac and reduce the dose of
and reduce the dose of
opioids
opioids

CHRONIC IDIOPATHIC
CHRONIC IDIOPATHIC
INFLAMMATORY
INFLAMMATORY
DISEASE OF THE
DISEASE OF THE
BOWEL
BOWEL

CROHN’S DISEASE
CROHN’S DISEASE
Regional, transmural, granulomatous
Regional, transmural, granulomatous
enteritis.
enteritis.
Chronic, idiopathic inflammatory dse
Chronic, idiopathic inflammatory dse
Ethnic groups ---> East Europe
Ethnic groups ---> East Europe
(Ashkenazi Jewish)
(Ashkenazi Jewish)
Female predominance, 2x higher smokers
Female predominance, 2x higher smokers
Familial association (30x in siblings / 13 x
Familial association (30x in siblings / 13 x
in 1
in 1st
st
degree relatives).
degree relatives).
Higher socioeconomic status
Higher socioeconomic status
Breast feeding
Breast feeding is protective
is protective

Etiology:
Etiology:
Unknown
Unknown
Hypothesis:
Hypothesis:
1.
1. Infectious:
Infectious: - Chlamydia / Pseudomonas /
- Chlamydia / Pseudomonas /
Mycobacterium paratuberculosis / Listeria
Mycobacterium paratuberculosis / Listeria
monocytogenesis / Measles / Yersinia
monocytogenesis / Measles / Yersinia
enterocolitica
enterocolitica
2.
2. Immunologic abnormalities:
Immunologic abnormalities:
• Humeral & cell-mediated immune reactions against
Humeral & cell-mediated immune reactions against
gut cells.
gut cells.
3.
3. Genetic factors:
Genetic factors:
• Chromosome 16
Chromosome 16 (IBD1 --> NOD2)
(IBD1 --> NOD2)

Pathology:
Pathology:
Affect any portion of GIT:
Affect any portion of GIT:
– Small bowel alone (30%)
Small bowel alone (30%)
– Ileocolitis (55%)
Ileocolitis (55%)
– Colon alone (15%)
Colon alone (15%)
Hallmark
Hallmark – focal,
– focal,
transmural inflammation of
transmural inflammation of
the intestine
the intestine
Earliest sign
Earliest sign -->
--> aphthous
aphthous
ulcers
ulcers surrounded by halo
surrounded by halo
erythema over a non-
erythema over a non-
caseating granuloma.
caseating granuloma.

CHRON’S DISEASE
CHRON’S DISEASE

Pathology:
Pathology:
As the aphthous ulcer enlarge
As the aphthous ulcer enlarge
and coalesce transversely
and coalesce transversely
forming
forming cobblestone
cobblestone
appearance.
appearance.
Advanced dse
Advanced dse ---> transmural
---> transmural
inflammation. This results to
inflammation. This results to
COMPLICATIONS
COMPLICATIONS
– adhesions to adjacent bowel,
adhesions to adjacent bowel,
– stricture formation (fibrosis),
stricture formation (fibrosis),
– intra-abdominal abscesses,
intra-abdominal abscesses,
– fistula or free perforation
fistula or free perforation
(peritonitis)
(peritonitis)
Skip lesions and w/ fat
Skip lesions and w/ fat
wrapping
wrapping (encroachment of
(encroachment of
mesenteric fat onto the serosal
mesenteric fat onto the serosal
surface) -->
surface) --> pathognomonic
pathognomonic
for Crohn’s.
for Crohn’s.

ADVANCED CHRON’S DSE
ADVANCED CHRON’S DSE

CHRON’S DSE. ANAL
CHRON’S DSE. ANAL
FISTULA
FISTULA

Clinical Manifestation:
Clinical Manifestation:
Most common symptom:
Most common symptom:
1.
1. Abdominal pain
Abdominal pain
2.
2. Diarrhea
Diarrhea
3.
3. Weight loss
Weight loss
Other symptoms depends on type of complications:
Other symptoms depends on type of complications:
1.
1. obstruction (fibrosis)
obstruction (fibrosis)
2.
2. perforation (peritonitis, fistula, intraabdominal abscess)
perforation (peritonitis, fistula, intraabdominal abscess)
3.
3. toxic megacolon (marked colonic dilatation, adb. tenderness, fever
toxic megacolon (marked colonic dilatation, adb. tenderness, fever
& leukocytosis)
& leukocytosis)
4.
4. cancer (6x greater/more advanced---> poor prognosis)
cancer (6x greater/more advanced---> poor prognosis)
5.
5. perianal dse (fissure, fistula, stricture or abscess)
perianal dse (fissure, fistula, stricture or abscess)
Extra-intestinal manifestation:
Extra-intestinal manifestation:
– erythema nodosum & peripheral arthritis are correlated w/ severity
erythema nodosum & peripheral arthritis are correlated w/ severity
of intestinal inflammation.
of intestinal inflammation.

