31 8 10 Small Intestine

8/3/2019 31 8 10 Small Intestine

1/41

SMALL

INTESTINE

LESIONS

PROF. DR. T. BHAVANI SHANKAR.MS.PROFESSOR OF SURGERY.,K.M.C


2/41

INTESTINAL

OBSTRUCTIONTypes

1. Dynamic

2.Adynamic


3/41

1.DYNAMIC:obstruction can be

externalo

r internalpartial or complete

acute or chronic

proximal or distal

congenital or acquired


4/41

CAUSES:Adhesion,

hernias,congenital bands,

malrotation,

volvulus.


5/41

Dynamicintestinal

obstructionsite:

80% small bowel

20% co

lo

n (10% due to

malignancy)


6/41

P

ATHOGENESIS1. Changes proximal toobstruction

Intestinal Obstruction Increased peristalsis vigorous motility obstruction not relieved

peristalsis stops flaccid paralyzed dilated bowl.


7/41

2. changes at site ofobstruction

impairment of venous return congestion,

bowelw

all edema

co

mpro

mised arterialsupply ischemia, discoloration, loss of

peristalsis gangrene perforation peritonitis


8/41

3.Changes distal to site of

obstruction

- Inactive and collapsed.


9/41

CLINICAL FEATURESAbdominal pain,

vomiting,

distension,

Visible intestinal peristalsis

constipation,

dehydration,

to

xemia,fever,

bowel sounds initially increased latter decreased or absent,

PR rectum dilated, empty.


10/41

INVESTIGATIONS:Plain X-ray erect abd. Multiple fluid levels,

dilated bowel loops.

USG Abd.,

CT Abd.,

routine blood investigation.


11/41

TREATMENT:Nil per Oral

NG aspiration

IVF

Antibiotics

Blood transfusion


12/41

SURGICAL TREATMENTImmediate laparotomy to relieve obstruction,check for viability ofbowel - colour, shinning,peristalsis, pulsation, bleeding from edge, bowelwall, mesentry, friability,

if non-viable resection and anastomosis,

peritonealwash,

abd. Closed in layers.


13/41

COMP

LICATIONS:Pelvic abscess,

subphrenic abscess,

biliary fistula,burst abd.,

Adhesions,

incisional hernias.


14/41

INTUSSUCEPTION:

Invagination of portion ofbowel in to its adjacentsegment (telescopy).

Types:

ileo

co

licileoileocolic

colocolic

Age: pediatric age group, especiallyweaning.

Parts:

Apex onewhich advances

intussuceptum inner segmentwhich enters

intussucepeins outer segmentwhich receives


15/41

CLINICAL FEATURESMale : Female = 3:2

Age: 6 to 9 months

Colicky Abd. Pain.Red currant jelly stools

Mass around umbilicus

RIF empty (sign of dance)

Contraction of Mass under palpating fingers,

features of intestinal obstruction,

step ladder peristalsis.


16/41

INVESTIGATION:

1. Barium enema Clear sign,coiled spring sign.

2. USG target sign, pseudo kidney

sign, bulls eye sign.


17/41

TREATMENT:

IVF, Antibiotics.

Non-operative:Reduction by hydrostatic pressure using saline or

barium sulphate solution or air,

infuse into rectum via foleys. (contraindicated ifcomplete obstruction, perforation, peritonitis)


18/41

SURGICAL:

Laparotomy manual reduction by milking

outwith warm packs.

Ileocolic resectionRecurrence hydrostatic reduction 10%

Open manual reduction 2%

resection 1%


19/41

DUODINAL ATRESIA:

defective fusion foregutwith midgut and failure

of canalisation. Usually completes stenosis of

seco

nd parto

f duo

denum and the levelo

fampulla of vater.

May be 1. pre-ampullary (non bilious vomitting)

2. Post ampullary (bilious vomitting,common 80 to 90%).


20/41

TYPES:

1. Complete atresia (commonest)

2. fibrous cord

3. Incomplete of partial obstruction


21/41

Associative

conditions:1. Annular pancreas

2. Down syndrome

3. Malrotation

4. Congenital heart disease

5. Ano rectal malformation


22/41

CLINICAL FEATURES

Jaundice,

vomiting,GOO,

dehydration,growth retardation.


23/41

INVESTIGATIONS

1. Clean X-ray double bubble sign, absence of

air in distil bowel2. USG distended stomach and proximal

duodenum, railroad track duodenum.


24/41

SURGERY:

Duodenoduodenostomy

Kimuras diamond shaped anastomosis

transversely opened proximal bowel,

anasto

mo

sisw

ith lo

ngitudinallyo

pened distalpouch.


