The small and large intestines. Abdominal pain.. Surgical anatomy.. Angiodysplasia ( vascular malformation).. Diverticular disease.. Tumors..

Abdominal pain 1.Visceral. 2.Peritoneal.

Small bowel (grossly). 1.Duodenum – ligament of Trietz. 2.Jejunum – thick wall with two series of arcades. 3.Ilium – thin wall with several series of arcades. 4.By mesenteric attachment proximal small bowel lies in upper part of abdomen and the distal part lies in lower abdomen.

Large bowel(grossly) distinguished. 1.Taenia coli. 2.Appendices epiplicae.

Vascular anomalies( Angiodysplasia). Heamangioma (capillary or cavernous), a few millimeters dilated tortuous sub mucous veins in the ascending colon presented in form of (massive bleeding). Patient is an old age having aortic stenosis. Diagnosis is clinical, instrumental (endoscopy), angiography., Tm99 labeled RBCs. Treatment is endoscopic and operative.

Massive bleeding 1. Angiodysplasia. 2.Inflammatory bowel disease. 3.Diverticular disease. 4.Ischemic colitis.

Diverticular diseases Diverticulum is a sac created by herniation of mucosa thru the muscle layer. Congenital : The primary, the true one containing the three layers, on the anti mesenteric side, often single. The acquired. The secondary, the false type, which lack the muscle Layer, on the mesenteric side, often multiple.

Divrticula of small bowel Duodenal: a. The primary diverticulum, on second part, symptomless, incidentally find, interfere with ampula marking on duodenoscopy. B. The secondary one, in duodenal cup, in DU. Jejunal: Symptomless or causing pain, malabsorption, acute abdomen, associated with connective tissue diseases. Ileum: The Mickle’s diverticulum.

Mickle’s diverticulum True one, on anti mesenteric, concept of 2(2%, 2 feet, 2 inches). Clinically 1. Inflammation(mimic appendicitis). 2. bleeding. 3. Peptic ulceration. 4. Intussusceptions. 5. Intestinal obstruction(by band). Diagnosis: Clinically, small bowel enema, Tc99 scanning (heterotopic mucosa).

Diverticulosis coli True, congenital, Rt. Side(ascending), single. False, acquired, left side(sigmoid), multiple. Rectum is free, muscles Completely surrounding the rectum. 5% of population, saint trait, fiber lacking food. Become symptomatic when intra luminal pressure increase- segmentation increase- herniation at site of B.V entry.

Diverticulosis coli (presentation). Pain: low intensity, recurrent. Bleeding: massive in 17%. Inflammation: and its sequelae. Malignant changes. Diagnosis: a. Clinical( exclude irritable bowel syndrome). b. Barium enema (saw tooth).c. sigmoidoscopy (diverticulum between hypertrophied mucosa). Treatment depends on the presentation. Resection and established continuity.

Tumors of the large bowels. Polyps.. Carcinoma.

Polyps Clinical description to any elevated mucosa. Histological it is a mucosal elevation covered a core containing blood vessel. Single or multiple. True or pseudo polyp. True multiple: ( Polyposis syndrome). Pseudo single: ( pseudo polyp in ulcerative colitis).

Types of polyps Inflammatory. Metaplastic or hyper plastic. Hamartomatous: 1. Juvenile. 2. Peutz-Jegher’s. Neoplastic: 1. Benign : Adenoma (tubular, villous, tubulo villous), lipoma(almost always in caecum causing intussusceptions) and Angiodysplasia. 2. Intermediate : the carcinoid. 3. Malignant : the adeno carcinoma.

Polyposis syndrome Familial intestinal adenomatous polyposis: APC gene on chromosome 5, involves small and large bowel, 100% malignant potential.. Gardner’s syndrome: Same like familial intestinal adenomatous Polyposis with two differences; a. a soft tissue tumor like sebaceous cyst and a hard tissue tumor like exostosis may exist. b. 40% malignant potential.

Second killer in males, fourth in females. Usually after 50. Frequently starting as benign polyp. Synchronization in 5%. Tumor approaching full circumference in one year.

Grading means degree of differentiation: a. Well diff. b. Moderately diff. c. Poorly diff. Staging means Tumor’s spread(Duke’s). Duke 1.a. Insitue. b. Beyond basement membrane. Duke 2. a. to the muscles b. to the serosa. Duke 3. a. To regional lymph node. b. To pelvic nods. Duke 4. a. Micro metastasis. b. Macro metastasis.. In brief : Duke 1 mucosa. Duke 2 Wall. Duke 3 nodes.

T1 in the Sub mucosa.. T2 muscularis properia. T3 Peri colic fat, serosa intaked. T4 Breach serosa and spread. No no nodes involve. N1 up to 2 nodes. N2 more than 2 nodes. M0 no metastasis. M1 Metastasis there. L0 no lymphatic vessel involve. L1 l.v involve. V0 no B.v involve. V1 B.v involve. Ro no residual tumor. R1 Margin involve.

Presentations

History and examination, PR exam. Stool for occult blood. Barium enema (double contrast). Ultrasound. CT scan with contrast. MRI. Colonoscopy and biopsy. CEA(tumor marker), of value in recurrence.

In elective case:. Large bowel preparation.. Resects and Anastomose.. In Emergency case (obstruction ): Resection- colostomy (don’t Anastomose)- maturation of colostomy- bowel preparation- closure of colostomy..

Mechanical cleansing. Bacteriological sterilization.

Whole bowel preparation. Three days preparation. One day preparation. On table preparation.

Antibiotics (oral): a. Non absorbable (neomycin). b. Absorbable (metronidazole, erythromycin).

Mobile tumor. Liver free of metastasis. Peritoneum free of seeding. No lymph nods metastasis.

Stomas (artificial anus) (Colostomy and ileostomy)