Diagnosis:
Diagnosis:
1.
1. Endoscopy
Endoscopy
(esophagogastroduodenoscopy (EGD)
(esophagogastroduodenoscopy (EGD)
/colonoscopy) w/ biopsy.
/colonoscopy) w/ biopsy.
2.
2. Barium enema / intestinal series
Barium enema / intestinal series
3.
3. Enteroclysis
Enteroclysis (small bowel) more
(small bowel) more
accurate
accurate
4.
4. CT scan – to reveal intra-abd. abscesses
CT scan – to reveal intra-abd. abscesses

Treatment:
Treatment:
I.
I. Medical:
Medical:
– Intravenous fluids
Intravenous fluids
– NGT to rest GIT (elemental diet/TPN)
NGT to rest GIT (elemental diet/TPN)
– Medications:
Medications:
1.
1. to relieve diarrhea
to relieve diarrhea
2.
2. relieve pain
relieve pain
3.
3. control infection (antibiotic)
control infection (antibiotic)
4.
4. Anti-inflammatory ( aminosalicylates, corticosteroid,
Anti-inflammatory ( aminosalicylates, corticosteroid,
immunomodulators – azathioprime 6-
immunomodulators – azathioprime 6-
mercaptopurine and cyclosporine)
mercaptopurine and cyclosporine)

I.
I. Surgical:
Surgical:
– Indicated if:
Indicated if:
with complications
with complications
– Types:
Types:
Segmental resection w/ primary anastomosis:
Segmental resection w/ primary anastomosis:
– Microscopic evidence of the dse at the resection
Microscopic evidence of the dse at the resection
margin does not compromise a safe anastomosis,
margin does not compromise a safe anastomosis,
hence, a frozen section is unnecessary.
hence, a frozen section is unnecessary.
Stricturoplasty
Stricturoplasty
Bypass procedures (gastrojejunostomy)
Bypass procedures (gastrojejunostomy)

Tuberculous Enteritis:
In developing and under develop countries
In developing and under develop countries
Resurgence in develop countries due to:
Resurgence in develop countries due to:
– AIDS epidemic
AIDS epidemic
– Influx of Asian migrants
Influx of Asian migrants
– Use of immunosuppressive agents
Use of immunosuppressive agents
Forms:
Forms:
– Primary infection
Primary infection (caused by M. tuberculosis
(caused by M. tuberculosis
bovine from ingested milk)
bovine from ingested milk)
– Secondary infection
Secondary infection (swallowing bacilli from
(swallowing bacilli from
active pulmonary TB)
active pulmonary TB)

Tuberculous
Tuberculous
Enteritis
Enteritis

Patterns:
Patterns:
1.
1. Hypertrophic – causes stenosis or obstruction
Hypertrophic – causes stenosis or obstruction
2.
2. Ulcerative – diarrhea and bleeding
Ulcerative – diarrhea and bleeding
3.
3. Ulcero-hypertrophic
Ulcero-hypertrophic
Treatment:
Treatment:
– Chemotherapy (given 2 wks prior to surgery up
Chemotherapy (given 2 wks prior to surgery up
to 1 yr).
to 1 yr).
Rifampicin
Rifampicin
Isoniazid
Isoniazid
Ethambutol
Ethambutol
– Surgery (perforation, obstruction, hemorrhage).
Surgery (perforation, obstruction, hemorrhage).

Typhoid enteritis:
Typhoid enteritis:
Caused by Salmonella typhi
Caused by Salmonella typhi
Diagnosis:
Diagnosis:
– Culture from blood or feces
Culture from blood or feces
– Agglutinins against O and H antigen
Agglutinins against O and H antigen
Treatment:
Treatment:
– Medical:
Medical:
Chloramphenicol / trimethropin-sulfamethoxazole /
Chloramphenicol / trimethropin-sulfamethoxazole /
amoxycillin / quinolones
amoxycillin / quinolones
– Surgical:
Surgical:
perforations / hemorrhage
perforations / hemorrhage
Segmental resection (w/ primary anastomosis or
Segmental resection (w/ primary anastomosis or
ileostomy)
ileostomy)

DIVERTICULAR
DIVERTICULAR
DISEASE OF THE
DISEASE OF THE
SMALL BOWEL
SMALL BOWEL

Meckels Diverticulum
Most prevalent congenital anomaly of GIT
Most prevalent congenital anomaly of GIT
True diverticula
True diverticula
60% contains heterotopic mucosa:
60% contains heterotopic mucosa:
– Gastric mucosa
Gastric mucosa (60%)
(60%)
– Pancreatic acini
Pancreatic acini
– Brunner’s gland
Brunner’s gland
– Pancreatic islets
Pancreatic islets
– Colonic mucosa
Colonic mucosa
– Endometriosis
Endometriosis
– Hepatobiliary tissues
Hepatobiliary tissues

Rules of Twos:
Rules of Twos:
– 2% prevalence
2% prevalence
– 2:1 female
2:1 female
predominance
predominance
– Location 2 feet
Location 2 feet
proximal to the
proximal to the
ileocecal valve in
ileocecal valve in
adults.
adults.
– Half of those are
Half of those are
asymptomatic are
asymptomatic are
younger than 2 years
younger than 2 years
of age.
of age.

Complications:
Complications:
– Bleeding (most common
Bleeding (most common)
) – due to ileal
– due to ileal
mucosal ulceration.
mucosal ulceration.
– Obstruction:
Obstruction:
Volvulus of the intestine
Volvulus of the intestine
Entrapment of intestine by the mesodiverticular
Entrapment of intestine by the mesodiverticular
band
band
Intussuception
Intussuception
Stricture due to diverticulitis
Stricture due to diverticulitis
As Littre’s hernia – found in inguinal or femoral
As Littre’s hernia – found in inguinal or femoral
hernia sac.
hernia sac.

