small intestine diseases 2

23/4/8 small intestine disease 1

Intestinal ObstructionIntestinal Obstruction

肠梗阻肠梗阻

23/4/8 small intestine disease 2

DefinationDefination

A blockade of the flow of intestinal content.

23/4/8 small intestine disease 3

Etiology and classification 1.According to its basic causes:

mechanical obstruction

dynamic obstruction

obstruction of vascular supply origin

23/4/8 small intestine disease 4

2.According to whether the vascular supply to

intestinal wall is compromised, Simple and

strangulation obstruction.

23/4/8 small intestine disease 5

3.According to obstruction level or site. high and low obstruction

4.According to the extent of obstruction Incomplete and complete obstruction,

5.According to mode of onset and progression of obstruction. Acute and chronic obstruction

23/4/8 small intestine disease 6

6. Open-loop Obstruction: Closed-loop Obstruction:

23/4/8 small intestine disease 7

PathophysiologyPathophysiology A.Local EffectsA.Local Effects

Intestinal gas increases Intestinal fluid accumulates Intestinal flora is abnormal Intestinal motility (peristalsis) is abnormal

23/4/8 small intestine disease 8

B.B. Systemic EffectsSystemic Effects

Water and electrolyte losing Gut original endotoxemia Cardiopumonary dysfunction Shock and other organs insufficiency

23/4/8 small intestine disease 9

Clinical manifestations Abdominal pain Nausea and vomiting Obstipation Abdominal distention.

23/4/8 small intestine disease 10

Physical Examination

the signs of dehydration:

Vital Signs:

23/4/8 small intestine disease 11

a.Inspection: visible peristalsis

distending gut

incisions of previous surgery

23/4/8 small intestine disease 12

b.Palpation: Localized tenderness Signs of localized or generalized peritonitis:

referred tenderness

muscle spasm the mass in abdominal cavity

23/4/8 small intestine disease 13

c.Percussion: Tympanic resonance Shifting dullness demonstrates ascites.

23/4/8 small intestine disease 14

d.Auscultation: Bowel sounds increased Intestinal sound is absent

23/4/8 small intestine disease 15

Laboratory StudyLaboratory Study

Hemoconcentration Leukocyte counts Water and electrolyte imbalance Acid-base imbalance

23/4/8 small intestine disease 16

Radiological ExaminationRadiological Examination A plain abdominal film

dilated loops of small intestine multiple air-fluid level

Computed tomography

23/4/8 small intestine disease 17

23/4/8 small intestine disease 18

EndoscopyEndoscopy

Early ileal carcinoma demonstrating submucosal invasion

23/4/8 small intestine disease 19

•disposable capsule: disposable capsule:

30 x 11 mm30 x 11 mm

Capsule Capsule endoscopyendoscopy

23/4/8 small intestine disease 20

Capsule endoscopyCapsule endoscopy

provide more than five hours of real-color images The data is later downloaded to a computer

workstation and processed to produce a 20-minute video clip of the images transmitted by the capsule

23/4/8 small intestine disease 21

Capsule endoscocpy : normal Capsule endoscocpy : normal findingsfindings

23/4/8 small intestine disease 22

Capsule endoscopyCapsule endoscopy

angiodysplasia, jejunum bleeding angiodysplasia, ileum

23/4/8 small intestine disease 23

Diagnosis

must make clear the following questions:

1.Whether intestinal obstruction exists:

Through symptoms and signs, the

diagnosis can be made without difficulty.

Abdominal Radiology is much helpful in

diagnosis.

23/4/8 small intestine disease 24

2.Whether the obstruction is

mechanical or dynamic:

mechanical obstruction, typical

symptoms and signs.

paralytic obstruction, cramping

abdominal pain is absent, distention is

prominent

23/4/8 small intestine disease 25

3.Whether the obstruction is simple or strangulation obstruction: Indications for strangulation:a. Developing continuous violently rather than intermittent painb. Crisis rapidly and presence of toxemia (elevated temperature and leukocyte count), shock and rapid pulsec. Obvious peritoneal irritationd. A palpable tender abdominal mass with asymmetric distention

23/4/8 small intestine disease 26

e. Bloody gastrointestinal contents

f. Single distending gut loop or pseudo-neoplasm sign on plain abdominal film

g. A large amount of bloody ascites

h. No relieving evidence to intensive nonoperative treatment

23/4/8 small intestine disease 27

4.Whether the obstruction is high or low: Vomiting, in proximal intestinal obstruction.

