Download Intestinal Resection

Intestinal Resection
Ileal resection
Vitamin
B12 & Bile salt malabsorption.
Watery diarrhea & Fat malabsorption.
Lithogenic bile formation: Gallbladder stones.
Oxalate renal stones.
Investigations
Barium
Follow through.
Tests for B12 & Bile acid absorption.
Treatment
Parantral Vit.B12 supply.
Colystyramine or Aluminium Hydroxide for diarrhea.
Massive Resection ( Short Bowel Syndrome )
Aetiology:
 Children:
1-Congenital anomalies ( Artesia ,Volvulus ).
2-Necrotizing Enterocolitis.
 Adults:
1-Crohn ,s disease.
2-Mesenteric infarction.
3-Radiation Enteritis.
4-Volvolus.
Radiation Enteritis & Proctocolitis
Clinical features:
A-Acute phase:
 Nausea , vomiting , cramping abdominal pain & diarrhea.
 Rectal involvement: rectal mucus , tenesmus & bleeding .
B-Chronic complications:
 Proctocolitis.
 Small bowel stricture.
 Fistulae: Recto-vaginal ,colo-vesical.
 Adhesions.
 Malabsorption: Bacterial overgrowth, bile salt malabsorption (
Ileal damage ).
Investigations:
In acute phase rectal changes at sigmoidoscopy: like
ulcerative proctitis.
Barium follow through: Small bowel stricture, ulcer & fistulae.
Management:

Anti- diarrheal agents.
 Local steroid enemas.
 Antibiotic.
 Nutritional supply.
 Colystyramin ( 4 g ).
 Endoscopic laser therapy.
 Surgery for complications.
Motility disorders
Chronic intestinal pseudo-obstruction
Causes:
 Primary or Idiopathic:
1-Rare familial visceral myopathies or neuropathies.
2-Congenital aganglionosis.

Secondary:
1- Drugs: ex. Opiates ,TCA , Phenothiazines.
2-Smooth muscle disorders: ex. Scleroderma.
3-Myenteric plexus disorders : ex. Paraneoplastic
syndrome.
4-CNS disorders: ex. Parkinsonism.
5-Endocrine & Metabolic disorders: ex.
hypothyroidism.
Clinical features:





Recurrent episodes of nausea , abdominal discomfort & distension.
Alternating constipation & diarrhea.
Weight loss from malabsorption, fear of eating .
Dysphagia.
Bladder dysfunction.
Investigations:



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Plain abdominal X-Ray: Distended loops of the bowel + air fluid level.
Barium studies: No mechanical obstruction.
Laprotomy: to exclude obstruction & to obtain full thickness biopsies
of the intestine.
Electron microscopy, Histochemistry & especial stain for deficiency of
rare & specific syndromes.
Management:




Treatment of underlying cause.
Prokinetic agents ( Domperidone ).
Antibiotic.
Nutritional & psychiatric support.
,
Whipple s
disease
Characterized by infiltration of intestinal
mucosa by (foamy macrophages) which stain
+ve with Periodic Acid Shiff ( PAS ) reagent.
Multisystem involvement.
EM: G +ve Bacilli ( Tropheryma whippelli)
within the macrophages.
Villi are widened & flattened .
Obstruction of lymphatic cause fat
malabsorbtion.
Management
 Is
often fatal if not treated.
 Respond
to IV Ceftriaxone(2g daily for 2 weeks)
followed by oral co-trimoxazole for at least one
year.
 Symptoms
resolve within a week & biopsy
changes revert to normal in few weeks.
 Long
term follow up is essential. relapse usually
occur in CNS which treated by same treatment or
Doxycycline & Hydroxychroroquine.
Abdominal Tuberculosis
 Caused
by M tuberculosis which is
swallowed after coughing.
 Many patients have no pulmonary
symptoms & a normal CXR.
 The area most commonly affected is
the ileocaecal region.
 The presentations & radiological
findings may be very similar to Crohns
disease.




