SURGICAL DISEASES OF THE SMALL INTESTINE BY PROF. SALEH M AL SALAMAH FRCS Prof. surgery and consultant general and laparoscopic surgeon college of medicine king Saud university Riyadh ksa

OBJECTIVES At the end of this lecture students will be able to describe: The clinical presentation and Management of Small bowel obstruction. The clinical features and Management of Crohn’s disease. Presentation and Management of Small bowel tumors. Clinical features and Management of Small bowel ischemia. Short bowel syndrome , causes and management. Meckel’s Diverticulum, presentation and management.

INTESTINAL OBSTRUCTION CLASSIFICATION MECHANICAL (Dynamic) vs ILEUS (Adynamic) ACUTE vs CHRONIC SMALL vs LARGE INTESTINAL

CLINICAL FEATURES Colicky central abdominal pain Vomiting Abdominal distension Constipation

INVESTIGATIONS Complete Blood Count Blood Chemistry Abdominal X Ray, erect and supine films CT abdomen with oral and I/V contrast Investigations required for GA fitness if surgery is planned

Paralytic Ileus ( ADYNAMIC OBSTRUCTION) This may be defined as a state in which there is failure of transmission of peristaltic waves secondary to neuromuscular failure. The resultant stasis leads to accumulation of fluid and gas within the bowel, with associated distension, vomiting, absence of bowel sounds and constipation.

Post open cholecystectomy paralytic ileus

Vascular Disease of Intestine MESENTERIC ISCHEMIA Arterial or Venous Acute or Chronic Symptoms: Acute: Sudden abdominal pain, passage of altered blood, shock. Chronic: Abdominal angina, weight loss or diarrhoea. Investigations: AXR, CT angiography Treatment: Resuscitation, Gut Resection, Embolectomy, Vascular bypass or Endarterectomy.

CROHN’S DISEASE REGIONAL ILEITIS A disease of uncertain aetiology, but thought to be result of inflammation caused by an unusual strains of mycobacteria. It is characterized by full thickness inflammatory process of any part of GIT from lips to anal margin. Pathological features include full thickness inflammation, edema, fissures/ulceration, non- caseating foci of epithelioid and giant cells.

CLINICAL FEATURES CROHN’S DISEASE ACUTE Pain right iliac fossa with tenderness mimicking acute appendicitis. Features of low small bowel obstruction Rarely perforation of small intestine causing peritonitis. CHRONIC Colicky abdominal pain with diarrhoea Weight loss Perianal fistulas Fistulation into adjacent organs like bladder, colon, vagina.

INVESTIGATIONS Barium meal and follow through CT abdomen with oral and I/V contrast Blood : Anemia, high C- reactive protein and low Vit-B12 levels Colonoscopy/ Enteroscopy with biopsy

Barium follow through showing “String sign of Kantor”

TREATMENT Corticosteroids Aminosalicylates Immunomodulators e.g. azathioprine Monoclonal antibodies Antibiotics for perianal disease Surgery: Resections, strictureplasty or colectomies.

Intestinal Tuberculosis Uncommon in developed countries except when associated with AIDS. Both human and bovine strains of mycobacterium can affect. Starts when ingested from infected source or from swallowed sputum from open pulmonary tuberculosis. Pathology: Ulceration, stricture formation and lymph node enlargement.

Clinical Features & Investigations General: Weight loss, low grade fever, fatigue. Abdominal: Vague lower abdominal pain, distension, borborygmi, diarrhoea, constipation and ulceration leading to lower GI blood loss. Palpable mass in right iliac fossa. Blood / Serum: CBC, ESR, PCR, Culture. Radiological: CXR, CT abdomen, Barium follow through. Endoscopy

TREATMENT OF INTESTINAL TUBERCULOSIS Course of Anti-tuberculosis drugs Surgery for complications like: Stricture formation Perforation Haemorrhage

Meckel’s Diverticulum Embryological remnant of Vitello-intestinal duct. Occurs in 2% population, 2 feet from ileocecal valve and 2 inches long and 2 times common in men. Presents as : Persistent vitello-intestinal fistula Acute diverticulitis Perforation and peritonitis Intestinal obstruction Bleeding due to ectopic gastric mucosa.

Treatment Asymptomatic and incidentally discovered Meckel’s diverticulum are left as such. Narrow necked, inflamed or symptomatic diverticulum is excised.

Tumors of the Small Intestine Primary tumours of small gut are uncommon and form only 5% of the GIT neoplasms. Aetiological factors include: A. Inherited Conditions: Polyposis coli, Peutz-Jegherz Syndrome, Gardner's syndrome. B. Immunocompromised states: Coeliac disease, AIDS, transplant recipients. C. Geographical Areas: Lymphomas more common in Middle East.

Classification of Tumours Benign Adenomas GIST (Gastrointestinal Stromal tumours) Lipomas Neurofibromas Malignant Lymphomas both primary and part of generalised disease. Adenocarcinomas Carcinoids Secondary tumours from lung, breast or malignant melanoma.

Small intestinal Lymphoma

Clinical Presentation It can be Acute or Chronic Acute presentation is with intestinal obstruction, GI bleeding or perforation leading to peritonitis. Chronic symptoms include malaise, abdominal pain, weight loss, diarrhoea and anaemia.

Investigations & Treatment Blood : Anemia and high ESR, Tumour markers, high 5-HIAA levels in Carcinoids. Radiological: CT or MRI abdomen with oral and intravenous contrast. Endoscopy: Upper GI endoscopy, Enteroscopy, Colonoscopy. TREATMENT: This depends upon presentation, stage and type of the tumour.

SHORT GUT SYNDROME Short gut syndrome has been arbitrarily defined as the presence of less than 200 cm of residual small bowel in adult patients. OR A functional definition, in which insufficient intestinal absorptive capacity results in the clinical manifestations of diarrhoea, dehydration and malnutrition.

Aetiological Causes Crohn's disease; Mesenteric infarction Radiation enteritis Midgut volvulus Multiple fistulae Small-bowel tumours

Treatment Nutritional Support including TPN. Gut lengthening procedures Intestinal Transplantation

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