Small Intestine.ppt

Small IntestineSmall IntestineJames Taclin C. Banez, MDJames Taclin C. Banez, MD

Small IntestineSmall Intestineone of the most important organs for one of the most important organs for immune defenseimmune defenselargest endocrine organ of the bodylargest endocrine organ of the bodyStarts from the pylorus and ends at the Starts from the pylorus and ends at the cecumcecum3 parts:3 parts:

1.1. DuodenumDuodenum (20cm) (20cm)2.2. JejunumJejunum (100 to 110cm) (100 to 110cm)3.3. IleumIleum (150 to 160 cm) (150 to 160 cm)

AnatomyAnatomyHas plicae circulares or valves of Has plicae circulares or valves of KerkringKerkring

A.A. Duodenum:Duodenum: Retro-peritonealRetro-peritoneal Supplied by the celiac arterySupplied by the celiac artery

B.B. Jejunum:Jejunum: Occupies upper left of the abdomenOccupies upper left of the abdomen Thicker wall and wider lumen than the Thicker wall and wider lumen than the

ileumileum Mesentery has less fat and forms only Mesentery has less fat and forms only

1-2 arcades1-2 arcadesC.C. Ileum:Ileum:

Occupies the lower right; has more fat Occupies the lower right; has more fat and forms more arcadesand forms more arcades

Contains Contains Payer’s patchesPayer’s patches Ileum & jejunum is supplied by the SMAIleum & jejunum is supplied by the SMA

FunctionFunctionA.A. Digestion & Absorption:Digestion & Absorption:B.B. Endocrine Function:Endocrine Function:

– Secretes numerous hormones involved in GIT Secretes numerous hormones involved in GIT function.function.

1.1. SecretinSecretin2.2. CholecystokeninCholecystokenin3.3. Gastric inhibitory peptideGastric inhibitory peptide4.4. EnteroglucagonEnteroglucagon5.5. Vasoactive intestinal peptideVasoactive intestinal peptide6.6. MotilinMotilin7.7. BombesinBombesin8.8. SomatostatinSomatostatin9.9. NeurotensinNeurotensin

FunctionFunctionC.C. Immune function:Immune function:

1.1. Major source ofMajor source of IgAIgA2.2. Integrity of the GUT wallIntegrity of the GUT wall prevents bacterial prevents bacterial

translocation into the wall of the intestine translocation into the wall of the intestine and abdominal cavity which can lead to and abdominal cavity which can lead to sepsissepsis

3.3. Gut associated lymphoid tissueGut associated lymphoid tissue – part of the – part of the immune defense system which clears the immune defense system which clears the abdominal cavity of pathogenic bacteria abdominal cavity of pathogenic bacteria found in found in Peyer’s patchesPeyer’s patches

Small Bowel Surgical LesionsSmall Bowel Surgical Lesions

1.1. Small bowel obstruction:Small bowel obstruction:a.a. MechanicalMechanicalb.b. IleusIleus

2.2. Small bowel infectionSmall bowel infection3.3. Chronic inflammationChronic inflammation4.4. NeoplasmNeoplasm5.5. DiverticulaDiverticula6.6. Short bowel syndromeShort bowel syndrome

Small Bowel ObstructionSmall Bowel ObstructionCauses of Causes of Mechanical ObstructionMechanical Obstruction::

1.1. Post-operative adhesionPost-operative adhesion (75%) (75%)2.2. HerniasHernias3.3. Crohn’s diseaseCrohn’s disease4.4. Neoplasm (primary or extrinsic compression Neoplasm (primary or extrinsic compression

or invasion)or invasion)5.5. Superior mesenteric artery syndrome Superior mesenteric artery syndrome

(compression of transverse duodenum)(compression of transverse duodenum)

Pathophysiology:Pathophysiology:

Accdg. to it’s anatomical relationship to Accdg. to it’s anatomical relationship to the intestinal wall:the intestinal wall:

1.1. Intraluminal Intraluminal ( foreign bodies, gallstone, and ( foreign bodies, gallstone, and meconium)meconium)

2.2. IntramuralIntramural (neoplasm, Crohn’s, (neoplasm, Crohn’s, hematomas)hematomas)

3.3. Extrinsic Extrinsic (adhesion, hernias & (adhesion, hernias & carcinomatosis)carcinomatosis)

Pathophysiology:Pathophysiology:Air-fluid level:Air-fluid level: Gas – due to swallowed airGas – due to swallowed air Fluid – a) swallowed fluidFluid – a) swallowed fluid

b) gastrointestinal b) gastrointestinal secretion secretion

(increase epithelial water (increase epithelial water secretion).secretion).

Bowel distention / Bowel distention / elevated intramural elevated intramural pressure ---> ischemia pressure ---> ischemia ------> necrosis.------> necrosis.(strangulated bowel (strangulated bowel obstruction)obstruction)

Pathophysiology:Pathophysiology:

Partial small-bowel obstructionPartial small-bowel obstruction – – passage of gas and fluid.passage of gas and fluid.Complete small-bowel obstruction Complete small-bowel obstruction (obstipation)(obstipation)– Closed loop obstructionClosed loop obstruction (obstructed (obstructed

proximal and distal) ex. volvulusproximal and distal) ex. volvulus

Manifestation:Manifestation:1.1. colicky abdominal paincolicky abdominal pain2.2. nausea / vomitingnausea / vomiting3.3. obstipationobstipation4.4. abdominal distentionabdominal distention5.5. hyperactive bowel soundhyperactive bowel sound6.6. signs of dehydration (sequestration of fluid in signs of dehydration (sequestration of fluid in

bowel wall and lumen as well as poor oral bowel wall and lumen as well as poor oral intake)intake)

7.7. lab. findings:lab. findings:a.a. hemoconcentrationhemoconcentrationb.b. fluid & electrolyte imbalancefluid & electrolyte imbalancec.c. leucocytosisleucocytosis

Manifestation:Manifestation:Features of Strangulated obstructionFeatures of Strangulated obstruction::

1.1. tachycardiatachycardia2.2. localized abd. tendernesslocalized abd. tenderness3.3. feverfever4.4. marked leucocytosismarked leucocytosis5.5. acidosisacidosis6.6. lab result:lab result:

- - elevated serum amyase, lipase, LDH, elevated serum amyase, lipase, LDH, phosphate and potassiumphosphate and potassium

