Lower GI surgery Dr.Ishara Maduka

Contents Anatomy Intestinal obstruction Appendicitis Inflammatory bowel disease Colorectal carcinoma Stomas

Anatomy revision

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

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

Mechanical obstruction - causes

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)

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

Intraluminal/ Obturator Lesions Gallstone Enterolith Bezoar Foreign body

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.

Normal peristaltic wave

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

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

Investigations Supine abdominal X ray Other Ix depending on DD

Supine x ray in Intestinal obstruction

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

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

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

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

Risk

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

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

Treatment Treatment is surgical for confirmed acute appendicitis.

Inflammatory bowel disease IBD

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

Clinical features Diarrhoea PR bleeding Weight loss Fever during attacks

Colorectal carcinoma

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

Adenoma carcinoma sequence

Risk factors Age Adenomas, Polyps Sedentary lifestyle, Diet, Obesity Family History of CRC Inflammatory 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 alcohol increased risk

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

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

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

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

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

Stomas

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

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

Complications Necrosis Detachment Recession Stenosis Prolapse Ulceration Parastomal herniation Fistula formation

Retraction

Prolapse

Thank You