Distention in low obstruction

Abdominal radiography is helpful.

5.Whether the obstruction is complete or

incomplete: frequency of vomiting, extent of distention, and

radiography.

23/4/8 small intestine disease 28

6.Which causes leads to obstruction:

According to the age, history, symptoms and signs, radio

graphy.

Postoperative adhesions,

Postinflammatory origin

Henias

Congenital malformations

Intestinal intussusception

Obstruction of parasite origin

Carcinomas and dry feces.

23/4/8 small intestine disease 29

TreatmentTreatment

Principles: Correcting of fluid and electrolytes

imbalance and acid-base disturbance Relief of intestinal distention, and

removing the cause of obstruction

23/4/8 small intestine disease 30

A. Basic TreatmentA. Basic Treatment

Fluid and electrolytes replacement Volume restoration: colloid liquid Acidosis correction: sodium bicarbonate or

sodium lactate Potassium deficit

23/4/8 small intestine disease 31

Gastrointestinal decompression Intubation with gastrointestinal tube (g

astrointestinal tube suction) is the important step in the management of obstruction.

23/4/8 small intestine disease 32

Antibiotics Antibiotic treatment plays an important role

in the management of obstruction. Antibiotic would be given in any type of

obstruction The principle is giving the broad spectrum

(aerobic and anaerobic) with large dose and short course and taking the less cost

23/4/8 small intestine disease 33

Symptomatic treatment giving tranquilizer Antispasmodic Sedative

23/4/8 small intestine disease 34

23/4/8 small intestine disease 35

B.Nonoperative TreatmentB.Nonoperative Treatment

Indications: Nonstrangulated adhesive obstruction Obturative obstruction resulting of ascariasi

s and constipation Incomplete obstruction Intussusception in child Inguinal hernia

23/4/8 small intestine disease 36

Methods:a. Emollient: paraffin oil

b. Enema: suds

c. Traditional Chinese Herb intake

d. Acupuncture

e. Physical treatment

23/4/8 small intestine disease 37

close observation is very important.

worsed, transferred to surgical intervention.

23/4/8 small intestine disease 38

C. Surgical TreatmentC. Surgical Treatment

Indication: strangulated obstruction closed-loop obstruction simple obstruction without respond to nonop

eration more than 96 hours

23/4/8 small intestine disease 39

The surgical procedures includes:1)Lysis of adhesion, reduction of intussusception, torsion. 2)Enterectomy and anastomosis.3)Bypass procedure for nonresectable lesions.4)Enterostomy

Treatment of obstructing carcinoma colon

23/4/8 small intestine disease 40

1). Lysis of adhesion

23/4/8 small intestine disease 41

reduction of torsion

23/4/8 small intestine disease 42

2)Enterectomy and 3)Bypass procedure for anastomosis. nonresectable lesions.

23/4/8 small intestine disease 43

4)Enterostomy

23/4/8 small intestine disease 44

Postoperative care: Gastrointestinal decompression Electrolyte management Nutrition support Antibiotics

23/4/8 small intestine disease 45

23/4/8 small intestine disease 46

The Common Types Of Intestinal Obstruction

23/4/8 small intestine disease 47

Peritoneal Adhesions and Bands----Adhesive Obstruction

23/4/8 small intestine disease 48

Etiology

• Previous laparotomy

• Abdominal inflammatory

• Trauma

• Congenital diseases

23/4/8 small intestine disease 49

Pathology

• strangulated easily by band formation

23/4/8 small intestine disease 50

Classification

• diffuse adhesion

• adhesion angulation

• band compression

• internal hernia

23/4/8 small intestine disease 51

1. band compression 2. adhesion angulation

23/4/8 small intestine disease 52

Diagnosis

• intestinal obstruction

• previous laparotomy

• abdominal infection

• trauma

23/4/8 small intestine disease 53

Prophylaxis

• avoiding any unnecessary trauma, strangulation of tissue, contamination, and foreign body such as excessive suture. modifying the propensity of patient

23/4/8 small intestine disease 54

Treatment

• nonoperative:– nasogastric intubation– emollient filling stomach– enema with traditional Chinese herb

23/4/8 small intestine disease 55

• operative:– lysis of adhesions or bands– enterectomy for strangulated intestinal loop

or adhesive loop mass– bypass anastomosis for difficult situation or

critical case– placation for recurrent case

23/4/8 small intestine disease 56

Placation for recurrent case

23/4/8 small intestine disease 57

23/4/8 small intestine disease 58

Volvulus

• Definition: It is a twisting or rotation of the bowel upon its mesentery and induces strangulation when it twist more than 180°with a high mortality.