Diagnosis:Diagnosis:Focus on the following goals:Focus on the following goals:1.1. distinguish between mechanical obstruction distinguish between mechanical obstruction

from ileusfrom ileus2.2. determine the etiologydetermine the etiology3.3. whether it is partial or complete obstructionwhether it is partial or complete obstruction4.4. differentiate between simple and differentiate between simple and

strangulating obstructionstrangulating obstruction

Diagnosis:Diagnosis:1.1. Clinical history & PEClinical history & PE2.2. Radiological examination:Radiological examination:

a.a. FPA (supine and upright)FPA (supine and upright)Triad:Triad: 1. dilated small bowel (>3cm )1. dilated small bowel (>3cm )

2. air-fluid levels seen in upright2. air-fluid levels seen in upright3. paucity of air in the colon3. paucity of air in the colon

Sensitivity of 70-80% but with low specificity for Sensitivity of 70-80% but with low specificity for ileus and colonic obstruction mimicsileus and colonic obstruction mimics

False (-):False (-): - proximal small bowel obstruction- proximal small bowel obstruction- bowel lumen filled with fluid (can’t see - bowel lumen filled with fluid (can’t see air-fluid level)air-fluid level)

Diagnosis:Diagnosis:b.b. CT scanCT scan (90% sensitive / 90% specific) (90% sensitive / 90% specific)

– Findings of small bowel obstruction:Findings of small bowel obstruction:a.a. Discrete Discrete transition zonetransition zoneb.b. Intra-luminal contrast unable to passed beyond the Intra-luminal contrast unable to passed beyond the

transition zonetransition zonec.c. Colon containing little gas or fluidColon containing little gas or fluid

− Strangulation is suggested:Strangulation is suggested:a.a. Thickening of the bowel wallThickening of the bowel wallb.b. Pneumatosis intestinalisPneumatosis intestinalisc.c. Portal venous gasPortal venous gasd.d. Mesentery hazinessMesentery hazinesse.e. Poor uptake of intravenous contrast into the wall of the Poor uptake of intravenous contrast into the wall of the

affected bowelaffected bowel− Limitation:Limitation: unable to detect partial intestinaunable to detect partial intestina obstructionobstruction (<50% sensitivity) (<50% sensitivity)

Diagnosis:Diagnosis:c.c. Small bowel series (barium / gastrografin)Small bowel series (barium / gastrografin)

d.d. EnteroclysisEnteroclysis 200 to 250 ml of barium followed by 1 to 2 L of 200 to 250 ml of barium followed by 1 to 2 L of methylcellulose in water is instilled into the methylcellulose in water is instilled into the proximal jejunum via a long naso-enteric tubeproximal jejunum via a long naso-enteric tube

Treatment:Treatment:1.1. Correct fluid & electrolyte imbalanceCorrect fluid & electrolyte imbalance::

– Isotonic fluidIsotonic fluid– Monitor resuscitation (foley catheter/CVP)Monitor resuscitation (foley catheter/CVP)

2.2. NPO / TPNNPO / TPN3.3. Broad spectrum antibioticBroad spectrum antibiotic (due to bacterial (due to bacterial

translocation)translocation)4.4. Placed NGTPlaced NGT to decompress the stomach and to decompress the stomach and

decrease nausea, distention and risk of decrease nausea, distention and risk of aspirationaspiration

5.5. Expeditious celiotomyExpeditious celiotomy (to minimize risk of (to minimize risk of strangulation).strangulation).

– Type of operation based on operative finding Type of operation based on operative finding causing intestinal obstructioncausing intestinal obstruction

Ileus / Pseudo-ObstructionIleus / Pseudo-Obstruction

Impaired intestinal motilityImpaired intestinal motilityMost common cause of delayed discharge Most common cause of delayed discharge following abdominal operationsfollowing abdominal operationsTemporary and reversibleTemporary and reversible

Ileus / Pseudo-ObstructionIleus / Pseudo-ObstructionEtiologies:Etiologies:1.1. Abdominal surgeryAbdominal surgery2.2. Infection & inflammation (sepsis/peritonitis)Infection & inflammation (sepsis/peritonitis)3.3. Electrolyte imbalance (Hypo K, Mg & Na)Electrolyte imbalance (Hypo K, Mg & Na)4.4. Drugs (anticholinergic, opiates)Drugs (anticholinergic, opiates)5.5. Visceral myopathies (degeneration/fibrosis of Visceral myopathies (degeneration/fibrosis of

smooth muscle)smooth muscle)6.6. Visceral neuropathies (degenerative disorders of Visceral neuropathies (degenerative disorders of

myenteric & submucosal plexuses)myenteric & submucosal plexuses)

Symptoms:Symptoms:1.1. Inability to tolerate solid & liquid by Inability to tolerate solid & liquid by

mouthmouth2.2. Nausea/vomitingNausea/vomiting3.3. Lack of flatus & bowel movementsLack of flatus & bowel movements4.4. Diminished or absent bowel soundDiminished or absent bowel sound5.5. Abdominal pain and distentionAbdominal pain and distention

Diagnosis:Diagnosis:1.1. History of recent abdominal surgeryHistory of recent abdominal surgery2.2. Discontinue opiates Discontinue opiates 3.3. Serum electrolyte determinationSerum electrolyte determination4.4. CT scan better than FPA in postoperative CT scan better than FPA in postoperative

setting to exclude presence of abscess or setting to exclude presence of abscess or mechanical obstructionmechanical obstruction

Therapy:Therapy:1.1. NPO, if prolong TPN is requiredNPO, if prolong TPN is required2.2. NGT to decompress the stomachNGT to decompress the stomach3.3. Correct fluid & electrolyte imbalanceCorrect fluid & electrolyte imbalance4.4. Give Give ketorolacketorolac and reduce the dose of and reduce the dose of

opioidsopioids

CROHN’S DISEASECROHN’S DISEASERegional, transmural, granulomatous Regional, transmural, granulomatous enteritis). enteritis). Chronic, idiopathic inflammatory dseChronic, idiopathic inflammatory dseEthnic groups ---> East Europe Ethnic groups ---> East Europe (Ashkenazi Jewish) (Ashkenazi Jewish) Female predominance, 2x higher smokersFemale predominance, 2x higher smokersFamilial association (30x in siblings / 13 x Familial association (30x in siblings / 13 x in 1in 1stst degree relatives). degree relatives).Higher socioeconomic statusHigher socioeconomic statusBreast feedingBreast feeding is protective is protective

Etiology:Etiology:UnknownUnknownHypothesis:Hypothesis:

1.1. Infectious:Infectious: - Chlamydia / Pseudomonas / - Chlamydia / Pseudomonas / Mycobacterium paratuberculosis / Listeria Mycobacterium paratuberculosis / Listeria monocytogenesis / Measles / Yersinia monocytogenesis / Measles / Yersinia enterocoliticaenterocolitica

2.2. Immunologic abnormalities:Immunologic abnormalities:• Humeral & cell-mediated immune reactions against Humeral & cell-mediated immune reactions against

gut cells.gut cells.