Abdominal pain can be acute or of several months duration
but diarrhea is less common in TB than in Crohns disease.
Low grade fever is common.
Can affect any part of the GIT & perianal disease & fistula
can occur.
Peritoneal TB may result in peritonitis with exudative
ascites .
 Diagnosis: High ESR , raised alkaline phosphatase

suggest hepatic involvement.
Histological confirmation by endoscopy ,laparoscopy or
liver biopsy can showed caseated granuloma, culture may
help , PCR of biopsy specimen make diagnosis possible.
 Management: Four Anti –TB drugs Isoniazid,
Rifampicin, Pyrazinamide & Ethambutole.
Adverse Food Reaction
Food intolerance
Lactose intolerance:
Lactose
Lactase
Glucose + galactose
Primary ( Racial ).
o Secondary ( Lactase deficiency ):
1-Coeliac disease .
2-Viral gastroenteritis.
o
Clinical features:
Asymptomatic.
o Colicky abdominal pain, abdominal distension, diarrhea.
o Picture like IBS.
** Lactose hydrogen breath test s useful non invasive confirmatory test **
o
Treatment:


lactose exclusion.
Commercial lactase preparations supply.
Food allergy:
Immune mediated disorders due to IgE Ab & type 1
hypersensitivity reaction.
Culprits: are peanuts , milk, Soya …. Etc.
Clinical manifestations:
Trivial – Life threatening or even fatal anaphylaxis.
Oral allergy syndrome: Urticaria & angioedema.
Allergic gastroenteropathy.
Gastrointestinal anaphylaxis.
** Double blind placebo- controlled food challenges are the
gold standard **
Treatment:
Elimination of offending antigen.
Antihistamines.
Disodium cromoglycate.
Treatment of anaphylaxis.
Tumours of the small intestine
Benign Tumours:
Adenoma , Leiomyoma , Lipoma & Hamartoma
Adenoma usually occur in preampullary area.
Usually asymptomatic , occult bleeding ,
obstruction due to intussusceptions , may be
multiple ( FAP ).
Hamartoma occur in Peutz-Jegher syndrome (
non malignant )
Malignant tumours
Adenocarcinoma , Carcinoid , Liemyosarcoma,
Lymphoma , Kaposi sarcoma in AIDS patients.
Adenocarcinoma: FAP
Coeliac disease
Peutz-Jeghers syndrome
Investigations: Barium Follow through
Small bowel enema.
Enteroscopy
Mesenteric angiography
CT scan
Carcinoid tumours
Derived from enterochromafin cells & most common in
ileum.
 Lesions >2cm :local extension & metastasis to the
liver.
 In the rectum & appendix usually benign.
Carcinoid syndrome
Systemic symptoms produced when secretory
products of the neoplastic enterochromafin
cells reach the systemic circulation ( 5HT,
serotonin) Bradykinin are released by
hepatic metastasis.
Clinical features
 Small
bowel obstruction.
 Intestinal ischemia.
 Hepatic metastasis: pain , hepatomegaly.
 Flushing & wheezing.
 Diarrhea.
 Cardiac involvement: TR, PS & Heart failure.
 Facial telangectasia.
Management

Surgical resection.

Treatment of Carcinoid syndrome is
palliative .

Surgical resection of the primary &
hepatic secondaries.

Octeriotide 200 Mg 8h.
Lymphoma


Non Hodgkin's lymphoma occur with increased frequency in
patients with Coeliac disease , AIDS & other immune deficiency
states.
Mostly B cell origin , while in Coeliac Enteropathy associated T
–cell lymphoma.
Presentations:
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Abdominal pain.
Malabsorption.
Obstruction.
Weight loss.
Perforation
Hepatosplenomegaly is rare.
Investigations:
Small bowel biopsy.
Barium follow through.
CT scan.
Treatment:
Surgical resection.
Radiotherapy + Combination chemotherapy.
Prognosis:
Stage at diagnosis.
Cell type.
Patient age.
Presence of B symptoms
Ischemic Gut Injury
 Acute Small Bowel Ischemia:
Occlusive: Emboli from the heart.
Non-occlusive: Decrease BP
HF
Arrhythmia.
Sudden blood loss
Pathology :Transient alteration of bowel function.
Transmural haemorrhage: Gangrene.
Clinical features
 Abdominal pain+
 Abdominal distension +
 Signs of peritonitis.
Investigations:
 Increased WBC count.
 Metabolic acidosis.
 Hyperphosphetemia.
Increased S. Amylase.
Plain XR: Thumb printing.
Mesenteric Angiography:
Treatment
Resuscitation.
Correction of heart disease.
IV antibiotics.
Laprotomy.
Embolectomy & vascular
reconstruction.
Small bowel transplantation.
 Chronic Mesenteric ischemia
Atherosclerosis of 2 or more Coeliac axis
branches.
Clinical features:
Post brandial pain.
Weight loss.
Diarrhea.
O/E: Signs of generalized arterial disease
Abdominal bruit.
Mesenteric angiography confirm the diagnosis.
Treatment: Vascular reconstruction.