23/4/8 small intestine disease 59

Etiology

• too long mesentery

• too heavy intestinal contents

• Malrotation

• adhesion

23/4/8 small intestine disease 60

Pathology

• Rotation around the mesenteric axis closed-loop obstruction

23/4/8 small intestine disease 61

Classification

• sigmoid colon volvulus in the elder with constipation

• small bowel volvulus in the younger with strenuous exercises after full dinner

23/4/8 small intestine disease 62

small bowel volvulus sigmoid colon volvulus

23/4/8 small intestine disease 63

Clinical Features

• sudden severe abdominal pain

• Others like SBO

23/4/8 small intestine disease 64

Diagnosis

• sigmoid colon volvulus: indentation (bird beak sign) while enema

• small bowel volvulus: shock in early stage and difficulty to differentiate from other types until laparotomy

23/4/8 small intestine disease 65

Volvulus of sigmoid colon• The coffee bean sign. • The greatly dilated

sigmoid almost fills the entire abdomen.

23/4/8 small intestine disease 66

Volvulus of sigmoid colon

• The bird sign

23/4/8 small intestine disease 67

Treatment

• fiber colonoscopic reduction for the early stage of the sigmoid vulvulus and then rectal tube fixed in place for 2-3 days

• surgical intervention immediately in small bowel volvulus and most of sigmoid vulvulus:– reduction for nonstrangulation situation

– Resection the gangrenous bowel (short bowel syndrome, sigmoid colostomy)

23/4/8 small intestine disease 68

23/4/8 small intestine disease 69

Intussusception

• Definition: It is the invagination of a part of the intestinal tract into the lumen of the adjacent intestine.

23/4/8 small intestine disease 70

23/4/8 small intestine disease 71

Etiology

• Irregular peristalsis in child less than 2 years old

• Intestinal neoplasm and abdominal inflammatory causing chronic recurrent intussusceptions

23/4/8 small intestine disease 72

Classification

• small intestine to small intestine

• colon to colon

• ileocecal intussusception (Dance sign: empty in right low quadrant)

23/4/8 small intestine disease 73

small intestine to small intestine

ileocecal intussusception Ileum, cecum to colon

colon to colon

23/4/8 small intestine disease 74

Clinical Features

• abdominal pain

• abdominal mass

• melena (currant jelly stool)

23/4/8 small intestine disease 75

Diagnosis

• colonic intussesception shows the glass sign while the enema

23/4/8 small intestine disease 76

barium enema

Intussusception

23/4/8 small intestine disease 77

• A 47-year-old man presenting with features of small-bowel obstruction.

• Image shows a coiled-spring appearance in the region of the cecum suggestive of an intussusception.

• At laparotomy, an ileocecal intussusception was found in association with a carcinoid tumor of the terminal ileum.

23/4/8 small intestine disease 78

• A complex mass of concentric rings of alternating low- and high-attenuating layers surrounding a very high attenuation center due to intraluminal Gastrografin.

• At laparotomy, a chronic jejunojejunal intussusception was found.

23/4/8 small intestine disease 79

Computed tomography

• Anatomic segment involved

• Tumor mass as lead point

• Three concentric circles indicating segment of bowel invaginated into another

23/4/8 small intestine disease 80

Treatment

• enema reduction for children and some early stage cases:– barium enema with hydrostatic pressure– or air enema with high-pressure

23/4/8 small intestine disease 81

• surgical intervention for adult patients, the failure of enema reduction, and the case with peritonitis:– reduction for nonstrangulation situation– resection the gangrenous bowel (short bowel

syndrome, colostomy)– remove the cause in adult

23/4/8 small intestine disease 82

23/4/8 small intestine disease 83

23/4/8 small intestine disease 84

Obturation

• Definition: It refers to intestinal lumen blockage by an intraluminal foreign body.