Clinical manifestation:
Clinical manifestation:
1.
1. Asymptomatic
Asymptomatic
2.
2. 4% symptomatic due to complication
4% symptomatic due to complication
50% are younger than 10y/o
50% are younger than 10y/o
Symptomatic (Bleeding > obstruction > diverticulitis)
Symptomatic (Bleeding > obstruction > diverticulitis)
a.
a. bleeding is 50% in children and pt younger 18y/o
bleeding is 50% in children and pt younger 18y/o
bleeding is rare in pt older than 30y/o
bleeding is rare in pt older than 30y/o
b.
b. intestinal obstruction most common in adult
intestinal obstruction most common in adult
c.
c. diverticulitis
diverticulitis is indistinguishable to appendicitis
is indistinguishable to appendicitis
Neoplasm seen: ---
Neoplasm seen: ---> Carcinoid
> Carcinoid

Diagnosis:
Diagnosis:
For asymptomatic usually discovered as an
For asymptomatic usually discovered as an
incidental findings in radiographic imaging,
incidental findings in radiographic imaging,
endoscopy, or intraoperatively.
endoscopy, or intraoperatively.
2.
2. Enteroclysis
Enteroclysis has 75% accuracy but not
has 75% accuracy but not
applicable during acute cases.
applicable during acute cases.
3.
3. Radionuclide scans
Radionuclide scans (99m Tc-pertechnate)
(99m Tc-pertechnate)
for ectopic gastric mucosa or in active
for ectopic gastric mucosa or in active
bleeding
bleeding
4.
4. Angiography
Angiography to localize site of bleeder
to localize site of bleeder

Management:
Management:
1.
1. Diverticulectomy:
Diverticulectomy:
diverticulitis
diverticulitis
obstruction (w/ removal of associated band)
obstruction (w/ removal of associated band)
2.
2. Segmental resection for:
Segmental resection for:
Bleeding
Bleeding
If with tumor
If with tumor

Acquired Small Bowel
Diverticula
Diverticula
Epidemiology:
Epidemiology:
False diverticula
False diverticula
Increases w/ age;
Increases w/ age;
seldom seen < 40y/o
seldom seen < 40y/o
(50-70y/o)
(50-70y/o)
Duodenum:
Duodenum:
Most common; usually
Most common; usually
adjacent to ampulla
adjacent to ampulla
Called
Called periampullary,
periampullary,
juxtapapillary, or peri-
juxtapapillary, or peri-
Vaterian diverticula
Vaterian diverticula
75% arise in the medial
75% arise in the medial
wall
wall

Diverticula
Diverticula
Jejunoileal:
Jejunoileal:
80% - jejunum
80% - jejunum
(tends to be large
(tends to be large
and multiple)
and multiple)
15% - ileum (tends
15% - ileum (tends
to be small and
to be small and
solitary)
solitary)
5% - both ileum and
5% - both ileum and
jejunum
jejunum

Acquired Small Bowel Diverticula
Pathophysiology:
Pathophysiology:
– Abnormalities of intestinal smooth muscle
Abnormalities of intestinal smooth muscle
or dysregulated motility leading to herniation.
or dysregulated motility leading to herniation.
– Associated w/:
Associated w/:
Bacterial overgrowth
Bacterial overgrowth – vit B12 deficiency,
– vit B12 deficiency,
megaloblastic anemia, malabsorption &
megaloblastic anemia, malabsorption &
steatorrhea
steatorrhea
Periampullary duodenal diverticula
Periampullary duodenal diverticula:
:
– Obstructive jaundice
Obstructive jaundice
– Pancreatitis
Pancreatitis
Intestinal obstruction
Intestinal obstruction due to compression of
due to compression of
adjacent bowel
adjacent bowel

Diagnosis:
Diagnosis:
Best diagnosed w/
Best diagnosed w/ enteroclysis
enteroclysis
Treatment:
Treatment:
1.
1. Asymptomatic ---> left alone
Asymptomatic ---> left alone
2.
2. Bacterial overgrowth --> antibiotics
Bacterial overgrowth --> antibiotics
3.
3. Bleeding and obstruction ---> segmental
Bleeding and obstruction ---> segmental
resection for jejunoileal diverticula.
resection for jejunoileal diverticula.

Treatment:
Treatment:
Diverticulectomy
Diverticulectomy if located
if located in the duodenum
in the duodenum
For medial duodenal diverticula ---> do lateral
For medial duodenal diverticula ---> do lateral
duodenotomy and oversewing of the bleeder
duodenotomy and oversewing of the bleeder
May invaginate the diverticula into the
May invaginate the diverticula into the
duodenal lumen then excised
duodenal lumen then excised
If related to the ampulla ---> extended
If related to the ampulla ---> extended
sphincterotoplasty
sphincterotoplasty
If perforated ----> excised and closed w/
If perforated ----> excised and closed w/
omental patch; if inflammed ---> placed
omental patch; if inflammed ---> placed
gastrojejunostomy
gastrojejunostomy

MESENTERIC
MESENTERIC
ISCHEMIA
ISCHEMIA

Mesenteric Ischemia
Mesenteric Ischemia
Clinical Syndrome:
Clinical Syndrome:
2.
2. Acute mesenteric ischemia
Acute mesenteric ischemia
Pathophysiology
Pathophysiology
Arterial embolus
Arterial embolus: (most common-50%; heart;
: (most common-50%; heart;
usually lodge distal to origin of the middle colic
usually lodge distal to origin of the middle colic
Arterial thrombosis
Arterial thrombosis: occlusion occurs at
: occlusion occurs at
proximal near it’s origin.
proximal near it’s origin.
Vasospasm
Vasospasm (nonocclusive mesenteric ischemia
(nonocclusive mesenteric ischemia
– NOMI): usually in critically-ill pt. receiving
– NOMI): usually in critically-ill pt. receiving
vasopressors.
vasopressors.
Venous thrombosis
Venous thrombosis: (5-15%) and 95% SMV
: (5-15%) and 95% SMV
– Primary – no etiologic factor identified
Primary – no etiologic factor identified
– Secondary – heritable or acquired coagulation disorder
Secondary – heritable or acquired coagulation disorder

