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

2. 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.

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

10. CLINICAL FEATURES Colicky central abdominal pain Vomiting
Abdominal distension
Constipation

11. 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

17. 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.

18. Post open cholecystectomy paralytic ileus

19. 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.

23. 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.

27. 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.

28. 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

29. Barium follow through showing “String sign of Kantor”

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

32. 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.

34. 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

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

36. 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.

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

40. 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.

41. 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.

42. Small intestinal Lymphoma

43. 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.

44. 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.

45. 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.

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

48. Treatment Nutritional Support including TPN.
Gut lengthening procedures
Intestinal Transplantation

50. THANK YOU