25/41

JEJUNOINEAL ATRESIA

due to

intrauterine mesentric vascularaccidents. Associated with malrotation,

gastroschisis, volvulus.

Site:

Proximal jejunum (common) distal ileum.

proximal segment dilated andhypertrophic, distal segment collapsed.


26/41

Martinsclassification (gries

fieldmodification)

Type1: Membaranous/mucosal with normal mesentery 20%

Type2: Lumen atretic, fibrous cord between the segments, normalmesentery 40%

Type III A : Atresia with U-shaped defect in mesentery 35%

Type III B : Atresia with christmas tree shaped defect in mesentery,apple peel atresia.

Type IV : multiple atresia


27/41

CLINICAL FEATURES:common in lowbirthweight babies, biliousvomiting, intestinal obstruction, jaundice,respiratory distress.

Investigations:X-ray triple bubble sign, multiple air fluid levels,USG.

Treatment:Resection and anastamosis of proximal segment.


28/41

VASCULAR LESIONS

Mesenteric vascular ischemia:

Superior mesenteric artery commonly

involved.

Causes:

Emboli (50%), Thrombosis, Non occlusive

Hypotension, Hypertension.


29/41

ISCHEMIC BOWEL

DISEASETypes: Acute-emboli, Chronic-Abd.anginaCF: Abd. Pain, vomiting, guarding, bloody diarrhoea, shock, ARDS.

Investigations: X-Ray Abd. USG Abd. CT angiogram, doppler study.

Treatment:

Emergency laparotomy Removal ofblock, if gangrenealready present (24-48 hours) resection and anastamosis, More

than 6 hours Emergency SMA angio done. Heparin 20000 unitsloading dose, 50,000 units maintenance, SMA site obstructionidentified. Emergency laparotomy done. Emboli removed or SMAarteiotomy and thrombus removal.


30/41

CLINICAL FEATURES

Abd. Pain,

vo

miting,guarding,

bloody diarrhea,

shock,

ARDS.


31/41

INVESTIGATIONS:

X-Ray erect Abd.

USG Abd.

CT angiogram,

doppler study.


32/41

TREATMENT:

Emergency laparotomy

If gangrenous bowel is already present(24-48 hours)

resection and anastomosis is doneMore than 6 hours Emergency SMA

angiogram is done.Removal ofblock,Heparin 20000 units loading dose,

50,000 units maintenance,SMA arteiotomy and thrombus/ embolus

removal.


33/41

NEOPLASM


34/41

Benign:1. Brunners gland adenoma

- in duo

denal sub

muco

sa- bleeding manifestations

- usually hyperplastic

- endoscopic resection


35/41

2. AdenomaA. TubularB. Villous

C. Tubulovillous

periampullary region,

ERCP and Biopsy done.

If size more than 2 cm chance of

malignancy present,transduodenal excision,

pancreato duodenectomy


36/41

3. Lipoma - sub mucosal form (intussusception)

4. Puetz jeghers syndrome

5. Hemangioma


37/41

MALIGNANT1.Adenocarcinoma:

- most common primary malignant small power tumour. In 40% ofsmall bowel tumours.

Site:80% duodenum and jejunum

FAP, adenoma, crohns disease are the causes.

CLINICAL FEATURES:

Anorexia bleeding diarrhoea obstruction.

Investigations:CT scan.

Treatment: Surgery resectionwith 5cm Clearance


38/41

2.NON HODGKINS LYMPHOMA

GIT most common extra nodal site

stomach MC 68%small bowl 30%

B-cell type 75%

T-cell type 25% (poor prognosis)

CLINICAL FEARURES:Malabsorption, mass abd., obst.

Investigation:

CT, Biopsy (CT guided, laparoscopic)

Treatment:Surgery resection

Chemo therapy


39/41

GISTRare but common non-epithelial tumour of small bowel.

Stomach (60% of GIST)

Small bowl 25% of GIST

Arises from interstitial cells of cajal

C-kit (tyrosine kinase) transmembrane receptor mutation

CLINICAL FEATURES:

Palpable mass, compression symptoms, haemorrhage.

Investigation:

CT scan, IHC, Tm markers.

Treatment: Wide surgical resectionDrugs: imatinibmesylate

SU11248


40/41

ADYNAMIC OBSTRUCTION

The cause of ileus is not due tomechanicalfactors either in the lumen /wall or extraluminal

CAUSES: Physiological-immediate post operative

Electrolyte imbalance

Vascular lesions

Retroperitoneal haematoma

# spine (lumbar) Intra abdominal sepsis

Abscess

Peritonitis


41/41

THANK YOU

Documents

31 8 10 Small Intestine