Mesenteric Ischemia
Mesenteric Ischemia
Clinical Syndrome:
Clinical Syndrome:
2.
2. Chronic Mesenteric Ischemia:
Chronic Mesenteric Ischemia:
Develops insidiously allows for collateral
Develops insidiously allows for collateral
circulation to develop
circulation to develop
Rarely leads to infarction.
Rarely leads to infarction.
Usually due to
Usually due to arteriosclerosis
arteriosclerosis
Usually two mesenteric arteries are involved
Usually two mesenteric arteries are involved

Mesenteric Ischemia
Mesenteric Ischemia
Manifestation:
Manifestation:
A.
A. Acute mesenteric ischemia:
Acute mesenteric ischemia:
Severe abdominal pain out of proportion to the
Severe abdominal pain out of proportion to the
degree of abd. tenderness (hallmark)
degree of abd. tenderness (hallmark)
− Colicky at the mid-abdomen.
Colicky at the mid-abdomen.
Nausea / vomiting, diarrhea
Nausea / vomiting, diarrhea
abd. distention,peritonitis, passage bloody stool
abd. distention,peritonitis, passage bloody stool
B.
B. Chronic mesenteric ischemia:
Chronic mesenteric ischemia:
Postprandial abd. pain “food-fear”, (most common)
Postprandial abd. pain “food-fear”, (most common)

Mesenteric Ischemia
Mesenteric Ischemia
No laboratory test sensitive for
No laboratory test sensitive for
the detection of acute mesenteric
the detection of acute mesenteric
ischemia prior to the onset of
ischemia prior to the onset of
intestinal infarction.
intestinal infarction.
The presence of it’s hallmark
The presence of it’s hallmark
sign, is an indication for
sign, is an indication for
immediate celiotomy.
immediate celiotomy.

Mesenteric Ischemia
Mesenteric Ischemia
Angiography
Angiography –
–
most reliable; 74 –
most reliable; 74 –
100% sensitivity
100% sensitivity
and 100%
and 100%
specificity;
specificity;
– It is
It is gold standard
gold standard
for the diagnosis of
for the diagnosis of
arterial mesenteric
arterial mesenteric
ischemia.
ischemia.

Mesenteric Ischemia
Mesenteric Ischemia
CT scanning
CT scanning is used to:
is used to:
– Disorder other abd.
Disorder other abd.
condition causing abd. pain
condition causing abd. pain
– Evidence of occlusion or
Evidence of occlusion or
stenosis of mesenteric
stenosis of mesenteric
vasculature.
vasculature.
– Evidence of ischemia in
Evidence of ischemia in
the intestine & mesentery
the intestine & mesentery
– Test of choice for acute
Test of choice for acute
mesenteric venous
mesenteric venous
thrombosis
thrombosis

Mesenteric Ischemia
Mesenteric Ischemia
Treatment:
Treatment:
w/ signs of peritonitis -->
w/ signs of peritonitis -->
celiotomy check for
celiotomy check for
viability of the bowel:
viability of the bowel:
Necrotic ---->
Necrotic ---->
segmental
segmental
resection
resection
Questionable
Questionable
viability ---->
viability ---->
second look
second look
laparotomie
laparotomies
s

Mesenteric Ischemia
Mesenteric Ischemia
Surgical revascularization
(embolectomy / thrombectomy /
(embolectomy / thrombectomy /
mesenteric bypass).
mesenteric bypass).
 Not done if:
Not done if:
1.
1. segment is necrotic
segment is necrotic
2.
2. is too unstable patient
is too unstable patient
 Done pt diagnosed w/ emboli or thrombus-
Done pt diagnosed w/ emboli or thrombus-
induced acute mesenteric ischemia w/o signs of
induced acute mesenteric ischemia w/o signs of
peritonitis.
peritonitis.
 May give thrombolysis
May give thrombolysis (streptokinase,
(streptokinase,
urokinase
urokinase,
, recombinant tissue plasminogen
recombinant tissue plasminogen
activator).
activator). Useful only in partially occluded
Useful only in partially occluded
vessels and has given w/in 12 hrs. after onset of
vessels and has given w/in 12 hrs. after onset of
symptoms.
symptoms.

NEOPLASM OF THE
NEOPLASM OF THE
SMALL BOWEL
SMALL BOWEL

Neoplasm
Neoplasm
Rare:
Rare:
1.
1. Rapid transit time
Rapid transit time
2.
2. Local immune system of the small bowel mucosa
Local immune system of the small bowel mucosa
(IgA)
(IgA)
3.
3. Alkaline pH
Alkaline pH
4.
4. Relatively low concentration of bacteria; low
Relatively low concentration of bacteria; low
concentration of carcinogenic products of bacterial
concentration of carcinogenic products of bacterial
metabolism.
metabolism.
5.
5. Presence of mucosal enzymes (hydrolases) that
Presence of mucosal enzymes (hydrolases) that
destroy certain carcinogens
destroy certain carcinogens
6.
6. Efficient epithelial cellular apoptotic
Efficient epithelial cellular apoptotic
mechanisms
mechanisms that serve to eliminate clones
that serve to eliminate clones
harboring genetic mutation
harboring genetic mutation