23/4/8 small intestine disease 85

Etiology

• impacted feces

• Gallstone

• Gutstone

• Group of ascarids

• foreign body

23/4/8 small intestine disease 86

Pathology

• simple mechanical obstruction

23/4/8 small intestine disease 87

Clinical Features

• severe abdominal pain and abdominal tender mass

23/4/8 small intestine disease 88

Diagnosis

• the differentiation between symptom and sign by different causes

23/4/8 small intestine disease 89

• A case of ascariasis in the small intestine found by barium meal examination

23/4/8 small intestine disease 90

Ascarids in small intestine

23/4/8 small intestine disease 91

obstruction caused by ascarids

23/4/8 small intestine disease 92

Treatment

• symptomatic management

• oxygen filling to stomach (100 ml/years old, total <1500 ml) for ascarids

• paraffin filling to stomach or enema for bezoar (stone in stomach)

• laparotomy for broken of obstructive mass, enterotomy for obstructive body

23/4/8 small intestine disease 93

23/4/8 small intestine disease 94

Other disese in small intestine

23/4/8 small intestine disease 95

tumor in small intestine

23/4/8 small intestine disease 96

trauma of small intestine

23/4/8 small intestine disease 97

23/4/8 small intestine disease 98

23/4/8 small intestine disease 99

small intestine diverticulum

23/4/8 small intestine disease 100

small intestine diverticulum and perforation

23/4/8 small intestine disease 101

Aneurysm type B-cell lymphoma of the Aneurysm type B-cell lymphoma of the

jejunum with remarkable wall thickeningjejunum with remarkable wall thickening

23/4/8 small intestine disease 102

A case of a metastatic jejunal tumor originating fA case of a metastatic jejunal tumor originating from pulmonary giant cell carcinoma in a patient rom pulmonary giant cell carcinoma in a patient whose chief complaint was melena.whose chief complaint was melena.

23/4/8 small intestine disease 103

DiscussionDiscussion

23/4/8 small intestine disease 104

CASE HISTORYCASE HISTORY

A 47-year-old male is admitted to the emergency room with a 36- hour history of lower abdominal pain, nausea, and vomiting. The patient describes the pain as crampy in nature and notes that his abdomen has become distended over the last 12 hours. His last bowel movement was three days prior to presentation.

23/4/8 small intestine disease 105

His past medical history is remarkable in that he underwent an appendectomy for acute appendicitis eight months ago. He is otherwise healthy and takes no medications.

23/4/8 small intestine disease 106

Physical exam reveals a temperature of 38. His abdomen is distended.℃

There is mild tenderness periumbilically but no guarding or rebound. High-pitched bowel sounds are present and rectal exam reveals no stool in the rectum.

23/4/8 small intestine disease 107

Admitting laboratory dateAdmitting laboratory date

A hemoglobin of 16, hematocrit 48, white blood cell count 12,200 with 74 polys.

Serum electrolytes are normal An abdominal X-RAY reveals multiple dilat

ed loops of small bowel with numerous air fluid levels. There is no gas or stool visible in the colon

23/4/8 small intestine disease 108

Symptoms of the patientsSymptoms of the patients

Pain Vomiting Obstipation Abdominal distention

23/4/8 small intestine disease 109

Signs of the patientsSigns of the patients

Vital Signs: temperature of 38℃

His abdomen is distended. Mild tenderness periumbilically but no guar

ding or rebound. High-pitched bowel sounds Rectal exam reveals no stool in the rectum

23/4/8 small intestine disease 110

Laboratory StudyLaboratory Study

A hemoglobin of 16, hematocrit 48, show hemoconcentration

White blood cell count 12,200 with 74 polys and 5 bands, show inflammation.

Serum electrolytes are normal

23/4/8 small intestine disease 111

Radiography examRadiography exam

An abdominal X-RAY reveals multiple dilated loops of small bowel with numerous air fluid levels. There is no gas or stool visible in the colon

To confirm the diagnosis

23/4/8 small intestine disease 112

DiagnosisDiagnosis

Intestinal obstuction

23/4/8 small intestine disease 113

Whether the obstruction is mechanic

al or dynamic:

the crampy abdominal pain and hig

h-pitched bowel sounds

23/4/8 small intestine disease 114

Whether the obstruction is simple or strangulation obstruction: Indications for strangulation:a. Developing continuous violently rather than intermittent painb. Crisis rapidly and presence of toxemia (elevated temperature and leukocyte count), shock and rapid pulsec. Obvious peritoneal irritationd. A palpable tender abdominal mass with asymmetric distention

23/4/8 small intestine disease 115

e. Bloody gastrointestinal contents

f. Single distending gut loop or pseudo-neoplasm sign on plain abdominal film

g. A large amount of bloody ascites

h. No relieving evidence to intensive nonoperative treatment

23/4/8 small intestine disease 116

Whether the obstruction is complete or

incomplete:

complete

23/4/8 small intestine disease 117

Postoperative adhesions,

Postinflammatory origin

Henias

Congenital malformations

Intestinal intussusception

Obstruction of parasite origin

Carcinomas and dry feces.

