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Lower GI surgeryDr.Ishara Maduka
ContentsAnatomyIntestinal obstructionAppendicitisInflammatory bowel diseaseColorectal carcinomaStomas
Anatomy revision
Intestinal obstruction - TypesTypes according to pathologyMechanical obstructionAdynamic obstruction
Types according to site of obstructionSmall intestinal obstructionLarge intestinal obstruction
Mechanical obstructionObstruction due to external or internal factor leading to narrowed lumen with normal peristalsis.
Mechanical obstruction - causes
Lesions Extrinsic to Intestinal WallAdhesions (usually postoperative) Hernia External (e.g., inguinal, femoral, umbilical, or ventral hernias) Internal (e.g., congenital defects such as paraduodenal, foramen of Winslow, and diaphragmatic hernias or postoperative secondary to mesenteric defects) Neoplastic Carcinomatosis, extraintestinal neoplasm Intra-abdominal abscess/ diverticulitisVolvulus (sigmoid, cecal)
Lesions Intrinsic to Intestinal WallCongenital Malrotation Duplications/cysts Traumatic HematomaIschemic stricture Infections Tuberculosis Actinomycosis Diverticulitis
Neoplastic Primary neoplasms Metastatic neoplasms Inflammatory Crohn's disease Miscellaneous Intussusception Endometriosis Radiation enteropathy/stricture
Intraluminal/ Obturator LesionsGallstone Enterolith Bezoar Foreign body
Whats adynamic obstructionAdynamic obstruction means failure of progression of bowel contents in absence of mechanical obstruction but due to absent or ill coordinated bowel contractions.
Normal peristaltic wave
Causes of Adynamic IleusFollowing celiotomysmall bowel- 24h, stomach- 48h, colon- 3-5dInflammation e.g. appendicitis, pancreatitisRetroperitoneal disorders e.g. ureter, spine, bloodThoracic conditions e.g. pneumonia, # ribsSystemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemiaDrugs e.g opiates, Ca-channel blockers, psychotropics
Symptoms and signs of bowel obstructionColicky central abdominal painVomiting - early in high obstructionAbdominal distension - extent depends on level of obstructionAbsolute constipation - late feature of small bowel obstructionDehydration associated with tachycardia, hypotension and oliguriaFeatures of peritonism indicate strangulation or perforation
InvestigationsSupine abdominal X rayOther Ix depending on DD
Supine x ray in Intestinal obstruction
TreatmentAdequate resuscitation prior to surgery is importantSurgery in under resuscitated patient is associated with increased mortalityIf obstruction presumed to be due to adhesions and there are no features of peritonismConservative management for up to 48 hours is often safeRequires regular clinical review
If features of peritonism or systemic toxicity presentNeed to consider early operationExact procedure will depend on underlying cause
AppendicitisInflammation of the appendix is called appendicitis.Patients present with pain in the right iliac fossa.
Differentials for pain in RIFAppendicitisUrinary tract infectionNon-specific abdominal painPelvic inflammatory diseaseRenal colicEctopic pregnancyConstipation
Risk
Clinical featuresCentral abdominal pain moving to right iliac fossaNausea, vomiting, anorexiaLow-grade pyrexiaLocalised tenderness in right iliac fossaFeatures of peritonism rebound tenderness, percussion tenderness
InvestigationsAppendicitis is a clinical diagnosisUSS, FBC, UFR can help to exclude differential diagnoses
TreatmentTreatment is surgical for confirmed acute appendicitis.
Inflammatory bowel diseaseIBD
IBDChronic inflammatory condition involving the bowels which have a protracted, relapsing course.2 pathologiesUlcerative colitis Crohns disease
Clinical featuresDiarrhoea
PR bleeding
Weight loss
Fever during attacks
Colorectal carcinoma
Epidemiologyone of the most common cancers in the worldUS:4th most common cancer (after lung, prostate, and breast cancers)2nd most common cause of cancer death (after lung cancer)2001:130,000 new cases of CRC 56,500deaths caused by CRC
Adenoma carcinoma sequence
Risk factorsAgeAdenomas, PolypsSedentary lifestyle, Diet, ObesityFamily History of CRCInflammatory Bowel Disease (IBD)Hereditary Syndromes (familial adenomatous polyposis (FAP))
Dietary factors implicated in colorectal carcinogenesis
consumption of red meat
animal and saturated fat
refined carbohydrates
alcoholincreased risk
Contd..dietary fiber
vegetables
fruits
antioxidant vitamins
calcium
folate (B Vitamin)decreased risk
Symptoms and signsGeneral symptomsweight loss
loss of appetite
night sweats
feverSpecific symptomsrectal bleeding
change in bowel habits
obstruction
abdominal pain & mass
iron-deficiency anemia
TreatmentSurgical resection the only curative treatment
Likelihood of cure is greater when disease isdetected at early stage
Early detection and screening is of pivotalimportance
Screening for CRC
fecal occult blood test (FOBT)chemical test for blood in a stool sample. annual screening by FOBT reduces colorectal cancer deaths by 33%
Flexible sigmoidoscopy can detect about 65%75% of polyps and 40%65% of colorectal cancers. rectum and sigmoid colon are visually inspected
SurgeryHemicolectomy or colectomy depending on the location of the tumour.A stoma may have to be created either temporarily or permanently.
Stomas
Whats a stomaA stoma is a surgically created communication between a hollow viscus and the skinIncludes a colostomy, ileostomy, urostomy, caecostomy, jejunostomy and gastrostomyFunctionally they can be end or loop stoma
PositioningAway from umbilicus, scars, costal margin and anterior superior iliac spineEnsure compatible with the clothing worn by the patientIdeally should be marked preoperatively by stoma nurse
ComplicationsNecrosisDetachmentRecessionStenosisProlapseUlcerationParastomal herniationFistula formation
Retraction
Prolapse
Thank You