Neoplasm
Neoplasm
50 – 60 y/o
50 – 60 y/o
Risk factors:
Risk factors:
1.
1. Red meat
Red meat
2.
2. Ingestion of smoked or cured foods
Ingestion of smoked or cured foods
3.
3. Crohn’s dse
Crohn’s dse
4.
4. Celiac sprue
Celiac sprue
5.
5. Hereditary nonpolyposis colorectal cancer
Hereditary nonpolyposis colorectal cancer
(HNPCC)
(HNPCC)
6.
6. Familial adenomatous polyposis
Familial adenomatous polyposis (FAD) – 100%
(FAD) – 100%
to develop
to develop duodenal CA
duodenal CA
7.
7. Peutz-Jeghers syndrome
Peutz-Jeghers syndrome

Neoplasm
Neoplasm
Symptoms:
Symptoms:
– Most are asymptomatic
Most are asymptomatic
– Symptoms:
Symptoms:
3.
3. Vague abdominal pain
Vague abdominal pain (epigastric discomfort, N/V,
(epigastric discomfort, N/V,
abd. pain, diarrhea).
abd. pain, diarrhea).
4.
4. Bleeding
Bleeding (hematochezia or hematemesis)
(hematochezia or hematemesis)
5.
5. Obstruction
Obstruction (intussuception, circumferencial growth,
(intussuception, circumferencial growth,
kinking of the bowel, intramural growth).
kinking of the bowel, intramural growth).
 Most common mode of presentation is
Most common mode of presentation is --->
--->
crampy abd. pain, distention, nausea /
crampy abd. pain, distention, nausea /
vomiting
vomiting
 Hemorrhage
Hemorrhage usually indolent 2
usually indolent 2nd
nd
common
common
mode of presentation
mode of presentation

Neoplasm
Neoplasm
Diagnosis:
Diagnosis:
– For most are asymptomatic it is rarely
For most are asymptomatic it is rarely
diagnosed preoperatively
diagnosed preoperatively
– Serological examination
Serological examination
Serum 5-hydroxyindole acetic acid (HIAA)
Serum 5-hydroxyindole acetic acid (HIAA) for
for
carcinoid.
carcinoid.
CEA
CEA associated w/ small intestinal
associated w/ small intestinal
adenocarcinoma but only if w/ liver metastasis.
adenocarcinoma but only if w/ liver metastasis.

Neoplasm
Neoplasm
Diagnosis:
Diagnosis:
– Radiological examination:
Radiological examination:
Enteroclysis
Enteroclysis (test of choice – 90% sensitivity)
(test of choice – 90% sensitivity)
UGIS w/ intestinal follow through
UGIS w/ intestinal follow through
CT scan
CT scan
Angiography / RBC scan --> bleeding lesions
Angiography / RBC scan --> bleeding lesions
– Endoscopy:
Endoscopy:
EGD (esophagus, gastric, and duodenum)
EGD (esophagus, gastric, and duodenum)
Colonoscopy
Colonoscopy

I.
I. Benign tumors:
Benign tumors:
Adenomas:
Adenomas: (most common benign neoplasm):
(most common benign neoplasm):
True adenomas:
True adenomas:
Associated w/ bleeding and obstruction
Associated w/ bleeding and obstruction
Usually seen in the
Usually seen in the ileum
ileum
Majority are asymptomatic
Majority are asymptomatic
Villous adenoma:
Villous adenoma:
Most common in the
Most common in the duodenum
duodenum
“
“soap bubble” appearance on contrast radiography
soap bubble” appearance on contrast radiography
No report of secretory diarrhea
No report of secretory diarrhea
Brunner’s gland adenoma
Brunner’s gland adenoma
In the
In the duodenum
duodenum
No malignant potential
No malignant potential
Mimic PUD
Mimic PUD

Benign tumors:
Benign tumors:
A.
A. Leiomyoma:
Leiomyoma:
Most common
Most common
symptomatic benign
symptomatic benign
lesion
lesion
Associated w/
Associated w/ bleeding
bleeding
Diagnosed by
Diagnosed by
angiography
angiography and
and
commonly located in the
commonly located in the
jejunum
jejunum
2 growth pattern:
2 growth pattern:
1.
1. Intramurally ---->
Intramurally ---->
obstruction
obstruction
2.
2. Both intramural and
Both intramural and
extramural
extramural (Dumbbell
(Dumbbell
shaped)
shaped)

Benign tumors:
Benign tumors:
A.
A. Lipoma:
Lipoma:
Most common in the
Most common in the
ileum
ileum
Causes obstruction
Causes obstruction
(lead point of an
(lead point of an
intussusception)
intussusception)
Bleeding due to ulcer
Bleeding due to ulcer
formation
formation
No malignant
No malignant
degeneration
degeneration

Benign tumors:
Benign tumors:
A.
A. Peutz-Jeghers
Peutz-Jeghers
Syndrome:
Syndrome:
– Inherited syndrome
Inherited syndrome
of:
of:
Mucocutaneous
Mucocutaneous
melatonic
melatonic
pigmentation
pigmentation (face,
(face,
buccal mucosa, palm,
buccal mucosa, palm,
sole, peri-anal area)
sole, peri-anal area)
Gastrointestinal
Gastrointestinal
polyp
polyp (enteric
(enteric
jejunum and ileum
jejunum and ileum
are most frequent
are most frequent
part of GIT followed
part of GIT followed
by colon, rectum and
by colon, rectum and
stomach).
stomach).