Which causes leads to obstruction:

His past medical history is remarkable in that he underwent an appendectomy for acute appendicitis eight months ago.

23/4/8 small intestine disease 118

Adhesive obstruction: diagnosis based on not finding any other cause of obstruction

Obstruction due to carcinomatosis: mass or bowel wall thickening along serosa of bowel at the transition zone

Crohn's disease: inflammatory mesenteric mass or discrete loculated fluid collection

Sigmoid volvulus: whirl sign

23/4/8 small intestine disease 119

Acute cholecystitis: enlarged thick walled gallbladder

Pancreatitis: swelling and fluid around pancreas

Mesenteric ischemia: thickened bowel wall, focal dilatation, pneumatosis

Acute appendicitis: inflammatory changes in fat around appendix

23/4/8 small intestine disease 120

TreatmentTreatment

Nonoperative Treatment Correcting of fluid and electrolytes im

balance and acid-base disturbance Gastrointestinal decompression Antibiotics Symptomatic treatment

23/4/8 small intestine disease 121

By close observation Exacerbated, transferred to

surgical intervention.

23/4/8 small intestine disease 122

Surgical treatment: if doubt strangulated obstruction Lysis of adhesion Enterectomy and anastomosis

23/4/8 small intestine disease 123

ConclusionConclusion

23/4/8 small intestine disease 124

Diagnosis

must make clear the following questions:1.Whether intestinal obstruction exists

2.Whether the obstruction is mechanical or dynamic

23/4/8 small intestine disease 125

3.Whether the obstruction is simple or strangulation obstruction: Indications for strangulation:a. Developing continuous violently rather than intermittent painb. Crisis rapidly and presence of toxemia (elevated temperature and leukocyte count), shock and rapid pulsec. Obvious peritoneal irritationd. A palpable tender abdominal mass with asymmetric distention

23/4/8 small intestine disease 126

e. Bloody gastrointestinal contents

f. Single distending gut loop or pseudo-neoplasm sign on plain abdominal film

g. A large amount of bloody ascites

h. No relieving evidence to intensive nonoperative treatment

23/4/8 small intestine disease 127

4.Whether the obstruction is high or low

5.Whether the obstruction is complete or incomplete

6.Which causes leads to obstruction

23/4/8 small intestine disease 128

TreatmentTreatment Basic TreatmentBasic Treatment

Fluid and electrolytes replacement Gastrointestinal decompression Antibiotics Symptomatic treatment

23/4/8 small intestine disease 129

Surgical TreatmentSurgical Treatment

Indication: strangulated obstruction closed-loop obstruction simple obstruction without respond to nonop

eration more than 96 hours

23/4/8 small intestine disease 130

The surgical procedures includes:1)Lysis of adhesion, reduction of intussusception, torsion. 2)Enterectomy and anastomosis.3)Bypass procedure for nonresectable lesions.4)Enterostomy and exteriorization of intestine. Treatment of obstructing carcinoma colon

23/4/8 small intestine disease 131

The Common Types Of The Common Types Of Intestinal ObstructionIntestinal Obstruction

23/4/8 small intestine disease 132

Adhesive ObstructionAdhesive Obstruction

23/4/8 small intestine disease 133

DiagnosisDiagnosis

intestinal obstruction previous laparotomy abdominal infection trauma

23/4/8 small intestine disease 134

TreatmentTreatment

nonoperative: operative:

23/4/8 small intestine disease 135

VolvulusVolvulus

Definition: It is a twisting or rotation of the bowel upon its mesentery and induces strangulation when it twist more than 180°with a high mortality.

23/4/8 small intestine disease 136

ClassificationClassification

sigmoid colon volvulus in the elder with constipation

small bowel volvulus in the younger with strenuous exercises after full dinner

23/4/8 small intestine disease 137

IntussusceptionIntussusception

Definition: It is the invagination of a part of the intestinal tract into the lumen of the adjacent intestine.

23/4/8 small intestine disease 138

EtiologyEtiology

Irregular peristalsis in child less than 2 years old

Intestinal neoplasm and abdominal inflammatory causing chronic recurrent intussusceptions

23/4/8 small intestine disease 139

Clinical FeaturesClinical Features

abdominal pain abdominal mass melena (currant jelly stool)

23/4/8 small intestine disease 140

Obturation Obturation EtiologyEtiology

impacted feces Gallstone Gutstone Group of ascarids foreign body

23/4/8 small intestine disease 141