3.3. Genetic factors:Genetic factors:• Chromosome 16Chromosome 16 (IBD1 --> NOD2) (IBD1 --> NOD2)

Pathology:Pathology:Affect any portion of GIT:Affect any portion of GIT:

– Small bowel alone (30%)Small bowel alone (30%)– Ileocolitis (55%)Ileocolitis (55%)– Colon alone (15%)Colon alone (15%)

HallmarkHallmark – focal, – focal, transmural inflammation of transmural inflammation of the intestinethe intestineEarliest signEarliest sign --> --> aphthous aphthous ulcersulcers surrounded by halo surrounded by halo erythema over a non-erythema over a non-caseating granuloma.caseating granuloma.

Pathology:Pathology:As the aphthous ulcer enlarge As the aphthous ulcer enlarge and coalesce transversely and coalesce transversely forming forming cobblestone cobblestone appearance.appearance.Advanced dseAdvanced dse ---> transmural ---> transmural inflammation. This results to:inflammation. This results to:

1.1. adhesions to adjacent bowel,adhesions to adjacent bowel,2.2. stricture formation (fibrosis), stricture formation (fibrosis), 3.3. intra-abdominal abscesses, intra-abdominal abscesses, 4.4. fistula or free perforation fistula or free perforation

(peritonitis)(peritonitis)Skip lesions and w/ fatSkip lesions and w/ fat wrappingwrapping (encroachment of (encroachment of mesenteric fat onto the serosal mesenteric fat onto the serosal surface) --> surface) --> pathognomonic pathognomonic for Crohn’s.for Crohn’s.

Clinical Manifestation:Clinical Manifestation:Most common symptom:Most common symptom:

1.1. Abdominal painAbdominal pain2.2. DiarrheaDiarrhea3.3. Weight lossWeight lossOther symptoms depends on type of Other symptoms depends on type of complications:complications:

1.1. obstruction (fibrosis)obstruction (fibrosis)2.2. perforation (peritonitis, fistula, intraabdominal abscess)perforation (peritonitis, fistula, intraabdominal abscess)3.3. toxic megacolon (marked colonic dilatation, adb. toxic megacolon (marked colonic dilatation, adb.

tenderness, fever & leukocytosis)tenderness, fever & leukocytosis)4.4. cancer (6x greater/more advanced---> poor prognosis)cancer (6x greater/more advanced---> poor prognosis)5.5. perianal dse (fissure, fistula, stricture or abscess)perianal dse (fissure, fistula, stricture or abscess)Extra-intestinal manifestation:Extra-intestinal manifestation:

– erythema nodosum & peripheral arthritis are correlated erythema nodosum & peripheral arthritis are correlated w/ severity of intestinal inflammation.w/ severity of intestinal inflammation.

Diagnosis:Diagnosis:

1.1. Endoscopy Endoscopy (esophagogastroduodenoscopy (EGD) (esophagogastroduodenoscopy (EGD) /colonoscopy) w/ biopsy./colonoscopy) w/ biopsy.

2.2. Barium enema / intestinal series Barium enema / intestinal series 3.3. Enteroclysis (small bowel) more accurateEnteroclysis (small bowel) more accurate4.4. CT scan – to reveal intra-abd. abscessesCT scan – to reveal intra-abd. abscesses

Treatment:Treatment:I.I. Medical:Medical:

– Intravenous fluidsIntravenous fluids– NGT to rest GIT (elemental diet/TPN)NGT to rest GIT (elemental diet/TPN)– Medications:Medications:

1.1. to relieve diarrheato relieve diarrhea2.2. relieve painrelieve pain3.3. control infection (antibiotic)control infection (antibiotic)4.4. Anti-inflammatory ( aminosalicylates, corticosteroid, Anti-inflammatory ( aminosalicylates, corticosteroid,

immunomodulators – azathioprime 6-immunomodulators – azathioprime 6-mercaptopurine and cyclosporinemercaptopurine and cyclosporine

5.5. Infliximab Infliximab – chimeric monoclonal anti-tumor-– chimeric monoclonal anti-tumor-necrosis-factor antibody inducing remission and in necrosis-factor antibody inducing remission and in promoting closure of enterocutaneous fistulaspromoting closure of enterocutaneous fistulas

II.II. Surgical:Surgical:– Indicated if: Indicated if:

with complicationswith complicationsMedication-induced complications ariseMedication-induced complications arise

– Cushingoid features, cataract, glaucoma, systemic Cushingoid features, cataract, glaucoma, systemic hypertension, compression fracture or aseptic hypertension, compression fracture or aseptic necrosisnecrosis

– Types:Types:Segmental resection w/ primary anastomosis:Segmental resection w/ primary anastomosis:

– Microscopic evidence of the dse at the resection Microscopic evidence of the dse at the resection margin does not compromise a safe anastomosis, margin does not compromise a safe anastomosis, hence, a frozen section is unnecessary.hence, a frozen section is unnecessary.

StricturoplastyStricturoplastyBypass procedures (gastrojejunostomy)Bypass procedures (gastrojejunostomy)

Prognosis:Prognosis:High recurrence rate (most common High recurrence rate (most common proximal to the site of previous proximal to the site of previous resection).resection).70% recur w/in 1 yr and 85% w/in 3 yrs.70% recur w/in 1 yr and 85% w/in 3 yrs.Most common complication:Most common complication:

1.1. Wound infectionWound infection2.2. Postoperative intra-abdominal abscessPostoperative intra-abdominal abscess3.3. Anastomotic leaksAnastomotic leaks

60-300 x more frequent to develop CA60-300 x more frequent to develop CA

Tuberculous Enteritis:Tuberculous Enteritis:In developing and under develop countriesIn developing and under develop countriesResurgence in develop countries due to:Resurgence in develop countries due to:

1.1. AIDS epidemicAIDS epidemic2.2. Influx of Asian migrantsInflux of Asian migrants3.3. Use of immunosuppressive agentsUse of immunosuppressive agentsForms:Forms:

1.1. Primary infectionPrimary infection (caused by M. tuberculosis (caused by M. tuberculosis bovine from ingested milk)bovine from ingested milk)

2.2. Secondary infectionSecondary infection (swallowing bacilli from (swallowing bacilli from active pulmonary) TBactive pulmonary) TB

Tuberculous Enteritis:Tuberculous Enteritis:Patterns:Patterns:

1.1. Hypertrophic – causes stenosis or obstructionHypertrophic – causes stenosis or obstruction2.2. Ulcerative – diarrhea and bleedingUlcerative – diarrhea and bleeding3.3. Ulcero-hypertrophicUlcero-hypertrophicTreatment:Treatment:

– Chemotherapy (given 2 wks prior to surgery up Chemotherapy (given 2 wks prior to surgery up to 1 yr).to 1 yr).

