BY PROF. SALEH MOHAMMED AL SALAMAH

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.

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

CLINICAL FEATURES  Colicky central abdominal pain  Vomiting  Abdominal distension  Constipation

 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

 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

 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.

 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.

 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.

 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 : o Persistent vitello-intestinal fistula o Acute diverticulitis o Perforation and peritonitis o Intestinal obstruction o Bleeding due to ectopic gastric mucosa.

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

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.

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.

 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.

 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 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.

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

 Nutritional Support including TPN.  Gut lengthening procedures  Intestinal Transplantation