Benign tumors:
Benign tumors:
A.
A. Peutz-Jeghers
Peutz-Jeghers
Syndrome:
Syndrome:
– Symptoms:
Symptoms:
colicky abd. pain (due to
colicky abd. pain (due to
intermittent
intermittent
intussuception)
intussuception)
Hemorrhage
Hemorrhage
2.
2. Treatment:
Treatment:
Segmental resection of
Segmental resection of
the bowel causing
the bowel causing
obstruction or bleeding.
obstruction or bleeding.
Cure impossible due to
Cure impossible due to
widespread intestinal
widespread intestinal
involvement
involvement

I.
I. Malignant neoplasm:
Malignant neoplasm:
Histologic types:
Histologic types:
Tumor type
Tumor type Cell of origin
Cell of origin Frequency
Frequency Predominant
Predominant
Site
Site
adenocarcinoma
adenocarcinoma Epithelial cell
Epithelial cell 35 – 50%
35 – 50% Duodenum
Duodenum
carcinoid
carcinoid Enterochromaffin
Enterochromaffin
cell
cell
20 – 40%
20 – 40% Ileum
Ileum
lymphoma
lymphoma lymphocyte
lymphocyte 10 – 15%
10 – 15% Ileum
Ileum
GIST
GIST
(gastrointestinal
(gastrointestinal
stromal tumors)
stromal tumors)
? Interstitial cell
? Interstitial cell
of Cajal
of Cajal
10 – 15%
10 – 15% -
-

Malignant neoplasm:
Malignant neoplasm:
1.
1. Adenocarcinoma:
Adenocarcinoma:
Most common CA of
Most common CA of
small bowel
small bowel
Most common in
Most common in
duodenum and
duodenum and
proximal jejunum
proximal jejunum
Half involve the
Half involve the
ampulla of Vater.
ampulla of Vater.

Malignant neoplasm:
Malignant neoplasm:
1.
1. Carcinoid:
Carcinoid:
From
From Enterochromaffin cells
Enterochromaffin cells or
or
Kultchitsky cells
Kultchitsky cells
Arise from foregut, midgut & hindgut
Arise from foregut, midgut & hindgut
Appendix (46%) > Ileum (28%) >
Appendix (46%) > Ileum (28%) >
Rectum (17%)
Rectum (17%)

Malignant neoplasm:
Malignant neoplasm:
1.
1. Carcinoid:
Carcinoid:
Aggressive behavior than the appendiceal
Aggressive behavior than the appendiceal
carcinoid.
carcinoid.
 appendix – 3% metastasize; Ileum – 35% metastasize
appendix – 3% metastasize; Ileum – 35% metastasize
 Appendix – solitary; Ileum – 30% multiple
Appendix – solitary; Ileum – 30% multiple
25-50% w/ carcinoid tumor with liver metastasis
25-50% w/ carcinoid tumor with liver metastasis
develops
develops carcinoid syndrome
carcinoid syndrome.
.
 Secretes
Secretes serotonin, bradykinin and substance P
serotonin, bradykinin and substance P
1.
1. Diarrhea
Diarrhea
2.
2. Flushing
Flushing
3.
3. Hypotension
Hypotension
4.
4. tachycardia
tachycardia
5.
5. fibrosis of endocardium and valves of the right
fibrosis of endocardium and valves of the right
heart
heart.
.

Malignant neoplasm:
Malignant neoplasm:
1.
1. Lymphomas:
Lymphomas:
Most common
Most common
intestinal neoplasm
intestinal neoplasm
in children under
in children under
10y/o.
10y/o.
In adult = 10-15% of
In adult = 10-15% of
small bowel
small bowel
malignant tumors
malignant tumors
Most common
Most common
presentation
presentation
1.
1. intestinal
intestinal
obstruction
obstruction
2.
2. Perforation (10%)
Perforation (10%)

Malignant neoplasm:
Malignant neoplasm:
1.
1. Lymphomas:
Lymphomas:
Criteria of primary lymphomas of the small
Criteria of primary lymphomas of the small
bowel:
bowel:
1.
1. Absence of peripheral lymphadenopathy
Absence of peripheral lymphadenopathy
2.
2. Normal chest x-ray w/o evidence of
Normal chest x-ray w/o evidence of
mediastinal LN enlargement.
mediastinal LN enlargement.
3.
3. Normal WBC count and differential
Normal WBC count and differential
4.
4. At operation, the bowel lesion must
At operation, the bowel lesion must
predominate and the only nodes are
predominate and the only nodes are
associated w/ the bowel lesion
associated w/ the bowel lesion
5.
5. Absence of disease in the liver and spleen
Absence of disease in the liver and spleen

Treatment:
Treatment:
I.
I. For Benign lesions:
For Benign lesions:
– All symptomatic benign tumors should be
All symptomatic benign tumors should be
surgically resected or removed
surgically resected or removed
endoscopically (EGD / colonoscopy).
endoscopically (EGD / colonoscopy).
– Duodenal tumors:
Duodenal tumors:
 1 cm. ----> endoscopic polypectomy
1 cm. ----> endoscopic polypectomy
 2cm. ----> surgically resected (Whipples –
2cm. ----> surgically resected (Whipples –
located near the ampulla of Vater).
located near the ampulla of Vater).
 Duodenal adenomas
Duodenal adenomas w/ FAP shd undergo
w/ FAP shd undergo
Whipples for it is usually multiple and sessile
Whipples for it is usually multiple and sessile
and has
and has 100% degenerate to CA.
100% degenerate to CA.