RifampicinRifampicinIsoniazidIsoniazidEthambutolEthambutol

– Surgery (perforation, obstruction, hemorrhage).Surgery (perforation, obstruction, hemorrhage).

Typhoid enteritis:Typhoid enteritis:Caused by Salmonella typhiCaused by Salmonella typhiDiagnosis:Diagnosis:– Culture from blood or fecesCulture from blood or feces– Agglutinins against O and H antigenAgglutinins against O and H antigen

Treatment:Treatment:– Medical:Medical:

Chloramphenicol / trimethropin-sulfamethoxazole / Chloramphenicol / trimethropin-sulfamethoxazole / amoxycillin / quinolonesamoxycillin / quinolones

– Surgical:Surgical:perforations / hemorrhageperforations / hemorrhageSegmental resection (w/ primary anastomosis or Segmental resection (w/ primary anastomosis or ileostomy)ileostomy)

NeoplasmNeoplasmRare:Rare:

1.1. Rapid transit timeRapid transit time2.2. Local immune system of the small bowel mucosa Local immune system of the small bowel mucosa

(IgA)(IgA)3.3. Alkaline pHAlkaline pH4.4. Relatively low concentration of bacteria; low Relatively low concentration of bacteria; low

concentration of carcinogenic products of bacterial concentration of carcinogenic products of bacterial metabolism.metabolism.

5.5. Presence of mucosal enzymes (hydrolases) that Presence of mucosal enzymes (hydrolases) that destroy certain carcinogensdestroy certain carcinogens

6.6. Efficient epithelial cellular apoptotic mechanisms Efficient epithelial cellular apoptotic mechanisms that serve to eliminate clones harboring genetic that serve to eliminate clones harboring genetic mutationmutation

NeoplasmNeoplasm50 – 60 y/o50 – 60 y/oRisk factors:Risk factors:

1.1. Red meatRed meat2.2. Ingestion of smoked or cured foodsIngestion of smoked or cured foods3.3. Crohn’s dseCrohn’s dse4.4. Celiac sprueCeliac sprue5.5. Hereditary nonpolyposis colorectal cancerHereditary nonpolyposis colorectal cancer

(HNPCC)(HNPCC)6.6. Familial adenomatous polyposisFamilial adenomatous polyposis (FAD) – 100% (FAD) – 100%

to develop to develop duodenal CAduodenal CA7.7. Peutz-Jeghers syndromePeutz-Jeghers syndrome

NeoplasmNeoplasmSymptoms:Symptoms:

– Most are asymptomatic Most are asymptomatic – Symptoms:Symptoms:1.1. Vague abdominal painVague abdominal pain (epigastric discomfort, N/V, (epigastric discomfort, N/V,

abd. pain, diarrhea).abd. pain, diarrhea).2.2. BleedingBleeding (hematochezia or hematemesis) (hematochezia or hematemesis)3.3. ObstructionObstruction (intussuception, circumferencial growth, (intussuception, circumferencial growth,

kinking of the bowel, intramural growth).kinking of the bowel, intramural growth). Most common mode of presentation isMost common mode of presentation is ---> --->

crampy abd. pain, distention, nausea / crampy abd. pain, distention, nausea / vomitingvomiting

HemorrhageHemorrhage usually indolent 2 usually indolent 2ndnd common common mode of presentationmode of presentation

NeoplasmNeoplasm

Diagnosis:Diagnosis:– For most are asymptomatic it is rarely For most are asymptomatic it is rarely

diagnosed preoperativelydiagnosed preoperatively– Serological examinationSerological examination

Serum 5-hydroxyindole acetic acid (HIAA)Serum 5-hydroxyindole acetic acid (HIAA) for for carcinoid.carcinoid.CEACEA associated w/ small intestinal associated w/ small intestinal adenocarcinoma but only if w/ liver metastasis.adenocarcinoma but only if w/ liver metastasis.

NeoplasmNeoplasmDiagnosis:Diagnosis:

– Radiological examination:Radiological examination:1.1. EnteroclysisEnteroclysis (test of choice – 90% sensitivity) (test of choice – 90% sensitivity)2.2. UGIS w/ intestinal follow throughUGIS w/ intestinal follow through3.3. CT scanCT scan4.4. Angiography / RBC scan --> bleeding lesionsAngiography / RBC scan --> bleeding lesions

– Endoscopy:Endoscopy:EGD (esophagus, gastric, and duodenum)EGD (esophagus, gastric, and duodenum)ColonoscopyColonoscopy

I.I. Benign tumors:Benign tumors:A.A. Adenomas:Adenomas: (most common benign neoplasm (most common benign neoplasm

– duodenum):– duodenum):1.1. True adenomas:True adenomas:

Associated w/ bleeding and obstructionAssociated w/ bleeding and obstructionUsually seen in the Usually seen in the ileumileumMajority are asymptomaticMajority are asymptomatic

2.2. Villous adenoma:Villous adenoma:Most common in the Most common in the duodenumduodenum““soap bubble” appearance on contrast radiographysoap bubble” appearance on contrast radiographyNo report of secretory diarrheaNo report of secretory diarrhea

3.3. Brunner’s gland adenomaBrunner’s gland adenomaIn the In the duodenumduodenumNo malignant potentialNo malignant potentialMimic PUDMimic PUD

Benign tumors:Benign tumors:B.B. Leiomyoma:Leiomyoma:

Most common symptomatic benign lesionMost common symptomatic benign lesionAssociated w/ Associated w/ bleedingbleedingDiagnosed by Diagnosed by angiography angiography and commonly and commonly located in the located in the jejunumjejunum2 growth pattern:2 growth pattern:

1.1. Intramurally ----> obstructionIntramurally ----> obstruction2.2. Both intramural and extramural Both intramural and extramural (Dumbbell (Dumbbell

shaped)shaped)

Benign tumors:Benign tumors:C.C. Lipoma:Lipoma:

Most common in the Most common in the ileumileumCauses obstruction (lead point of an Causes obstruction (lead point of an intussusception)intussusception)Bleeding due to ulcer formationBleeding due to ulcer formationNo malignant degenerationNo malignant degeneration

Benign tumors:Benign tumors:D.D. Peutz-Jeghers Syndrome:Peutz-Jeghers Syndrome:

– Inherited syndrome of:Inherited syndrome of:1.1. Mucocutaneous melatonic pigmentationMucocutaneous melatonic pigmentation (face, buccal (face, buccal

mucosa, palm, sole, peri-anal area)mucosa, palm, sole, peri-anal area)2.2. Gastrointestinal polypGastrointestinal polyp (enteric (enteric jejunum and ileumjejunum and ileum are are

most frequent part of GIT followed by colon, rectum and most frequent part of GIT followed by colon, rectum and stomach).stomach).

