small intestine diseases 2

23/4/8 small intestine disease 1

Intestinal ObstructionIntestinal Obstruction

肠梗阻肠梗阻


DefinationDefination

A blockade of the flow of intestinal content.


Etiology and classification 1.According to its basic causes:

mechanical obstruction

dynamic obstruction

obstruction of vascular supply origin


2.According to whether the vascular supply to

intestinal wall is compromised, Simple and

strangulation obstruction.


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


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


PathophysiologyPathophysiology A.Local EffectsA.Local Effects

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


B.B. Systemic EffectsSystemic Effects

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


Clinical manifestations Abdominal pain Nausea and vomiting Obstipation Abdominal distention.


Physical Examination

the signs of dehydration:

Vital Signs:


a.Inspection: visible peristalsis

distending gut

incisions of previous surgery


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

referred tenderness

muscle spasm the mass in abdominal cavity


c.Percussion: Tympanic resonance Shifting dullness demonstrates ascites.


d.Auscultation: Bowel sounds increased Intestinal sound is absent


Laboratory StudyLaboratory Study

Hemoconcentration Leukocyte counts Water and electrolyte imbalance Acid-base imbalance


Radiological ExaminationRadiological Examination A plain abdominal film

dilated loops of small intestine multiple air-fluid level

Computed tomography



EndoscopyEndoscopy

Early ileal carcinoma demonstrating submucosal invasion


•disposable capsule: disposable capsule:

30 x 11 mm30 x 11 mm

Capsule Capsule endoscopyendoscopy


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


Capsule endoscocpy : normal Capsule endoscocpy : normal findingsfindings


Capsule endoscopyCapsule endoscopy

angiodysplasia, jejunum bleeding angiodysplasia, ileum


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.


2.Whether the obstruction is

mechanical or dynamic:

mechanical obstruction, typical

symptoms and signs.

paralytic obstruction, cramping

abdominal pain is absent, distention is

prominent


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


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


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.


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.


TreatmentTreatment

Principles: Correcting of fluid and electrolytes

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

removing the cause of obstruction


A. Basic TreatmentA. Basic Treatment

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

sodium lactate Potassium deficit


Gastrointestinal decompression Intubation with gastrointestinal tube (g

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


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


Symptomatic treatment giving tranquilizer Antispasmodic Sedative



B.Nonoperative TreatmentB.Nonoperative Treatment

Indications: Nonstrangulated adhesive obstruction Obturative obstruction resulting of ascariasi

s and constipation Incomplete obstruction Intussusception in child Inguinal hernia


Methods:a. Emollient: paraffin oil

b. Enema: suds

c. Traditional Chinese Herb intake

d. Acupuncture

e. Physical treatment


close observation is very important.

worsed, transferred to surgical intervention.


C. Surgical TreatmentC. Surgical Treatment

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

eration more than 96 hours


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


1). Lysis of adhesion


reduction of torsion


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


4)Enterostomy


Postoperative care: Gastrointestinal decompression Electrolyte management Nutrition support Antibiotics



The Common Types Of Intestinal Obstruction


Peritoneal Adhesions and Bands----Adhesive Obstruction


Etiology

• Previous laparotomy

• Abdominal inflammatory

• Trauma

• Congenital diseases


Pathology

• strangulated easily by band formation


Classification

• diffuse adhesion

• adhesion angulation

• band compression

• internal hernia


1. band compression 2. adhesion angulation


Diagnosis

• intestinal obstruction

• previous laparotomy

• abdominal infection

• trauma


Prophylaxis

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


Treatment

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


• 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


Placation for recurrent case



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.


Etiology

• too long mesentery

• too heavy intestinal contents

• Malrotation

• adhesion


Pathology

• Rotation around the mesenteric axis closed-loop obstruction


Classification

• sigmoid colon volvulus in the elder with constipation

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


small bowel volvulus sigmoid colon volvulus


Clinical Features

• sudden severe abdominal pain

• Others like SBO


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


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

sigmoid almost fills the entire abdomen.

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Volvulus of sigmoid colon

• The bird sign


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)



Intussusception

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



Etiology

• Irregular peristalsis in child less than 2 years old

• Intestinal neoplasm and abdominal inflammatory causing chronic recurrent intussusceptions


Classification

• small intestine to small intestine

• colon to colon

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


small intestine to small intestine

ileocecal intussusception Ileum, cecum to colon

colon to colon


Clinical Features

• abdominal pain

• abdominal mass

• melena (currant jelly stool)


Diagnosis

• colonic intussesception shows the glass sign while the enema


barium enema

Intussusception


• 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.



• 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.



Computed tomography

• Anatomic segment involved

• Tumor mass as lead point

• Three concentric circles indicating segment of bowel invaginated into another


Treatment

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


• 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




Obturation

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


Etiology

• impacted feces

• Gallstone

• Gutstone

• Group of ascarids

• foreign body


Pathology

• simple mechanical obstruction


Clinical Features

• severe abdominal pain and abdominal tender mass


Diagnosis

• the differentiation between symptom and sign by different causes


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


Ascarids in small intestine


obstruction caused by ascarids


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



Other disese in small intestine


tumor in small intestine


trauma of small intestine




small intestine diverticulum


small intestine diverticulum and perforation


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

jejunum with remarkable wall thickeningjejunum with remarkable wall thickening


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.


DiscussionDiscussion


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.


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.


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.


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


Symptoms of the patientsSymptoms of the patients

Pain Vomiting Obstipation Abdominal distention


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


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


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


DiagnosisDiagnosis

Intestinal obstuction


Whether the obstruction is mechanic

al or dynamic:

the crampy abdominal pain and hig

h-pitched bowel sounds


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







Whether the obstruction is complete or

incomplete:

complete


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.


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


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


TreatmentTreatment

Nonoperative Treatment Correcting of fluid and electrolytes im

balance and acid-base disturbance Gastrointestinal decompression Antibiotics Symptomatic treatment


By close observation Exacerbated, transferred to

surgical intervention.


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


ConclusionConclusion


Diagnosis

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

2.Whether the obstruction is mechanical or dynamic


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







4.Whether the obstruction is high or low

5.Whether the obstruction is complete or incomplete

6.Which causes leads to obstruction


TreatmentTreatment Basic TreatmentBasic Treatment

Fluid and electrolytes replacement Gastrointestinal decompression Antibiotics Symptomatic treatment


Surgical TreatmentSurgical Treatment

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

eration more than 96 hours


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


The Common Types Of The Common Types Of Intestinal ObstructionIntestinal Obstruction


Adhesive ObstructionAdhesive Obstruction


DiagnosisDiagnosis

intestinal obstruction previous laparotomy abdominal infection trauma


TreatmentTreatment

nonoperative: operative:


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.


ClassificationClassification

sigmoid colon volvulus in the elder with constipation

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


IntussusceptionIntussusception

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


EtiologyEtiology

Irregular peristalsis in child less than 2 years old

Intestinal neoplasm and abdominal inflammatory causing chronic recurrent intussusceptions


Clinical FeaturesClinical Features

abdominal pain abdominal mass melena (currant jelly stool)


Obturation Obturation EtiologyEtiology

impacted feces Gallstone Gutstone Group of ascarids foreign body


Health & Medicine

small intestine diseases 2