Treatment:
Treatment:
I.
I. Malignant lesions:
Malignant lesions:
1.
1. Adenocarcinoma:
Adenocarcinoma:
 Wide local resection w/ it’s mesentery to
Wide local resection w/ it’s mesentery to
achieve regional lymphadenectomy
achieve regional lymphadenectomy
 Chemotherapy has no proven efficacy in the
Chemotherapy has no proven efficacy in the
adjuvant or palliative treatment of small-
adjuvant or palliative treatment of small-
intestinal adenoCA.
intestinal adenoCA.
2.
2. Small intestinal lymphoma:
Small intestinal lymphoma:
 For localized: segmental resection w/ adjacent
For localized: segmental resection w/ adjacent
mesentery
mesentery
 If w/ diffused involvement: -->chemotherapy
If w/ diffused involvement: -->chemotherapy
rather than surgery, is primary therapy
rather than surgery, is primary therapy

Treatment:
Treatment:
1.
1. Carcinoid:
Carcinoid:
• Segmental intestinal resection & regional
Segmental intestinal resection & regional
lymphadenectomy.
lymphadenectomy.
− <
< 1cm rarely has LN metastases
1cm rarely has LN metastases
− > 3cm 75 to 90% LN metastases
> 3cm 75 to 90% LN metastases
• 30% are multiple, hence entire small
30% are multiple, hence entire small
bowel shd be examined prior to surgery
bowel shd be examined prior to surgery.
.

Treatment:
Treatment:
1.
1. Carcinoid:
Carcinoid:
• If w/ metastatic lesions---> debulking,
If w/ metastatic lesions---> debulking,
associated w/ long-term survival &
associated w/ long-term survival &
amelioration of symptoms of carcinoid
amelioration of symptoms of carcinoid
syndrome
syndrome
• Chemotherapy: ---> 30 -50% response
Chemotherapy: ---> 30 -50% response
1.
1. Doxorubicin
Doxorubicin
2.
2. 5-fluorouracil
5-fluorouracil
3.
3. Streptozocin
Streptozocin
• Octreotide
Octreotide: - most effective for
: - most effective for
management of symptoms of carcinoid
management of symptoms of carcinoid
syndrome
syndrome

Treatment:
Treatment:
1.
1. Metastatic cancers:
Metastatic cancers:
Melanoma
Melanoma associated w/
associated w/
propensity for metastasis to
propensity for metastasis to
the small bowel.
the small bowel.
Palliative resection / bypass
Palliative resection / bypass
procedure
procedure
Systemic therapy depends on
Systemic therapy depends on
the responds of the primary
the responds of the primary
site.
site.

SHORT BOWEL
SHORT BOWEL
SYNDROME
SYNDROME

Short Bowel Syndrome
 Presence of
Presence of less than 200cm
less than 200cm of residual
of residual
small bowel in adult pts.
small bowel in adult pts.
 Functional definition: - insufficient
Functional definition: - insufficient
intestinal absorptive capacity results in
intestinal absorptive capacity results in
the clinical manifestations of:
the clinical manifestations of:
1.
1. Diarrhea
Diarrhea
2.
2. Dehydration
Dehydration
3.
3. malnutrition
malnutrition

Etiologies (adult):
Etiologies (adult):
2.
2. Acute mesenteric ischemia
Acute mesenteric ischemia
3.
3. Malignancy
Malignancy
4.
4. Crohn’s disease
Crohn’s disease
Etiologies (pediatric):
Etiologies (pediatric):
7.
7. Intestinal atresias
Intestinal atresias
8.
8. Volvulus
Volvulus
9.
9. Necrotizing enterocolitis
Necrotizing enterocolitis

Medical therapy:
Medical therapy:
– Mx of primary condition causing
Mx of primary condition causing
intestinal resection
intestinal resection
– Correct fluid & electrolyte imbalance
Correct fluid & electrolyte imbalance
due to severe diarrhea
due to severe diarrhea
– TPN, enteral nutrition is gradually
TPN, enteral nutrition is gradually
introduced, once ileus is resolved
introduced, once ileus is resolved

Medical therapy:
Medical therapy:
– H2 receptor antagonist --> to reduce
H2 receptor antagonist --> to reduce
gastric acid secretion
gastric acid secretion
– Antimotility agents (loperamide HCL or
Antimotility agents (loperamide HCL or
diphenoxylate)
diphenoxylate)
– Octreotide – to reduce volume of
Octreotide – to reduce volume of
gastrointestinal secretion
gastrointestinal secretion
– TPN complication:
TPN complication:
1.
1. Catheter sepsis
Catheter sepsis
2.
2. Venous thrombosis
Venous thrombosis
3.
3. Liver and kidney failure
Liver and kidney failure
4.
4. osteoporosis
osteoporosis

Surgical Therapy
Surgical Therapy:
:
– Non-transplant:
Non-transplant:
 Goal is to increase nutrient and fluid absorption
Goal is to increase nutrient and fluid absorption
by either slowing intestinal transit or increasing
by either slowing intestinal transit or increasing
intestinal length
intestinal length
 Slow intestinal transit:
Slow intestinal transit:
1.
1. Segmental reversal of the small bowel
Segmental reversal of the small bowel
2.
2. Interposition of a segment of colon
Interposition of a segment of colon
3.
3. Construction of small intestinal valves
Construction of small intestinal valves
4.
4. Electrical pacing of the small bowel
Electrical pacing of the small bowel
– Limited case report
Limited case report
– Frequently associated w/ intestinal obstruction
Frequently associated w/ intestinal obstruction