– Symptoms:Symptoms:1.1. colicky abd. pain (due to intermittent intussuception)colicky abd. pain (due to intermittent intussuception)2.2. HemorrhageHemorrhage

– Treatment:Treatment:Segmental resection of the bowel causing obstruction or Segmental resection of the bowel causing obstruction or bleeding.bleeding.Cure impossible due to widespread intestinal involvementCure impossible due to widespread intestinal involvement

II.II. Malignant neoplasm:Malignant neoplasm:Histologic types:Histologic types:Tumor typeTumor type Cell of originCell of origin FrequencyFrequency Predominant Predominant

SiteSite

adenocarcinomaadenocarcinoma Epithelial cellEpithelial cell 35 – 50%35 – 50% DuodenumDuodenum

carcinoidcarcinoid Enterochromaffin Enterochromaffin cellcell

20 – 40%20 – 40% IleumIleum

lymphomalymphoma lymphocytelymphocyte 10 – 15%10 – 15% IleumIleum

GIST GIST (gastrointestinal (gastrointestinal stromal tumors)stromal tumors)

? Interstitial cell ? Interstitial cell of Cajalof Cajal

10 – 15%10 – 15% --

Malignant neoplasm:Malignant neoplasm:

1.1. Adenocarcinoma:Adenocarcinoma:Most common CA of small bowelMost common CA of small bowelMost common in duodenum and proximal Most common in duodenum and proximal jejunumjejunumHalf involve the ampulla of Vater.Half involve the ampulla of Vater.


2.2. Carcinoid:Carcinoid:From enterochromaffin cells or From enterochromaffin cells or Kultchitsky cellsKultchitsky cellsArise from foregut, midgut & hindgutArise from foregut, midgut & hindgutAppendix (46%) > Ileum (28%) > Appendix (46%) > Ileum (28%) > Rectum (17%)Rectum (17%)

Malignant neoplasm:Malignant neoplasm:2.2. Carcinoid:Carcinoid:

Aggressive behavior than the appendiceal Aggressive behavior than the appendiceal carcinoid. carcinoid.

appendix – 3% metastasize; Ileum – 35% metastasizeappendix – 3% metastasize; Ileum – 35% metastasizeAppendix – solitary; Ileum – 30% multipleAppendix – solitary; Ileum – 30% multiple

25-50% w/ carcinoid tumor with liver 25-50% w/ carcinoid tumor with liver metastasis develops metastasis develops carcinoid syndromecarcinoid syndrome..

Secretes Secretes serotonin, bradykinin and substance Pserotonin, bradykinin and substance P1.1. DiarrheaDiarrhea2.2. FlushingFlushing3.3. HypotensionHypotension4.4. tachycardia tachycardia 5.5. fibrosis of endocardium and valves of the right heart.fibrosis of endocardium and valves of the right heart.


3.3. Lymphomas:Lymphomas:Most common intestinal neoplasm in Most common intestinal neoplasm in children under 10y/o.children under 10y/o.In adult = 10-15% of small bowel malignant In adult = 10-15% of small bowel malignant tumorstumorsMost common presentationMost common presentation

1.1. intestinal obstructionintestinal obstruction2.2. Perforation (10%)Perforation (10%)

Malignant neoplasm:Malignant neoplasm:3.3. Lymphomas:Lymphomas:

Criteria of primary lymphomas of the small Criteria of primary lymphomas of the small bowel:bowel:

1.1. Absence of peripheral lymphadenopathyAbsence of peripheral lymphadenopathy2.2. Normal chest x-ray w/o evidence of Normal chest x-ray w/o evidence of

mediastinal LN enlargement.mediastinal LN enlargement.3.3. Normal WBC count and differentialNormal WBC count and differential4.4. At operation, the bowel lesion must At operation, the bowel lesion must

predominate and the only nodes are predominate and the only nodes are associated w/ the bowel lesionassociated w/ the bowel lesion

5.5. Absence of disease in the liver and spleenAbsence of disease in the liver and spleen

Malignant neoplasm:Malignant neoplasm:4.4. GISTs: (gastrointestinal stromal tumors)GISTs: (gastrointestinal stromal tumors)

Most common Most common mesenchymal tumorsmesenchymal tumors arising in the arising in the small bowelsmall bowel70% arises from the 70% arises from the stomachstomach followed by the followed by the small small bowelbowel15% of small bowel malignancies15% of small bowel malignanciesFormerly classified as: Formerly classified as:

1.1. LeiomyomasLeiomyomas2.2. LeiomyosarcomasLeiomyosarcomas3.3. Smooth muscle tumors of small bowelSmooth muscle tumors of small bowelAssociated w/ Associated w/ overt hemorrhageovert hemorrhageHas its expression of the receptor Has its expression of the receptor tyrosine kinasetyrosine kinase KIT (CD117).KIT (CD117). There is pathological KIT signal There is pathological KIT signal transductiontransduction

Treatment:Treatment:I.I. For Benign lesions:For Benign lesions:

– All symptomatic benign tumors should be All symptomatic benign tumors should be surgically resected or removed surgically resected or removed endoscopically (EGD / colonoscopy).endoscopically (EGD / colonoscopy).

– Duodenal tumors:Duodenal tumors:1 cm. ----> endoscopic polypectomy1 cm. ----> endoscopic polypectomy2cm. ----> surgically resected (Whipples – 2cm. ----> surgically resected (Whipples – located near the ampulla of Vater).located near the ampulla of Vater).Duodenal adenomasDuodenal adenomas w/ FAP shd undergo w/ FAP shd undergo Whipples for it is usually multiple and sessile Whipples for it is usually multiple and sessile and has and has 100% degenerate to CA.100% degenerate to CA.

Treatment:Treatment:II.II. Malignant lesions:Malignant lesions:

1.1. Adenocarcinoma:Adenocarcinoma:Wide local resection w/ it’s mesentery to Wide local resection w/ it’s mesentery to achieve regional lymphadenectomyachieve regional lymphadenectomyChemotherapy has no proven efficacy in the Chemotherapy has no proven efficacy in the adjuvant or palliative treatment of small-adjuvant or palliative treatment of small-intestinal adenoCA.intestinal adenoCA.

