1. Lower GI surgery
Dr.Ishara Maduka

2. Contents Anatomy Intestinal obstruction Appendicitis
Inflammatory bowel disease
Colorectal carcinoma
Stomas

3. Anatomy revision

4. Intestinal obstruction - Types
Types according to pathology
Mechanical obstruction
Adynamic obstruction
Types according to site of obstruction
Small intestinal obstruction
Large intestinal obstruction

5. Mechanical obstruction
Obstruction due to external or internal factor leading to narrowed lumen with normal peristalsis.

6. Mechanical obstruction - causes

7. Lesions Extrinsic to Intestinal Wall
Adhesions (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/ diverticulitis
Volvulus (sigmoid, cecal)

8. Lesions Intrinsic to Intestinal Wall
Congenital
Malrotation
Duplications/cysts
Traumatic
Hematoma
Ischemic stricture
Infections
Tuberculosis
Actinomycosis
Diverticulitis
Neoplastic
Primary neoplasms
Metastatic neoplasms
Inflammatory
Crohn's disease
Miscellaneous
Intussusception
Endometriosis
Radiation enteropathy/stricture

9. Intraluminal/ Obturator Lesions
Gallstone
Enterolith
Bezoar
Foreign body

10. What’s adynamic obstruction
Adynamic obstruction means failure of progression of bowel contents in absence of mechanical obstruction but due to absent or ill coordinated bowel contractions.

11. Normal peristaltic wave

12. Causes of Adynamic Ileus
Following celiotomy
small bowel- 24h, stomach- 48h, colon- 3-5d
Inflammation e.g. appendicitis, pancreatitis
Retroperitoneal disorders e.g. ureter, spine, blood
Thoracic conditions e.g. pneumonia, # ribs
Systemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemia
Drugs e.g opiates, Ca-channel blockers, psychotropics

13. Symptoms and signs of bowel obstruction
Colicky central abdominal pain
Vomiting - early in high obstruction
Abdominal distension - extent depends on level of obstruction
Absolute constipation - late feature of small bowel obstruction
Dehydration associated with tachycardia, hypotension and oliguria
Features of peritonism indicate strangulation or perforation

14. Investigations
Supine abdominal X ray
Other Ix depending on DD

15. Supine x ray in Intestinal obstruction

16. Treatment Adequate resuscitation prior to surgery is important
Surgery in under resuscitated patient is associated with increased mortality
If obstruction presumed to be due to adhesions and there are no features of peritonism
Conservative management for up to 48 hours is often safe
Requires regular clinical review

17. If features of peritonism or systemic toxicity present
Need to consider early operation
Exact procedure will depend on underlying cause

18. Appendicitis Inflammation of the appendix is called appendicitis.
Patients present with pain in the right iliac fossa.

19. Differentials for pain in RIF
Appendicitis
Urinary tract infection
Non-specific abdominal pain
Pelvic inflammatory disease
Renal colic
Ectopic pregnancy
Constipation

20. Risk

21. Clinical features Central abdominal pain moving to right iliac fossa
Nausea, vomiting, anorexia
Low-grade pyrexia
Localised tenderness in right iliac fossa
Features of peritonism – rebound tenderness, percussion tenderness

22. Investigations Appendicitis is a clinical diagnosis
USS, FBC, UFR can help to exclude differential diagnoses

23. Treatment
Treatment is surgical for confirmed acute appendicitis.

24. Inflammatory bowel disease
IBD

25. IBD
Chronic inflammatory condition involving the bowels which have a protracted, relapsing course.
2 pathologies
Ulcerative colitis
Crohns disease

26. Clinical features Diarrhoea PR bleeding Weight loss
Fever during attacks

27. Colorectal carcinoma

28. Epidemiology one of the most common cancers in the world
US: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 56,500 deaths caused by CRC

30. Adenoma carcinoma sequence

31. Risk factors Age Adenomas, Polyps Sedentary lifestyle, Diet, Obesity
Family History of CRC
Inflammatory Bowel Disease (IBD)
Hereditary Syndromes (familial adenomatous polyposis (FAP))

32. Dietary factors implicated in colorectal carcinogenesis
consumption of red meat
animal and saturated fat
refined carbohydrates
alcohol
increased risk

33. Contd.. dietary fiber vegetables fruits antioxidant vitamins calcium
folate (B Vitamin)
decreased risk

37. Symptoms and signs Specific symptoms General symptoms rectal bleeding
change in bowel habits
obstruction
abdominal pain & mass
iron-deficiency anemia
General symptoms
weight loss
loss of appetite
night sweats
fever

38. Treatment Surgical resection the only curative treatment
Likelihood of cure is greater when disease is
detected at early stage
Early detection and screening is of pivotal
importance

39. 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

40. Surgery
Hemicolectomy or colectomy depending on the location of the tumour.
A stoma may have to be created either temporarily or permanently.

41. Stomas

42. What’s a stoma
A stoma is a surgically created communication between a hollow viscus and the skin
Includes a colostomy, ileostomy, urostomy, caecostomy, jejunostomy and gastrostomy
Functionally they can be end or loop stoma

45. Positioning
Away from umbilicus, scars, costal margin and anterior superior iliac spine
Ensure compatible with the clothing worn by the patient
Ideally should be marked preoperatively by stoma nurse

46. Complications Necrosis Detachment Recession Stenosis Prolapse
Ulceration
Parastomal herniation
Fistula formation

47. Retraction

48. Prolapse

49. Thank You