GOD BLESS
GOD BLESS
SALAMAT PO
SALAMAT PO

Diagnosis:
Diagnosis:
b.
b. Enteroclysis
Enteroclysis
200 to 250 ml of barium followed by 1 to 2 L of
200 to 250 ml of barium followed by 1 to 2 L of
methylcellulose in water is instilled into the
methylcellulose in water is instilled into the
proximal jejunum via a long naso-enteric tube
proximal jejunum via a long naso-enteric tube

Factors predictive of achieving
Factors predictive of achieving
independence from TPN:
independence from TPN:
1.
1. Presence or absence of an intact colon
Presence or absence of an intact colon
(capacity to absorb fluid & electrolytes and
(capacity to absorb fluid & electrolytes and
absorb short-chain FA).
absorb short-chain FA).
2.
2. Intact ileocecal valve
Intact ileocecal valve
3.
3. A healthy, rather disease, residual small
A healthy, rather disease, residual small
intestine is associated w/ decreased severity
intestine is associated w/ decreased severity
of malabsorption
of malabsorption
4.
4. Resection of jejunum is better tolerated than
Resection of jejunum is better tolerated than
the ileum, due to bile salt and vit B12
the ileum, due to bile salt and vit B12
absorption capacity of the ileum.
absorption capacity of the ileum.

Surgical Therapy:
Surgical Therapy:
– Non-transplant:
Non-transplant:
 Intestinal lengthening operation:
Intestinal lengthening operation:
1.
1. Longitudinal Intestinal lengthening and tailoring (LILT)
Longitudinal Intestinal lengthening and tailoring (LILT)
2.
2. Serial transverse enteroplasty procedure (STEP)
Serial transverse enteroplasty procedure (STEP)
– Intestinal transplant
Intestinal transplant

Prognosis (CHRON’S DSE)
Prognosis (CHRON’S DSE)
 High recurrence rate (most common
High recurrence rate (most common
proximal to the site of previous
proximal to the site of previous
resection).
resection).
 70% recur w/in 1 yr and 85% w/in 3 yrs.
70% recur w/in 1 yr and 85% w/in 3 yrs.
 Most common complication:
Most common complication:
1.
1. Wound infection
Wound infection
2.
2. Postoperative intra-abdominal abscess
Postoperative intra-abdominal abscess
3.
3. Anastomotic leaks
Anastomotic leaks
• 60-300 x more frequent to develop CA
60-300 x more frequent to develop CA

Mesenteric Ischemia
Mesenteric Ischemia
NOMI
NOMI – std tx. Is infusion of vasodilator
– std tx. Is infusion of vasodilator
(papavarine hydrochloride)
(papavarine hydrochloride) into the SMA. If
into the SMA. If
w/ signs of peritonitis --> immediate celiotomy
w/ signs of peritonitis --> immediate celiotomy
and resect necrotic segment.
and resect necrotic segment.
Acute mesenteric venous thrombosis
Acute mesenteric venous thrombosis
 Std tx. anticoagulant (heparin / warfarin).
Std tx. anticoagulant (heparin / warfarin).
 Signs of peritonitis --> explore and resects if
Signs of peritonitis --> explore and resects if
needed
needed
For chronic arterial mesenteric ischemia:
For chronic arterial mesenteric ischemia:
 Surgical revascularization
1.
1. Aortomesenteric bypass grafting
Aortomesenteric bypass grafting
2.
2. Mesenteric endarterectomy
Mesenteric endarterectomy
3.
3. Percutaneous transluminal mesenteric
Percutaneous transluminal mesenteric
angioplasty alone or w/ stent.
angioplasty alone or w/ stent.

Malignant neoplasm:
Malignant neoplasm:
1.
1. GISTs: (gastrointestinal stromal tumors)
GISTs: (gastrointestinal stromal tumors)
Most common
Most common mesenchymal tumors
mesenchymal tumors arising in the
arising in the
small bowel
small bowel
70% arises from the
70% arises from the stomach
stomach followed by the
followed by the small
small
bowel
bowel
15% of small bowel malignancies
15% of small bowel malignancies
Formerly classified as:
Formerly classified as:
1.
1. Leiomyomas
Leiomyomas
2.
2. Leiomyosarcomas
Leiomyosarcomas
3.
3. Smooth muscle tumors of small bowel
Smooth muscle tumors of small bowel
Associated w/
Associated w/ overt hemorrhage
overt hemorrhage
Has its expression of the receptor
Has its expression of the receptor tyrosine kinase
tyrosine kinase KIT
KIT
(CD117).
(CD117). There is pathological KIT signal
There is pathological KIT signal
transduction
transduction

Treatment:
Treatment:
1.
1. Small-intestine GISTs:
Small-intestine GISTs:
– Segmental resection
Segmental resection
– If was preoperatively diagnosed, lymphadenectomy
If was preoperatively diagnosed, lymphadenectomy
shd not be done, for rarely associated w/ LN
shd not be done, for rarely associated w/ LN
metastases.
metastases.
– Resistant to conventional chemotherapy
Resistant to conventional chemotherapy
– IMATINIB (Gleevec):
IMATINIB (Gleevec):
− Formerly known as ST1571
Formerly known as ST1571
− 80% of pt w/ unresectable lesions showed clinical
80% of pt w/ unresectable lesions showed clinical
benefits
benefits
− 50 – 60% showed evidence of reduction in tumor
50 – 60% showed evidence of reduction in tumor
volume
volume
− Role as neoadjuvant and adjuvant tx under investigation
Role as neoadjuvant and adjuvant tx under investigation

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