2.2. Small intestinal lymphoma:Small intestinal lymphoma:For localized: segmental resection w/ adjacent For localized: segmental resection w/ adjacent mesenterymesenteryIf w/ diffused involvement: -->chemotherapy If w/ diffused involvement: -->chemotherapy rather than surgery, is primary therapyrather than surgery, is primary therapy

Treatment:Treatment:

3.3. Carcinoid:Carcinoid:Segmental intestinal resection & regional Segmental intestinal resection & regional lymphadenectomy.lymphadenectomy.− < < 1cm rarely has LN metastases1cm rarely has LN metastases− > 3cm 75 to 90% LN metastases> 3cm 75 to 90% LN metastases

30% are multiple, hence entire small 30% are multiple, hence entire small bowel shd be examined prior to surgerybowel shd be examined prior to surgery..

Treatment:Treatment:3.3. Carcinoid:Carcinoid:

Is w/ metastatic lesions---> debulking, Is w/ metastatic lesions---> debulking, associated w/ long-term survival & associated w/ long-term survival & amelioration of symptoms of carcinoid amelioration of symptoms of carcinoid syndromesyndromeChemotherapy: ---> 30 -50% responseChemotherapy: ---> 30 -50% response

1.1. DoxorubicinDoxorubicin2.2. 5-fluorouracil5-fluorouracil3.3. StreptozocinStreptozocin

OctreotideOctreotide: - most effective for : - most effective for management of symptoms of carcinoid management of symptoms of carcinoid syndromesyndrome

Treatment:Treatment:4.4. Small-intestine GISTs:Small-intestine GISTs:

Segmental resectionSegmental resectionIf was preoperatively diagnosed, lymphadenectomy If was preoperatively diagnosed, lymphadenectomy shd not be done, for rarely associated w/ LN shd not be done, for rarely associated w/ LN metastases.metastases.Resistant to conventional chemotherapyResistant to conventional chemotherapyIMATINIB (Gleevec):IMATINIB (Gleevec):

− Formerly known as ST1571Formerly known as ST1571− 80% of pt w/ unresectable lesions showed clinical 80% of pt w/ unresectable lesions showed clinical

benefitsbenefits− 50 – 60% showed evidence of reduction in tumor 50 – 60% showed evidence of reduction in tumor

volumevolume− Role as neoadjuvant and adjuvant tx under investigationRole as neoadjuvant and adjuvant tx under investigation

Treatment:Treatment:

5.5. Metastatic cancers:Metastatic cancers:MelanomaMelanoma associated w/ propensity for associated w/ propensity for metastasis to the small bowel.metastasis to the small bowel.Palliative resection / bypass procedurePalliative resection / bypass procedureSystemic therapy depends on the responds Systemic therapy depends on the responds of the primary site.of the primary site.

Meckels DiverticulumMeckels DiverticulumMost prevalent congenital anomaly of GITMost prevalent congenital anomaly of GIT3:2 (male:female)3:2 (male:female)True diverticulaTrue diverticula60% contains heterotopic mucosa:60% contains heterotopic mucosa:

1.1. Gastric mucosaGastric mucosa (60%) (60%)2.2. Pancreatic aciniPancreatic acini3.3. Brunner’s glandBrunner’s gland4.4. Pancreatic isletsPancreatic islets5.5. Colonic mucosaColonic mucosa6.6. EndometriosisEndometriosis7.7. Hepatobiliary tissuesHepatobiliary tissues

Meckels DiverticulumMeckels DiverticulumRules of Twos:Rules of Twos:

1.1. 2% prevalence2% prevalence2.2. 2:1 female predominance2:1 female predominance3.3. Location 2 feet proximal to the ileocecal valve in Location 2 feet proximal to the ileocecal valve in

adults.adults.4.4. Half of those are asymptomatic are younger than 2 Half of those are asymptomatic are younger than 2

years of age.years of age.Complications:Complications:

1.1. Bleeding (most common)Bleeding (most common) – due to ileal mucosal – due to ileal mucosal ulceration.ulceration.

2.2. Obstruction:Obstruction:a.a. Volvulus of the intestineVolvulus of the intestineb.b. Entrapment of intestine by the mesodiverticular bandEntrapment of intestine by the mesodiverticular bandc.c. IntussuceptionIntussuceptiond.d. Stricture due to diverticulitisStricture due to diverticulitise.e. As Littre’s hernia – found in inguinal or femoral hernia sac.As Littre’s hernia – found in inguinal or femoral hernia sac.

Meckels DiverticulumMeckels DiverticulumClinical manifestation:Clinical manifestation:

1.1. AsymptomaticAsymptomatic2.2. 4% symptomatic due to complication4% symptomatic due to complication

50% are younger than 10y/o50% are younger than 10y/oSymptomatic (Bleeding > obstruction > diverticulitis)Symptomatic (Bleeding > obstruction > diverticulitis)– bleeding is 50% in children and pt younger 18y/obleeding is 50% in children and pt younger 18y/o– bleeding is rare in pt older than 30y/obleeding is rare in pt older than 30y/o– intestinal obstruction most common in adultintestinal obstruction most common in adult– diverticulitis is indistinguishable to appendicitisdiverticulitis is indistinguishable to appendicitis

Neoplasm seen: ---> CarcinoidNeoplasm seen: ---> Carcinoid

Meckels DiverticulumMeckels DiverticulumDiagnosis:Diagnosis:

For asymptomatic usually discovered as an For asymptomatic usually discovered as an incidental findings in radiographic imaging, incidental findings in radiographic imaging, endoscopy, or intraoperatively.endoscopy, or intraoperatively.

1.1. EnteroclysisEnteroclysis has 75% accuracy but not has 75% accuracy but not applicable during acute cases.applicable during acute cases.

2.2. Radionuclide scansRadionuclide scans (99m Tc-pertechnate) (99m Tc-pertechnate) for ectopic gastric mucosa or in active for ectopic gastric mucosa or in active bleedingbleeding

3.3. AngiographyAngiography to localize site of bleeder to localize site of bleeder

Meckels DiverticulumMeckels Diverticulum

Management:Management:Diverticulectomy:Diverticulectomy:

diverticulitisdiverticulitisobstruction (w/ removal of associated band)obstruction (w/ removal of associated band)

Segmental resection for:Segmental resection for:BleedingBleedingIf with tumorIf with tumor

Acquired Small Bowel DiverticulaAcquired Small Bowel DiverticulaEpidemiology:Epidemiology:

False diverticulaFalse diverticulaIncreases w/ age; seldom seen < 40y/o (50-Increases w/ age; seldom seen < 40y/o (50-70y/o)70y/o)

1.1. Duodenum:Duodenum: 1.1. Most common; usually adjacent to ampullaMost common; usually adjacent to ampulla2.2. Called Called periampullary, juxtapapillary, or peri-periampullary, juxtapapillary, or peri-

Vaterian diverticulaVaterian diverticula3.3. 75% arise in the medial wall75% arise in the medial wall

2.2. Jejunoileal:Jejunoileal:80% - jejunum (tends to be large and multiple)80% - jejunum (tends to be large and multiple)15% - ileum (tends to be small and solitary)15% - ileum (tends to be small and solitary)5% - both ileum and jejunum5% - both ileum and jejunum

Acquired Small Bowel DiverticulaAcquired Small Bowel Diverticula

Pathophysiology:Pathophysiology:Abnormalities of intestinal smooth muscleAbnormalities of intestinal smooth muscle or dysregulated motility leading to herniation.or dysregulated motility leading to herniation.Associated w/:Associated w/:

1.1. Bacterial overgrowthBacterial overgrowth – vit B12 deficiency, – vit B12 deficiency, megalobalstic anemia, malabsorption & megalobalstic anemia, malabsorption & steatorrheasteatorrhea

2.2. Periampullary duodenal diverticulaPeriampullary duodenal diverticula::1.1. Obstructive jaundiceObstructive jaundice2.2. PancreatitisPancreatitis

3.3. Intestinal obstructionIntestinal obstruction due to compression of due to compression of adjacent boweladjacent bowel


Diagnosis:Diagnosis:Best diagnosed w/ enteroclysisBest diagnosed w/ enteroclysis

Treatment:Treatment:Asymptomatic ---> left aloneAsymptomatic ---> left aloneBacterial overgrowth --> antibioticsBacterial overgrowth --> antibioticsBleeding and obstruction ---> segmental Bleeding and obstruction ---> segmental resection for jejunoileal diverticula.resection for jejunoileal diverticula.


Treatment:Treatment:Diverticulectomy if locatedDiverticulectomy if located in the duodenum in the duodenum1.1. For medial duodenal diverticula ---> do lateral For medial duodenal diverticula ---> do lateral

duodenotomy and oversewing of the bleederduodenotomy and oversewing of the bleeder2.2. May invaginate the diverticula into the May invaginate the diverticula into the

duodenal lumen then excisedduodenal lumen then excised3.3. If related to the ampulla ---> extended If related to the ampulla ---> extended

sphincterotoplastysphincterotoplasty4.4. If perforated ----> excised and closed w/ If perforated ----> excised and closed w/

omental patch; if to inflammed ---> placed omental patch; if to inflammed ---> placed gastrojejunostomy gastrojejunostomy

Mesenteric IschemiaMesenteric IschemiaClinical Syndrome:Clinical Syndrome:1.1. Acute mesenteric ischemiaAcute mesenteric ischemia

PathophysiologyPathophysiology1.1. Arterial embolus: (most common-50%; heart; Arterial embolus: (most common-50%; heart;

usually lodge distal to origin of the middle colicusually lodge distal to origin of the middle colic2.2. Arterial thrombosis: occlusion occurs at proximal Arterial thrombosis: occlusion occurs at proximal

near it’s origin.near it’s origin.3.3. Vasospasm (nonocclusive mesenteric ischemia – Vasospasm (nonocclusive mesenteric ischemia –

NOMI): usually in critically-ill pt. receiving NOMI): usually in critically-ill pt. receiving vasopressors.vasopressors.

4.4. Venous thrombosis: (5-15%) and 95% SMAVenous thrombosis: (5-15%) and 95% SMAa.a. Primary – no etiologic factor identifiedPrimary – no etiologic factor identifiedb.b. Secondary – heritable or acquired coagulation disorderSecondary – heritable or acquired coagulation disorder

Mesenteric IschemiaMesenteric IschemiaClinical Syndrome:Clinical Syndrome:2.2. Chronic Mesenteric Ischemia:Chronic Mesenteric Ischemia:

Develops insidiously allows for collateral Develops insidiously allows for collateral circulation to developcirculation to developRarely leads to infarction.Rarely leads to infarction.Usually due to Usually due to arteriosclerosisarteriosclerosisUsually two mesenteric arteries are involvedUsually two mesenteric arteries are involvedChronic mesenteric venous thrombosis can Chronic mesenteric venous thrombosis can lead to portal hypertensionlead to portal hypertension

Mesenteric IschemiaMesenteric IschemiaManifestation:Manifestation:

A.A. Acute mesenteric ischemia:Acute mesenteric ischemia:Severe abdominal pain out of proportion to the Severe abdominal pain out of proportion to the degree of abd. tenderness (hallmark)degree of abd. tenderness (hallmark)− Colicky at the mid-abdomen.Colicky at the mid-abdomen.Nausea / vomiting, diarrhea Nausea / vomiting, diarrhea On PE, early ischemia – char. AbsentOn PE, early ischemia – char. Absent onset of bowel necrosis – abd. distention,onset of bowel necrosis – abd. distention,peritonitis, passage bloody stoolperitonitis, passage bloody stool

B.B. Chronic mesenteric ischemia:Chronic mesenteric ischemia:Postprandial abd. pain “food-fear”, (most common) Postprandial abd. pain “food-fear”, (most common)

Mesenteric IschemiaMesenteric IschemiaNo laboratory test sensitive for No laboratory test sensitive for the detection of acute mesenteric the detection of acute mesenteric ischemia prior to the onset of ischemia prior to the onset of intestinal infarction.intestinal infarction.The presence of it’s hallmark The presence of it’s hallmark sign, is an indication for sign, is an indication for immediate celiotomy.immediate celiotomy.

Mesenteric IschemiaMesenteric IschemiaAngiographyAngiography – most reliable; 74 – 100% – most reliable; 74 – 100% sensitivity and 100% specificity; sensitivity and 100% specificity;

– It is gold standard for the diagnosis of Chronic It is gold standard for the diagnosis of Chronic arterial mesenteric ischemia. arterial mesenteric ischemia.

CT scanningCT scanning is used to: is used to:1.1. Disorder other abd. condition causing abd. Disorder other abd. condition causing abd.

painpain2.2. Evidence of occlusion or stenosis of Evidence of occlusion or stenosis of

mesenteric vasculature.mesenteric vasculature.3.3. Evidence of ischemia in the intestine & Evidence of ischemia in the intestine &

mesenterymesentery4.4. Test of choice for acute mesenteric venous Test of choice for acute mesenteric venous

thrombosisthrombosis

Mesenteric IschemiaMesenteric IschemiaTreatment:Treatment:

Therapeutic option for acute mesenteric Therapeutic option for acute mesenteric ischemia is based on:ischemia is based on:

1.1. Presence or absence of signs of peritonitisPresence or absence of signs of peritonitis2.2. Presence or absence of ischemic but viable intestinePresence or absence of ischemic but viable intestine3.3. General condition of the patientGeneral condition of the patient4.4. Specific vascular lesion causing mesenteric Specific vascular lesion causing mesenteric

ischemiaischemiaw/ signs of peritonitis --> celiotomy check for w/ signs of peritonitis --> celiotomy check for viability of the bowel:viability of the bowel: Necrotic ----> segmental resectionNecrotic ----> segmental resection Questionable viability ----> second look laparotomiesQuestionable viability ----> second look laparotomies

Mesenteric IschemiaMesenteric IschemiaSurgical revascularizationSurgical revascularization (embolectomy / (embolectomy / thrombectomy / mesenteric bypass).thrombectomy / mesenteric bypass).Not done if: Not done if:

segment is necroticsegment is necrotic is too unstable patientis too unstable patient

Done pt diagnosed w/ emboli or thrombus-induced Done pt diagnosed w/ emboli or thrombus-induced acute mesenteric ischemia w/o signs of peritonitis.acute mesenteric ischemia w/o signs of peritonitis.

May give thrombolysis May give thrombolysis (streptokinase, urokinase(streptokinase, urokinase, , recombinant tissue plasminogen activator).recombinant tissue plasminogen activator). Useful only in partially occluded vessels and has Useful only in partially occluded vessels and has given w/in 12 hrs. after onset of symptoms.given w/in 12 hrs. after onset of symptoms.

Mesenteric IschemiaMesenteric IschemiaNOMI NOMI – std tx. Is infusion of vasodilator – std tx. Is infusion of vasodilator (papavarine hydrochloride)(papavarine hydrochloride) into the SMA. If into the SMA. If w/ signs of peritonitis --> immediate celiotomy w/ signs of peritonitis --> immediate celiotomy and resect necrotic segment.and resect necrotic segment.Acute mesenteric venous thrombosisAcute mesenteric venous thrombosisStd tx. anticoagulant (heparin / warfarin).Std tx. anticoagulant (heparin / warfarin).Signs of peritonitis --> explore and resects if neededSigns of peritonitis --> explore and resects if needed

For chronic arterial mesenteric ischemia:For chronic arterial mesenteric ischemia:Surgical revascularization Surgical revascularization

Aortomesenteric bypass graftingAortomesenteric bypass graftingMesenteric endarterectomyMesenteric endarterectomyPercutaneous transluminal mesenteric angioplasty alone Percutaneous transluminal mesenteric angioplasty alone

or w/ stent.or w/ stent.

Short Bowel SyndromeShort Bowel Syndrome

Presence of Presence of less than 200cmless than 200cm of residual of residual small bowel in adult pts.small bowel in adult pts.Functional definition: - insufficient Functional definition: - insufficient intestinal absorptive capacity results in intestinal absorptive capacity results in the clinical manifestations of:the clinical manifestations of:

1.1. DiarrheaDiarrhea2.2. DehydrationDehydration3.3. malnutritionmalnutrition

Short Bowel SyndromeShort Bowel SyndromeEtiologies (adult):Etiologies (adult):1.1. Acute mesenteric ischemiaAcute mesenteric ischemia2.2. MalignancyMalignancy3.3. Crohn’s diseaseCrohn’s disease

Etiologies (pediatric):Etiologies (pediatric):1.1. Intestinal atresiasIntestinal atresias2.2. VolvulusVolvulus3.3. Necrotizing enterocolitisNecrotizing enterocolitis

Short Bowel SyndromeShort Bowel SyndromeFactors predictive of achieving Factors predictive of achieving

independence from TPN:independence from TPN:1.1. Presence or absence of an intact colon Presence or absence of an intact colon

(capacity to absorb fluid & electrolytes and (capacity to absorb fluid & electrolytes and absorb short-chain FA).absorb short-chain FA).

2.2. Intact ileocecal valveIntact ileocecal valve3.3. A healthy, rather disease, residual small A healthy, rather disease, residual small

intestine is associated w/ decreased severity intestine is associated w/ decreased severity of malabsorptionof malabsorption

4.4. Resection of jejunum is better tolerated than Resection of jejunum is better tolerated than the ileum, due to bile salt and vit B12 the ileum, due to bile salt and vit B12 absorption capacity of the ileum.absorption capacity of the ileum.


Medical therapy:Medical therapy:Mx of primary condition causing Mx of primary condition causing intestinal resectionintestinal resectionCorrect fluid & electrolyte imbalance Correct fluid & electrolyte imbalance due to severe diarrheadue to severe diarrheaTPN, enteral nutrition is gradually TPN, enteral nutrition is gradually introduced, once ileus is resolvedintroduced, once ileus is resolved

Short Bowel SyndromeShort Bowel SyndromeMedical therapy:Medical therapy:

H2 receptor antagonist --> to reduce H2 receptor antagonist --> to reduce gastric acid secretiongastric acid secretionAntimotility agents (loperamide HCL or Antimotility agents (loperamide HCL or diphenoxylate) diphenoxylate) Octreotide – to reduce volume of Octreotide – to reduce volume of gastrointestinal secretiongastrointestinal secretionTPN complication:TPN complication:1.1. Catheter sepsisCatheter sepsis2.2. Venous thrombosisVenous thrombosis3.3. Liver and kidney failureLiver and kidney failure4.4. osteoporosisosteoporosis

Short Bowel SyndromeShort Bowel SyndromeSurgical TherapySurgical Therapy::

Non-transplant:Non-transplant:Goal is to increase nutrient and fluid absorption Goal is to increase nutrient and fluid absorption by either slowing intestinal transit or increasing by either slowing intestinal transit or increasing intestinal lengthintestinal lengthSlow intestinal transit:Slow intestinal transit:1.1. Segmental reversal of the small bowel Segmental reversal of the small bowel 2.2. Interposition of a segment of colonInterposition of a segment of colon3.3. Construction of small intestinal valvesConstruction of small intestinal valves4.4. Electrical pacing of the small bowelElectrical pacing of the small bowel

Limited case reportLimited case reportFrequently associated w/ intestinal obstructionFrequently associated w/ intestinal obstruction


Surgical Therapy:Surgical Therapy:Non-transplant:Non-transplant:

Intestinal lengthening operation:Intestinal lengthening operation:1.1. Longitudinal Intestinal lengthening and tailoring (LILT)Longitudinal Intestinal lengthening and tailoring (LILT)2.2. Serial transverse enteroplasty procedure (STEP)Serial transverse enteroplasty procedure (STEP)

Intestinal transplantIntestinal transplant

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